Health inspection·October 6, 2023

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to implement their written policies and procedures that prohibited and prevented abuse, neglect, and exploitation of residents for 3 of 26 staff (CNA E, Hskg F, LVN G) reviewed for abuse and neglect, in that: Residents Affected - Some The facility failed to implement their abuse policy when a criminal background check and the EMR was not completed prior to their hire dates for CNA E, Hskg F and LVN G. These deficient practices could place residents at risk for abuse and neglect. The findings were: Record review of facility policy titled Abuse/Neglect, revised 03/29/2018 which read A. Screening: Criminal History and Background Checks. The facility will conduct criminal background checks of all personnel in accordance with Texas Health and Safety Code, Chapter 250. 1. The facility administrator will be responsible for ensuring compliance with the policy and Texas state law regarding criminal background checks. 2. All potential employees will be screened for history of abuse, neglect, or mistreating of elderly/individuals as defined by the applicable requirements of 483.13(c)(l)(ii)(A)and(B) [ .]. 1. Record review of the Staff Roster, dated 10/03/2023, revealed CNA E was hired on 09/18/2023. Record review of CNA E's staff records revealed CNA E's background check was searched on 09/19/2023 and her EMR was searched on 09/21/2023. 2. Record review of the Staff Roster, dated 10/03/2023, revealed Hskg F was hired on 07/14/2023. Record review of Hskg F's staff records revealed Hskg F's background check and her EMR were searched on 07/18/2023. 3. Record review of the Staff Roster, dated 10/03/2023, revealed LVN G was hired on 07/13/2023. Record review of LVN G's staff records revealed LVN G's background check and her EMR were searched on 07/18/2023. During an interview and record review, of training still needed by several staff, on 10/06/2023 at 1:19 p.m., HR stated she was responsible for the getting the EMR's and background checks completed for the new hired staff. She stated it was an oversight on her part in not getting them completed in a timely manner. HR stated the potential harm to residents was, them (a resident) getting hurt, if staff were not supposed to work with residents due to something showing up on their backgrounds or EMR checks. During an interview and record review, of training still needed by several staff, on 10/06/2023 at 2:23 p.m., the DON reviewed the record and stated she was not aware staff needed an annual EMR completed or that some of the new hired staff's documentation was not completed in a timely manner. The DON stated yes there was a potential harm to residents which was potentially the residents' safety. She further stated it was a team effort between the DON and HR to ensure staff completed all required documentation. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675372 If continuation sheet Page 2 of 19 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675372 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA Bahia Nursing and Rehabilitation 225 E Ward St Goliad, TX 77963 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete During an interview and record review, of training still needed by several staff, on 10/06/2023 at 2:35 p.m., the ADMN reviewed the record and stated he was not aware staff needed an annual EMR completed, however, he was aware that some of the new hired staff's documentation was not completed in a timely manner. The ADMN stated it was a team effort among all administration to ensure staff completed all required documentation. He stated yes there was potential harm to residents but that none was identified at this time. Event ID: Facility ID: 675372 If continuation sheet Page 3 of 19 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675372 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA Bahia Nursing and Rehabilitation 225 E Ward St Goliad, TX 77963 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections for 1 of 2 resident (Resident #15) reviewed for incontinent care, in that: While providing incontinent care for Resident #15, CNA C did not clean between Resident #16's buttocks'' cheeks. This deficient practice could place residents at-risk for infection and skin break down due to improper care practices. The findings were: Record review of Resident #15's face sheet, dated 10/06/2023, revealed an admission date of 05/14/2016 and, a readmission date of 12/06/2019, with diagnoses which included: Cerebrovascular disease (conditions that affect the blood vessels of the brain and the cerebral circulation), Cardiomegaly(enlarged heart), Chronic obstructive pulmonary disease(progressive lung disease characterized by airflow limitation), Major depressive disorder(mental disorder characterized by at least two weeks of pervasive low mood, low self-esteem, and loss of interest or pleasure), Alzheimer's disease (Gradual decline in memory, thinking, behavior and social skills). Record review of Resident #15's Annual MDS, dated [DATE], revealed Resident #15 has a BIMS score of 15, which indicated no cognitive impairment. Resident #15 was indicated to frequently be incontinent of bladder and bowel and needed limited to extensive assistance with his activities of daily living. Review of Resident #15's care plan, dated 09/18/2023, revealed a problem of The resident has occasional bladder incontinence requires limited assistance with toileting