Inspection·October 9, 2024

F 0695 Required Oxygen at 2-4 L per n/c daily continuous to maintain o2 sats greater than 95 Level of Harm - Minimal harm or potential for actual harm Goal - Will maintain oxygen saturation levels Intervention - Administer oxygen as ordered Residents Affected - Some Record review of Resident #1's Order Summary dated 10/9/2024 revealed the following in part: Oxygen at 2-4 liters PE Nasal cannula daily continuous to maintain 02 sat > [sic] 95% every shift for shortness of breath related to shortness of breath (start date 9/3/2024). Levalbuterol HCI (hydrochloric acid) solution nebulizer .63 mg/3ml. 1 vial inhale orally every 8 hours as needed for COPD (start date 9/3/2024) Record review of Resident #1's admission MDS dated [DATE] revealed a BIMS of 99, which indicated the resident was not able to complete the interview. Further review revealed Active Diagnoses - Debility, Cardiorespiratory conditions, Heart Failure, Hypertension (high blood pressure), Pulmonary - Asthma, Chronic Obstructive Pulmonary Disease. Record review of Resident #1's nurses notes dated 10/9/2026 at 11:46 a.m., written by LVN A revealed the following: Changed O2 tank this AM [morning] Attempted to get O2 reading O2 machiene [sic] not reading attempted to warm ands [sic] and gave breathing treatment no distress noted. O2 reading 92% no distress noted at this time. Resident #2 Record Review of Resident #2's face sheet dated 10/9/2024 for revealed she was a [AGE] year-old, female who was admitted to the facility on [DATE]. Her diagnoses included Dementia (memory loss), shortness of breath (difficulty breathing), Chronic obstructive pulmonary disease (common lung disease causing restricted airflow and breathing problems), cerebral infarction (disrupted blood flow to the brain), and hypertension (high blood pressure). Record review of the physician's orders dated 10/7/2024 revealed Resident #2 had orders for the following: Oxygen at 2-4 liters per nasal cannula daily continuous to maintain o2 sats > 95% (order date 11/1/2022) to receive 02 at 2L/m via NC Continuously every shift. Additional order dated 6/4/24 revealed Oxygen at 2-4 LPM via nasal cannula continuously. Monitor 02 sat. every shift. Record review Resident #2's Quarterly MDS assessment dated [DATE] revealed a BIMS score 14 indicating the resident was cognitively intact. Review of Section O: Special treatment revealed the resident was coded as receiving respiratory treatments - continuous oxygen therapy. Record Review of Resident #2's care plan dated 8/29/2022 revealed the following: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675999 If continuation sheet Page 2 of 6 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 675999 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/09/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St James House of Baytown 5800 W Baker Rd Baytown, TX 77520 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 0695 Required Oxygen: Continuous Level of Harm - Minimal harm or potential for actual harm Start date 8/29/2022 - Status - Active Care plan Goal - Will maintain oxygen saturation levels. Residents Affected - Some Intervention - Administer oxygen as ordered. Record review of the physician's orders dated 10/7/2024 revealed Resident #2 had orders for the following: Oxygen at 2-4 liters per nasal cannula daily continuous to maintain o2 sats > 95% (order date 11/1/2022) to receive 02 at 2L/m via NC Continuously every shift. Additional order dated 6/4/24 revealed Oxygen at 2-4 LPM via nasal cannula continuously. Monitor 02 sat. every shift. Observation on 10/9/2024 at 9:01 a.m. - 9:18 a.m. revealed Resident #1 was in her wheelchair, in a common area, with a portable O2 tank and cannula in her nose. The O2 gauge indicator was in the refill zone and the needle was on zero. An interview on 10/9/2024 at 9:02 a.m. was attempted. Resident #1 made a continuous moaning sound when asked if she had any shortness of breath . Resident #1 was not able to answer how she felt. Interview on 10/9/2024 at 9:03 a.m. CNA A said Resident #1 had been sitting in the common area for approximately 10-15 minutes. She said she had not checked Resident #1's oxygen gauge and the nurse was responsible. Interview on 10/9/2024 at 9:18 a.m. LVN A said she sat Resident #1 in the common area at approximately 8:45 a.m. She said the O2 gauge was close to the refill. She said she was completing other tasks for about 30 minutes. She said the gauge was in the refill zone, but it did not mean the resident was out of oxygen. She said she was not sure how long the gauge had been in the refill zone and the indicator was pointed to zero. She said the oxygen should be changed before it was empty. She said she was not able to determine if there was oxygen left in the tank and if the resident was receiving oxygen. Observation and interview on 10/9/2024 at 9:21 a.m. revealed LVN A attempted to measure Resident #1's oxygen saturations. LVN A rubbed Resident #1's hands with her hands for a minute. LVN A said Resident #1's hands were too cold for the pulse oximeter to get a reading. LVN A said she would give Resident #1 a breathing treatment because she was not sure if her 02 saturations were below her normal range. Observation and interview on 10/09/2024 at 9:25 a.m. with LVN A, in Resident #1's room, revealed the oxygen concentrator filter had a layer of light gray hairy substance. LVN A took Resident #1 into the room to give her a breathing treatment. LVN A said the nurses did not change the filters and she thought it was maintenance's responsibility. She said she was never told to clean the filters. Observation and interview on 10/09/2024 at 9:34 a.m., revealed Resident #2 was asleep in bed. Resident #2's concentrator was on and the tubing/cannula was on the floor next to the concentrator at the head of the bed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675999 If continuation sheet Page 3 of 6 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 675999 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/09/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St James House of Baytown 5800 W Baker Rd Baytown, TX 77520 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interview on 10/9/2024 at 10:15 a.m. Maint. said he was not told to clean the oxygen concentrator filters. He said a previous DON cleaned the filters. Observation and interview on 10/09/2024 at 11:37 a.m., revealed Resident #2 was asleep in bed. Resident #2's concentrator and tubing/cannula was in the same position as the earlier observation revealed. Resident #2 was aroused