Health inspection·April 20, 2023

F 0698 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few and they will only wait 5 minutes. She stated she needed help to get her pants. She stated she had not had breakfast yet and they were getting a sack lunch ready to take with her to dialysis. In an interview on 04/19/2023 at 3:40PM, LVN C stated that Resident #243 was late for dialysis because of the night shift. She stated she was not in the building at the time, but night shift was short staffed. She stated the night shift was responsible to get her up and ready for dialysis. She said this was the second time they did not get her up and she missed the morning pickup. Observation and interview on 04/20/2023 at 7:45AM, Resident #243 was sitting up in a wheelchair watching tv in her room. Resident #243 stated she got back from dialysis late last night. She stated she did not like the late time. She stated she preferred the early time because she returned around 10:00AM and will have the rest of the day to do what she liked. She stated she did not like it when they did not wake her up early yesterday and this had happened twice already. In an interview on 04/20/2023 at 1:27PM, the Administrator stated he expected nursing staff to follow the orders as written by the physician and not deviate from the orders. The Administrator stated if changes needed to be made, the physician should be contacted first and then get an order for the change. In an interview on 04/19/2023 at 4:03PM, the DON stated Resident #243 wanted to use her bus company for pick up. The DON stated the facility had offered to get a different transportation company and a different dialysis time. The DON stated the resident wanted to keep using her regular transportation and did not want to lose her chair time. The DON stated the bus agreed to pick her up, but she had to be waiting on the street and the bus will not drive onto the property. The DON stated the facility could not leave her on the street to wait. The DON stated the night shift nursing staff were responsible for getting Resident #243 up and ready in the morning. The DON stated she did not know what happened on night shift and stated she would investigate and get back to the surveyor. The DON did not get back to the surveyor with an answer. In an interview on 4/20/2023 at 3:55PM, the Administrator stated when Resident #243 first arrived at the facility the resident missed the bus for dialysis, they did not pick her up because she was not on the street waiting. The Administrator stated the bus will not drive up the driveway. He stated that they could not leave her on the street by herself, so the facility driver drove her to dialysis, and she did not miss her chair time. The Administrator stated the second time she missed the transportation bus, she needed to be up, and no one was available to sit outside with her. The Administrator stated nothing could be done because the aides were changing and getting other people up. Record review of Resident #243's progress note dated 04/19/2023 at 9:24AM an written by LVN C, read: New chair time for today's dialysis appointment is 3:30PM. Transportation has been arranged and pick up time will be 8:00PM. Record review of the facility policy titled, Facility Policy on Residents Receiving Dialysis Services, reviewed by the Administrator on 1/2023, read in part: The facility must ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences . Record review of the facility's admission Packet revealed the policy titled, Your Rights and Protections as a Nursing Home Resident .As a nursing home resident, you have certain rights and protections under federal and state law that help ensure you get the care and services you need. You have the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676223 If continuation sheet Page 2 of 13 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 676223 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bayou Pines Care Center 4905 Fleming Street LA Marque, TX 77568 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 0698 right to be informed, make your own decisions . 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: 676223 If continuation sheet Page 3 of 13 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 676223 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bayou Pines Care Center 4905 Fleming Street LA Marque, TX 77568 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment for 3 of 3 days reviewed for sufficient nursing staff. The facility failed to have sufficient nursing staff according to the Facility's Daily Sufficient Staffing Ratio on 4/18/2023, 4/19/2023, and 4/20/23 to esnure residents psychological, physiological, sociological, and safety needs were met. This failure could effect residents and place them at risk and diminish their quality of life and quality of care. Findings included: Record review of the Facility's Nursing Sign-in Sheet, dated 4/18/2023 revealed the following: - Morning shift 7:00 a.m. - 7:00 p.m. was 6 CNAs, 0 RNAs, 3 CMAs, 1 RN, and 1 LVN with a census of 91 residents. The Daily Sufficient Staffing Ratio was noted as 1 RN, 4 LVNs, 3 CMAs, and 10 CNAs. - Night shift - 7:00p.m. to 7:00a.m. was 1 RMAs, 2 CNAs, 1 CMA, 2 LVNS, and 1 RN. The Daily Sufficient Staffing Ratio on night