r/t Impaired Mobility, Medication Side Effects, Physical limitations, with a goal of The resident will remain free from skin breakdown due to incontinence and brief use Observation on 10/06/23 at 9:34 a.m. revealed, while providing incontinent care for Resident #15, CNA C cleaned the surface of the buttocks but did not clean the anal area or between the buttock's cheeks. During an interview on 10/06/2023 at 9:52 a.m. CNA C revealed she thought she had cleaned between Resident #15's buttocks' cheeks but confirmed she did not. She confirmed she should have cleaned the anal area. She confirmed receiving training for infection control and incontinent care within the last year. During an interview with the DON on 10/06/2023 at 10:28 a.m., the DON confirmed that during incontinent care the anal area of the buttocks needed to be cleaned. The facility was doing annual infection control and incontinent care training and annual skills checks but did not do spot checks during the year. Review of annual skills check for CNA C revealed CNA A passed competency for Perineal (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675372 If continuation sheet Page 4 of 19 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675372 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA Bahia Nursing and Rehabilitation 225 E Ward St Goliad, TX 77963 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 care/incontinent care on 04/04/2022. Level of Harm - Minimal harm or potential for actual harm Review of facility policy, titled Perineal care, dated 04/27/2022, revealed Gently perform care to the buttocks and anal area, working from front to back without contaminating the perineal area Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675372 If continuation sheet Page 5 of 19 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675372 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA Bahia Nursing and Rehabilitation 225 E Ward St Goliad, TX 77963 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0730 Observe each nurse aide's job performance and give regular training. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to conduct a performance review at least once every 12 months and provide regular in-service education based on the outcome of these reviews for 5 of 7 CNA's (CNA B, CNA C, CNA D, CNA H and CNA J) reviewed for performance reviews, in that: Residents Affected - Some The facility failed to conduct performance reviews at least every 12 months for CNA B, CNA C, CNA D, CNA H and CNA J This failure could result in residents not receiving the necessary care and services due to nurse aides not receiving training based on their performance review outcome. The findings were: 1. Record review of the Staff Roster, dated 10/03/2023, revealed CNA B was hired on 03/01/2021. Record review of CNA B's staff records revealed his last annual performance review was completed on 10/28/2022. 2. Record review of the Staff Roster, dated 10/03/2023, revealed CNA C was hired on 04/01/2021. Record review of CNA C's staff records revealed her last annual performance review was completed on 04/04/2022. 3. Record review of the Staff Roster, dated 10/03/2023, revealed CNA D was hired on 03/01/2021. Record review of CNA D's staff records revealed her last annual performance review was completed on 03//22/2022. 4. Record review of the Staff Roster, dated 10/03/2023, revealed CNA H was hired on 03/01/2021. Record review of CNA H's staff records revealed her last annual performance review was completed on 07/04/2021. 5. Record review of the Staff Roster, dated 10/03/2023, revealed CNA J was hired on 05/06/2021. Record review of CNA J's staff records revealed her last annual performance review was completed on 04/22/2022. During an interview and record review, of training still needed by several staff, on 10/06/2023 at 1:19 p.m., HR stated it was a team effort, from all administration, that was responsible for ensuring staff completed all their required training. She stated their company started using [Website Name] online as of 06/01/2023, which helped keep track of what training certain staff members needed to complete. HR further stated she emailed the supervisor, of the staff member in question, who tried to enforce that specific staff member to complete their required training. HR stated the potential harm to residents was, them (a resident) getting hurt, because of a staff member not knowing how to do their job correctly being the training was not completed. During an interview and record review, of training still needed by several staff, on 10/06/2023 at (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675372 If continuation sheet Page 6 of 19 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675372 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA Bahia Nursing and Rehabilitation 225 E Ward St Goliad, TX 77963 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0730 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 2:23 p.m., the DON reviewed the record and stated she was not aware that the annual competency was not done for the selected staff. She stated she just started as the DON a couple of weeks ago. The DON stated yes there was a potential harm to residents which was the residents safety. She further stated, it was between, the DON and the ADON would double team to ensure staff completed all required documentation. During an interview and record review, of training still needed by several staff, on 10/06/2023 at 2:35 p.m., the ADMN reviewed the record and stated he was not aware staff had not completed an annual performance review. The ADMN stated it was a team effort among all administration to ensure staff completed all required documentation. He stated yes there was potential harm to residents but that none was identified at this time. Record review of facility policy titled HR - Personnel Handbook, revised 09/20/2019, revelaed EMPLOYEE EDUCATION PROGRAM that All employees, regardless of status or classification, are required to complete mandatory training as defined by Federal, State and company policies. This facility provides multiple avenues of training that include an online learning management system, external CEU training, reimbursement for program or licensure training and more [ .]. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675372 If continuation sheet Page 7 of 19 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675372 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA Bahia Nursing and Rehabilitation 225 E Ward St Goliad, TX 77963 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and record review, the facility failed to ensure all drugs and biological were stored in locked compartments for 1 of 1 medication room reviewed for storage, in that: Controlled medications were not kept in a separate, permanently affixed compartment in the medication room. This deficient practice could place residents at risk of misappropriation of medications. The findings were: Observation in the medication room on 10/05/23 at 10:40 AM revealed a miniature fridge with a locked padlock. The front of the fridge was made of tinted glass. Inside the fridge were different insulin pens, too numerous to count, and two 30 ml bottles of lorazepam 2 mg/ml. The controlled medications were not in their own compartment and the miniature fridge was not permanently affixed to the counter it was sitting on. During an interview with the DON on 10/06/2023 at 11:30 a.m., she confirmed there was controlled and not controlled medications mixed in the fridge and not separated. She confirmed the fridge was locked with a padlock but not permanently affixed to the counter. She revealed she was new in the position as the DON and did not know the controlled medications had to be in their own compartment and the compartment needed to be permanently affixed Record review of the facility's policy titled, Storage of controlled substance,, dated 2003, revealed, The controlled drugs [ .] will be kept locked in a separate, permanently affixed compartment for the storage of controlled drugs FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675372 If continuation sheet Page 8 of 19 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675372 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA Bahia Nursing and Rehabilitation 225 E Ward St Goliad, TX 77963 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews failed to accommodate residents' food preferences for 1 of 17 (Resident #28) residents reviewed in that: The facility failed to ensure Resident #28 received her preference of a lettuce and tomato salad during the lunch meal on 10/03/2023 and her preference of an over easy egg. This failure could affect all residents with food preferences and could result in a decrease in resident choices and diminished interest in meals. The findings were: Record review of Resident #1's face sheet, dated 10/06/2023, reveled the resident was admitted on [DATE] with diagnoses that included: dementia, major depressive disorder, pain in spine, and history of breast cancer. Record review of Resident #1's Quarterly MDS assessment, dated 08/30/2023, revealed a BIMS score of 15, which indicated intact cognitive impairment. Record review of Resident #28's tray card revealed Dislikes: Strawberry; Greens, Turnip; Greens, Mustard. Record review of Resident #28's Dietary Profile, dated 02/07/2023, revealed A. Diet Order. 1. Current Diet Order; regular [ .] K. Likes/Dislikes [ .] 2. Dislikes: greens [ .]. Record review of the current weekly menu, dated 10/03/2023, revealed Tuesday's scheduled lunch meal was Fried Chicken, w/Southern Chicken gravy, Mashed Potatoes, Collard Greens, Cornbread [ .]. During an observation, of all kitchen reach-in refrigerators, on 10/03/2023 between 10:49 a.m. and 11:00 a.m., fresh produce was not seen in either of the two reach-in refrigerators. During a resident group meeting on 10/03/2023 at 2:05 p.m., an unknown resident stated Resident #28 was given collard greens, for lunch today, and she did not like greens. The unknown resident further stated Resident #28 then asked; an unknown staff member; for tomatoes and was told that the facility did not have any tomatoes. During an interview on 10/04/2023 at 10:30 a.m., Resident #28 stated she asked for a lettuce and tomato salad, during the lunch meal on 10/03/2023; because she did not like greens, and she was told they did not have it. She further stated the (unknown) staff member gave her tomato juice but it was room temp and so she did not drink it because it was not cold. Resident #28 also stated she preferred eating over easy eggs but that she tolerated the scrambled eggs, since she was admitted ; because she was told the facility could not make over easy eggs because of regulation. She was unable to recall who the staff member was for either occurrence. Resident #28 repeated how much she did not like greens and how they gave her tomato juice