when her name was called. Resident #2 touched on her chest and nose as she tried to find her oxygen. She said she did not know where the oxygen was and had not taken it off. She said she normally had it on. She said she could not remember if the nurse or aide came into her room. Interview and observation on 10/9/2024 at 11:39 a.m. CNA B said she was not aware the tubing for Resident #2's was on the floor. She said she had been in the resident's room but could not remember what time. She said she normally rounded every two hours. She said she was in another resident's room changing the sheets for the past several minutes. She said Resident #2 was supposed to have the oxygen on but was not sure if it was continuous or as needed. She said she had not placed the oxygen on Resident #2 at anytime during her shift . Interview on 10/9/2024 at 11:56 a.m. LVN B said she last checked on Resident #2 at 8:30 a.m. She said she was not aware Resident #2's oxygen cannula was not on. She said Resident #2 had a behavior of taking the oxygen off. LVN B said she normally made round to check on resident every two hours. She said Resident #2 could experience shortness of breath or low o2 saturations if she went without oxygen. Interview on 10/9/2024 at 12:35 p.m. the ADON said when a resident's portable oxygen tank was in the red refill zone, then the tank should be changed to a full tank. She said she expected the nurses to monitor the portable tank to ensure it was not empty. She said if the oxygen tank was empty, Resident #1 would not have received the therapeutic effect of the oxygen need to prevent shortness of breath. The ADON said she changed out Resident #2's cannula and ensured it was in place after it was found on the floor. The ADON said Resident #2 was care planned for taking the oxygen off . She said she was not able to explain why the cannula was in the same position on the floor for approximately two hours. Interview on 10/9/2024 at 1:49 p.m. the DON said nurse should check the portable oxygen tanks every shift. She said the nurses worked 6:30 a.m. - 2:30 p.m. The DON said possibly the tank was used yesterday (10/8/24) and it was not a full tank. She said normally the portable tanks were used for approximately 3 hours continuously before they are depleted. She said, If the gauge indicator is in the red (refill) section, the tank is empty. She said residents on continuous oxygen are at risk for lower oxygen saturations, confusion, and shortness of breath if they did not receive oxygen as ordered. The DON said she was not sure which staff changed out the concentrator filters and not instructed staff to do so . She said she was not sure how often the oxygen concentrator filters needed to be changed. She said the layer of gray matter that was on Resident #1's concentrator filter indicated the filter needed to be cleaned. She said the layer of gray matter could prevent the flow which could affect the resident. The DON said Resident #2 was on continuous o2 and the CNAs and nurses were responsible for ensuring Resident #2 had her oxygen on. She said Resident #2 could suffer from respiratory problems without the supplemental oxygen. Interview on 10/9/2024 at 2:08 p.m. the NP said he was notified approximately at 12:00 p.m. today about Resident #1's low o2 saturations (92%). He said because Resident #1 had COPD, any o2 saturations over 85% were good. He said the oxygen tank should have oxygen and not read zero. He said he was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675999 If continuation sheet Page 4 of 6 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 675999 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/09/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St James House of Baytown 5800 W Baker Rd Baytown, TX 77520 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some not sure if there was a risk to the resident, but there may not be efficient delivery flow of the oxygen if any was left in the tank. Interview on 10/9/2024 at 2:43 p.m. with the ADMIN, said he expected nurses to follow doctor's orders for oxygen administration. He said the DON and ADON were responsible for ensuring the oxygen tanks had adequate oxygen and were not empty. He said he monitored resident care by making rounds. The ADMIN said maintenance was responsible for checking the oxygen concentrator filters. He said he did not implement the process and it was prior to his hiring. He said he had not instructed maintenance to clean the oxygen concentrator filters. He said he was not aware of the risk and nursing would be better to ask what the risk was. Record review of facility policy Oxygen Administration not dated, reflected the following: Oxygen Administration Purpose - The purpose of this procedure is to provide guidelines for safe oxygen administration. 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration . 3. Assemble the equipment and supplies as needed General Guidelines 1. Oxygen therapy is administered by way of an oxygen mask, nasal cannula . b. The nasal cannula is a tub that is placed approximately one-half inch into the resident nose. It is held in place by an elastic band placed around the resident head . Steps in Procedure 10. Check the mask, tank, humidifying jar, etc., to be sure they are in good working order . 11. Observe the resident upon setup and periodically thereafter to be sure oxygen is being tolerated . Record review of online source (https://my.clevelandclinic.org/health/treatments/25181-oxygen-tank) Respiratory When is an Oxygen Tank Empty? dated 8/4/2023 reflected the following: An oxygen tank is considered empty when the pressure gauge reads near zero, indicating that the volume of oxygen inside has been nearly or completely used up. However, it's vital never to let the tank reach absolute zero, especially in medical settings, to ensure patient safety and to maintain tank integrity. Record review of manufacture manual for the oxygen concentrator (model A-1025DS - copyright dated 2023) revealed the following: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675999 If continuation sheet Page 5 of 6 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 675999 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/09/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St James House of Baytown 5800 W Baker Rd Baytown, TX 77520 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 0695 . Recommended cleaning interval- Air Filter - 7 days - cleaning method - mild dish soap and warm water. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675999 If continuation sheet Page 6 of 6