shift was noted as 1 RN, 2 LVNs, 3 CMAs, and 6 CNAs. Record review of the Facility's Nursing Sign-in Sheet, dated 4/19/2023 revealed the following: -Morning shift 7:00 a.m - 7:00 p.m. was 3 RMAs, 8 CNAs, 3 LVNs, and 1 RN with a census of 91. The Daily Sufficient Staffing Ratio was noted as 1 RN, 4 LVNs, 3 CMAs, and 10 CNAs. NIght shift 7:00p.m. to 7:00 a.m., revealed 1 RNA, 6 CNAs, 1 CMA, 2 LVNs, and 1 RN. The Daily Sufficient Staffing Ratio on night shift was noted as 1 RN, 2 LVNs, 3 CMAs, and 6 CNAs. Record review of the Facility's Nursing Sign-in Sheet, dated 4/20/2023 revealed the following: -Morning shift 7:00 a.m. - 7:00 p.m. was 1 RNAs, 4 CNAs, 2 CMAs, 1 RN, and 1 LVN with a census of 91. The Daily Sufficient Staffing for morning shift was noted as 1 RN, 4 LVNs, 3 CMAs, and 10 CNAs. Record review of Resident #46 Face Sheet revealed she was an [AGE] year old female who admitted to the facility on [DATE]. Her diagnosis history was parkinson's disease, acute respiratory failure, type II diabetes, and mellitus with hyper-glaucemia. Record review of the Comprehensive MDS, dated [DATE] for Resident #46 revealed she had a BIMS of 15 which indicated she was cognitively intact. Section G: Fuctional Status revealed she was total dependent with 2 staff assistance for transfers; she was extensive assistance with 2 staff assistance with toileting; and she was extensitive assistance with 1 staff assistance for dressing. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676223 If continuation sheet Page 4 of 13 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 676223 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bayou Pines Care Center 4905 Fleming Street LA Marque, TX 77568 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of Resident #13 Face Sheet revealed she was an [AGE] year old female who admitted to the facility on [DATE]. Her diagnosis history was malignant neoplasm of colon, obesity, artrial fibrillation, and hyperlipidemia. Record review of the Comprehensive MDS, dated [DATE] for Resdient #13 revealed she had a BIMS of 15 which indicated she was cognitively intact. Section G: Functional Status revealed she was total dependent with 2 staff assistance for transfers; she was extensive assitance with 2 staff assistance with toileting; and she was extensive assitance with 2 staff assistance for dressing. During observation and interview on 4/18/2023 at 10:48 a.m. with Resident #46 revealed her lying in bed watching television. She said she had a problem with the shortage of staff. She said when you need a nurse you must wait a long time for them to assist with help. She said she has waited several hours to be assisted with care. She said she had called for the nurse, and they would come to her room, but would say they have to come back later when they were done with their lunch. She said she had a bed sore, but staff had been keeping it clean. She said she does not like lying in urine and feces for a long period of time. During observation and interview on 4/18/2023 with Resident #13 at 10:55 a.m. revealed her sitting up in her bed with a bed side table next to her bed and there was a basket of items sitting on the table. She was using a breathing machine. She said she had two concerns. She said the second issue is when she urinated on herself, she had to wait too long to be changed. She said if the CNA is giving showers to other residents, they will not assist you. She said if the light is on, they would tell her that they would get with her as soon as they can. She said it normally takes them one to two hours to get back with her. She said it happens sometimes, but not all the time, but it happens enough. She said she has told staff about her concerns. She said there was not enough staff to assist with care. During an Interview on 4/19/2023 at 10:22a.m. with CNA C, said she checks on each resident every hour or hour in a half. She said if she was with a resident, the other resident will have to wait till she gets there. She said it does not take a long time for her to get there because it was not a far walk. She said if they were short in the morning, the resident might have to wait till after she was done with another resident. She said the night shift finishes their last round at 4:00a.m., so the resident might have to wait three hours till she arrives for her morning shift. She said it only takes four hours for a breakdown of skin. She said if they were not moved, changed, or repositioned, then a breakdown can happen. During an Interview on 4//19/2023 at 10:29a.m. with LVN B, said her and the staff checked on the residents for a minimum of every two hours. She said if a resident pressed a call light, she tries to answer it as quickly as possible. She said there has not had any residents complain about waiting a long time to be assisted with care. She said staff were good about assisting the residents in a timely manner. She said she has been at the facility since October 2022. During observation and Interview on 4/19/2023 at 2:11p.m., with CNA A, said she checks on the residents every hour in a half or two hours. She said she has not noticed a smell on 400 halls, but she does notice a smell on 200 halls. She said it smells like urine. She said the smell can come from not changing the residents and