at room temperature throughout her interview. During an observation on 10/05/2023 at 7:35 a.m., revealed pasteurized eggs located in reach-in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675372 If continuation sheet Page 9 of 19 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675372 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA Bahia Nursing and Rehabilitation 225 E Ward St Goliad, TX 77963 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some refrigerator #2 on the bottom shelf. Further observation revealed, on the serving steam table, only pre-cooked over hard eggs in one pan and pre-cooked scrambled eggs in a separate pan. During an interview 10/05/2023 at 7:58 a.m., the DM stated, after not recalling any fresh produce during thethe walk through of reach-in refrigerators on 10/03/2023, she completed her grocery cart every 5-7 days based what's on the menus and it (grocery cart) was supposed to come in today. During an observation on 10/05/2023 at 8:00 a.m., revealed no over easy eggs were cooked on the flat grill during the breakfast meal. Further observation revealed the flat top grill was in the off position during serving meal trays and all current dietary staff were located by the steam table while preparing and serving meal trays. During an interview on 10/05/2023 at 11:30 a.m., [NAME] S stated, no she did not cook any over easy eggs for this morning's breakfast and only had the over hard eggs on the steam table. [NAME] S stated over easy eggs were never served because of regulation. [NAME] R also mentioned, during this interview, the same information. [NAME] R also mentioned she was not cooking over easy eggs either. Both cooks stated that was because of regulation and they were not supposed to because it could harm the residents. [NAME] S, further stated, the alternate vegetable for the lunch meal on 10/03/2023 was tomato juice. [NAME] S stated she was the cook for that lunch meal and she cooked collard greens for the vegetable. During an interview on 10/05/2023 at 11:45 a.m., the DM stated the dietary staff was in a routine which was why they did not cook any over easy eggs. She stated she made the decision to serve tomato juice as the alternate for the collard greens the lunch meal on 10/03/2023 and she believed that it was an accurate alternative to the cooked collard greens. The DM stated she was not aware that a resident had asked for a lettuce and tomato salad. She, further, stated the kitchen was not able to provide the resident's preference because there was no lettuce and or tomoto in the kitchen, at that time. The DM stated the potential harm to residents by not honoring a resident's preference was the resident being upset. During an interview on 10/06/2023 at 2:29 p.m., the DON stated when a resident did not like the meal then staff should be offering an alternate. The DON further stated a resident's likes/dislikes were updated in their preferences. She then stated a resident's preference was supposed to be honored as long the facility was able to meet the need; reasonably. She stated that also depended on the menu and the nutritional value of what the resident wanted; to include fresh produce like a salad. The DON believed it was not necessarily a potential harm to a resident but instead the resident would be upset by not having honored their food preference. During an interview on 10/06/2023 at 2:31 p.m., the ADMN stated yes, the facility should honor a resident's preference to the extent that they could provide it reasonably. He also stated it depended on the menu and the nutritional value of what the resident wanted; which included fresh produce for salads. The ADMN stated yes there was a potential harm to resident but that none have been identified at this time. The facility policy titled Resident Menu, dated 2012, revealed 3. [ .] If a resident does not want the food prepared on the menu, not the alternate, then soup, salad, and/or sandwich will be offered [ .]. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675372 If continuation sheet Page 10 of 19 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675372 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA Bahia Nursing and Rehabilitation 225 E Ward St Goliad, TX 77963 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen (Main Kitchen), in that: 1. The facility failed to ensure items in the walk-in refrigerator and dry storage areas were dated and or discarded correctly. These deficient practices could place residents who ate food from the kitchen at risk for foodborne illness. The findings included: 1. During an observation and interview on 10/03/2023 at 11:49 a.m., revealed in reach-in refrigerator #1 a jar of pickles dated with 09/14/2023 but not clearly marked if opened or received; a container of chicken base with a received date of 09/14/2023 and no opened date; a container of minced garlic with no received or opened date; a gallon of teriyaki sauce with two dates 04/08/23 and 10/06/2023 and unable to determine which was the received date and which was the opened date. The DM stated she just put the minced garlic in the refrigerator this morning. During an observation and interview on 10/03/2023 at 11:00 a.m., revealed in the dry storage area an opened container of several different colored sprinkles with no received date or opened date. The DM stated she was not sure where it came from and threw it away. During an interview on 10/05/2023 at 11:45 a.m., the DM stated the procedure for receiving food from vendors was to check everything in and date the items with a received date, then dietary staff were supposed to date the items when it was opened and make sure to indicate opened clearly. The DM stated the potential harm to resident's was foodborne illnesses. During an interview on 10/06/2023 at 2:29 p.m., the ADMN stated, yes, items in the kitchen were supposed to be dated accordingly and done upon receiving that item or when opened. He stated the DM and the ADMN were ultimately responsible for the kitchen area. The ADMN stated yes there was a potential harm to residents but none had been identified at this time. Record review of facility policy titled Storage Refrigerators, dated 2018, revealed 5. Food must be covered when stored, with a date label identifying what is in the container. Record review of facility policy titled Dry Storage and Supplies, dated 2018, revealed 4. Open packages of food are stored in closed containers with tight covers, and dated as to when opened. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed 3-501.17 Ready -to-Eat, Time/Temperature Control for Safety Food, Date Marking. (B) Except as specified in (E) - (G) of this section, refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675372 If continuation sheet Page 11 of 19 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675372 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA Bahia Nursing and Rehabilitation 225 E Ward St Goliad, TX 77963 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm day the original container is opened in the FOOD ESTABLISHMENT shall be counted as Day 1; and (2) The day or date marked by the FOOD ESTABLISHMENT may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on FOOD safety. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675372 If continuation sheet Page 12 of 19 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675372 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA Bahia Nursing and Rehabilitation 225 E Ward St Goliad, TX 77963 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to establish and maintain an Infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infection for 1 of 5 residents (Resident #15) reviewed for infection control, in that: Residents Affected - Few CNA D failed to perform hand hygiene or change her gloves after touching the soiled briefs and before touching the clean briefs. This deficient practice could place residents at-risk for infection due to improper care practices. The findings included: Record review of Resident #15's face sheet, dated 10/06/2023, revealed an admission date of 05/14/2016 and, a readmission date of 12/06/2019, with diagnoses which included: Cerebrovascular disease (conditions that affect the blood vessels of the brain and the cerebral circulation), Cardiomegaly(enlarged heart), Chronic obstructive pulmonary disease(progressive lung disease characterized by airflow limitation), Major depressive disorder(mental disorder characterized by at least two weeks of pervasive low mood, low self-esteem, and loss of interest or pleasure), Alzheimer's disease (Gradual decline in memory, thinking, behavior and social skills). Record review of Resident #15's Annual MDS, dated [DATE], revealed Resident #15 has a BIMS score of 15, which indicated no cognitive impairment. Resident #15 was indicated to frequently be incontinent of bladder and bowel and needed limited to extensive assistance with his activities of daily living. Review of Resident #15's care plan, dated 09/18/2023, revealed a problem of The resident has occasional bladder incontinence requires limited assistance with toileting r/t Impaired Mobility, Medication Side Effects, Physical limitations, with a goal of The resident will remain free from skin breakdown due to incontinence and brief use. Observation on 10/06/23 at 9:34 a.m. revealed, while providing incontinent care for Resident #15, CNA D touched the soiled brief to remove it from under Resident #15. She did not change her gloves and sanitize her hands and touched the clean brief and fasten it to the resident. During an interview on 10/06/2023 at 9:52 a.m. CNA D confirmed not changing her gloves or sanitizing her hands. She realized she had forgotten after finishing the care for the resident. She had received infection control training within the year and understood it could be a risk of infection for the resident. During an interview with the DON on 10/06/2023 at 10:28 a.m., the DON confirmed the staff should change gloves and sanitize or wash their hands to avoid cross contamination while handling soiled and clean briefs. The facility provided annual infection control and incontinent care training to the staff, and annual skills checks were done. They did not do spot check during the year. Review of the annual skills check for CNA D revealed CNA D passed competency for Perineal (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675372 If continuation sheet Page 13 of 19 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675372 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA Bahia Nursing and Rehabilitation 225 E Ward St Goliad, TX 77963 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 care/incontinent care on 03/22/2022. Level of Harm - Minimal harm or potential for actual harm Record review of the facility policy, titled Fundamental of infection control precaution, dated 03/2023, revealed [ .] list of some situations that require hand hygiene: [ .] after handling soiled or used linens, dressings, bedpans, catheter and urinals Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675372 If continuation sheet Page 14 of 19 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675372 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA Bahia Nursing and Rehabilitation 225 E Ward St Goliad, TX 77963 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0941 Level of Harm - Minimal harm or potential for actual harm Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members. Based on interview and record review, the facility failed to provide effective communications mandatory training for 1 of 20 employees (OT Q) reviewed for training, in that: Residents Affected - Few The facility failed to ensure OT Q completed effective communication training. This failure could place residents at risk of miscommunication and social isolation due to lack of staff training. The findings were: Record review of the Staff Roster, dated 10/03/2023, revealed OT Q was hired on 02/20/2020. Record review of OT Q's training history, undated, revealed OT Q had not completed effective communication training since his hire date. During an interview and record review, of training still needed by several staff, on 10/06/2023 at 1:19 p.m., HR stated it was a team effort, from all administration, that was responsible for ensuring staff completed all their required training. She stated their company started using [Website Name] online as of 06/01/2023, which helped keep track of what training certain staff members needed to complete. HR further stated she emailed the supervisor, of the staff member in question, who tried to enforce that specific staff member to complete their required training. HR stated the potential harm to residents was, them (a resident) getting hurt, because of a staff member not knowing how to do their job correctly being the training was not completed. During an interview and record review, of training still needed by several staff, on 10/06/2023 at 2:25 p.m., the DON reviewed the record and stated she was not aware of any staff still needing to complete any training. The DON stated yes there was a potential harm to residents which was resident safety. She further stated it was a team effort between the DON and HR to ensure staff completed all required training. During an interview and record review, of training still needed by several staff, on 10/06/2023 at 2:27 p.m., the ADMN reviewed the record and stated he was not aware of any training not completed by staff. The ADMN stated it was a team effort among all administration to ensure staff completed all required documentation or training. He stated yes there was potential harm to residents but that none was identified at this time. Record review of facility policy titled HR - Personnel Handbook, revised 09/20/2019, revealed EMPLOYEE EDUCATION PROGRAM that All employees, regardless of status or classification, are required to complete mandatory training as defined by Federal, State and company policies. This facility provides multiple avenues of training that include an online learning management system, external CEU training, reimbursement for program or licensure training and more [ .]. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675372 If continuation sheet Page 15 of 19 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675372 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA Bahia Nursing and Rehabilitation 225 E Ward St Goliad, TX 77963 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0944 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program. Based on interviews and record reviews, the facility failed to ensure Quality Assurance and Performance Improvement (QAPI) training that outlines and informs staff of the elements and goals of the facility's QAPI program for 2 of 20 employees (CNA D and CNA J) reviewed for training, in that: The facility failed to ensure CNA D and CNA J completed QAPI training since their hired date. This failure could affect residents and place them at risk of poor care or victimization due to lack of staff training. The Findings were: 1. Record review of the Staff Roster, dated 10/03/2023, revealed CNA D was hired on 03/01/2021. Record review of CNA D 's training history, undated, revealed CNA D had not completed QAPI training since their hired date. 2. Record review of the Staff Roster, dated 10/03/2023, revealed CNA J was hired on 05/06/2021. Record review of CNA J's training history, undated, revealed CNA J had not completed QAPI training since their hired date. During an interview and record review, of training still needed by several staff, on 10/06/2023 at 1:19 p.m., HR stated it was a team effort, from all administration, that was responsible for ensuring staff completed all their required training. She stated their company started using [Website Name] online as of 06/01/2023, which helped keep track of what training certain staff members needed to complete. HR further stated she emailed the supervisor, of the staff member in question, who tried to enforce that specific staff member to complete their required training. HR stated the potential harm to residents was, them (a resident) getting hurt, because of a staff member not knowing how to do their job correctly being the training was not completed. During an interview and record review, of training still needed by several staff, on 10/06/2023 at 2:25 p.m., the DON reviewed the record and stated she was not aware of any staff still needing to complete any training. The DON stated yes there was a potential harm to residents which was resident safety. She further stated it was a team effort between the DON and HR to ensure staff completed all required training. During an interview and record review, of training still needed by several staff, on 10/06/2023 at 2:27 p.m., the ADMN reviewed the record and stated he was not aware of any training not completed by staff. The ADMN stated it was a team effort among all administration to ensure staff completed all required documentation or training. He stated yes there was potential harm to residents but that none was identified at this time. Record review of facility policy titled HR - Personnel Handbook, revised 09/20/2019, revealed EMPLOYEE EDUCATION PROGRAM that All employees, regardless of status or classification, are required to complete mandatory training as defined by Federal, State and company policies. This facility provides multiple avenues of training that include an online learning management system, external CEU (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675372 If continuation sheet Page 16 of 19 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675372 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA Bahia Nursing and Rehabilitation 225 E Ward St Goliad, TX 77963 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0944 training, reimbursement for program or licensure training and more [ .]. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675372 If continuation sheet Page 17 of 19 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675372 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA Bahia Nursing and Rehabilitation 225 E Ward St Goliad, TX 77963 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0949 Level of Harm - Minimal harm or potential for actual harm Provide behavior health training consistent with the requirements and as determined by a facility assessment. Based on interview and record review, the facility failed to provide mandatory effective behavioral health training for 2 of 20 employees (CNA I and LVN O) reviewed for training, in that: Residents Affected - Few The facility failed to ensure CNA I and LVN O completed behavioral health training since their hired date. This failure could place residents at risk of not attaining or maintaining their highest practicable physical, mental, and psychosocial well-being due to lack of staff training. The findings were: 1. Record review of the Staff Roster, dated 10/03/2023, revealed CNA I was hired on 01/26/2022. Record review of CNA I 's training history, undated, revealed CNA I had not completed behavioral health training since their hired date. 2. Record review of the Staff Roster, dated 10/03/2023, revealed LVN O was hired on 007/01/2022. Record review of LVN O 's training history, undated, revealed LVN O had not completed behavioral health training since their hired date. During an interview and record review, of training still needed by several staff, on 10/06/2023 at 1:19 p.m., HR stated it was a team effort, from all administration, that was responsible for ensuring staff completed all their required training. She stated their company started using [Website Name] online as of 06/01/2023, which helped keep track of what training certain staff members needed to complete. HR further stated she emailed the supervisor, of the staff member in question, who tried to enforce that specific staff member to complete their required training. HR stated the potential harm to residents was, them (a resident) getting hurt, because of a staff member not knowing how to do their job correctly being the training was not completed. During an interview and record review, of training still needed by several staff, on 10/06/2023 at 2:25 p.m., the DON reviewed the record and stated she was not aware of any staff still needing to complete any training. The DON stated yes there was a potential harm to residents which was resident safety. She further stated it was a team effort between the DON and HR to ensure staff completed all required training. During an interview and record review, of training still needed by several staff, on 10/06/2023 at 2:27 p.m., the ADMN reviewed the record and stated he was not aware of any training not completed by staff. The ADMN stated it was a team effort among all administration to ensure staff completed all required documentation or training. He stated yes there was potential harm to residents but that none was identified at this time. Record review of facility policy titled HR - Personnel Handbook, revised 09/20/2019, revealed EMPLOYEE EDUCATION PROGRAM that All employees, regardless of status or classification, are required to complete mandatory training as defined by Federal, State and company policies. This facility provides multiple avenues of training that include an online learning management system, external CEU (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675372 If continuation sheet Page 18 of 19 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675372 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA Bahia Nursing and Rehabilitation 225 E Ward St Goliad, TX 77963 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0949 training, reimbursement for program or licensure training and more [ .]. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675372 If continuation sheet Page 19 of 19