leaving things in the trash can. She said she has noticed the smell since she started working at the facility six months ago. She said the smell happens at night. She said when she comes into the facility in the mornings, she notices the smell. She said she has not had any residents come to her complaining about not being changed on time. She said she believes they were (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676223 If continuation sheet Page 5 of 13 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 676223 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bayou Pines Care Center 4905 Fleming Street LA Marque, TX 77568 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some short of staff. She said when she started working at the facility there were three aides per hall and now there were two. She said they just got three aides on her hall last week. She said she felt they were short of staff because a lot of staff put their two weeks' notice in last week. She said when they had only two aides, they teamwork the hall. She said on the other halls there wasn't a lot of teamwork. During observation and interview on 4/19/23 at 7:00p.m. with CNA D, said she has been working for this facility for approximately seven months. She said she has noticed a shortage at night on both matrixes. She said she worked the back of 100 halls, but sometimes she worked all the halls where the need is required. She said she noticed a urine smell. She said room [ROOM NUMBER]B was always smelling like urine. She said room [ROOM NUMBER]B usually smelled like urine. During an Interview on 4/20/2023 at 10:49a.m. with RN B, said she has worked at the facility for two years now. She said she was the RN for 100 halls. She said she provide creams, medication, and breathing treatment to the residents. She said she answer call lights and change and clean the residents. She said they can always use an extra person, but she does well with the CNA's she works with on her hall. She said you can never have enough staff. Record Review of the facility's policy titled Staffing revised on 10/2017 read in part . Our facility provides sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with resident care plans and the facility assessment. Licensed nurses and certified nursing assistants are available 24 hours a day to provide direct resident care services. Staffing numbers and the skill requirements of direct care staff are determined by the needs of the residents based on each resident's plan of care. Other support services (e.g., dietary, activities/recreational, social, therapy, environment, etc.) are also staffed to ensure the resident needs are met. Direct care staffing information per day (including agency and contract staff) is submitted to the CMS payroll-based journal system on the schedule specified by CMS, but no less than once a quater. Inquiries or concerns relative to our facility's staffing should be directed to the Administrator or his/her designee . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676223 If continuation sheet Page 6 of 13 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 676223 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bayou Pines Care Center 4905 Fleming Street LA Marque, TX 77568 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide pharmaceutical services, which included procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident for 2 of 8 residents (Residents #65 and #243) reviewed for pharmacy services. - The facility failed to administer Resident #65's Lidocaine Patch as ordered by leaving it on for 24 hours. -The facility failed to administer Resident #243's Sevelamer (a phosphate binder) as ordered by not administering with meals. These failures could place residents at risk of not receiving the therapeutic benefit of medications and/or adverse reactions to medications. Findings included: Resident #65 Record review of Resident #65's admission record dated 04/20/2023, revealed an [AGE] year-old female admitted to the facility on [DATE] and initially admitted on [DATE]. Her diagnoses included low blood sodium levels, anemia, acute kidney failure, diabetes, HTN (elevated blood pressure), presence of cardiac pacemaker, fatigue, muscle weakness, heart failure, headache, muscle paralysis affecting the right side of body following a stroke, malnutrition, dementia, depression, and chronic pain. Record review of Resident #65's quarterly MDS dated [DATE] revealed a BIMS score of 14 out of 15, indicating she was cognitively intact. She required limited assistance with most ADLs. She was always continent of bowel and bladder. She had no pain. Record review of Resident #65's Order Summary Report downloaded from the facility's electronic health records on 04/19/2023 at 3:23PM revealed an order for Aspercreme Lidocaine Patch 4% (Lidocaine). Apply to left shoulder topically one time a day for pain/sore joints and remove per schedule. The order date was 10/23/2022. Record review of Resident #65's April MAR, printed on 04/20/2023 at 10:23AM, revealed MAR reflected he physician orders to apply the Aspercreme Lidocaine Patch 4% to the left shoulder daily at 9:00AM and remove daily at 9:00PM. The removal of the Lidocaine Patch 4% at 9:00PM daily, was documented by check marks as completed. The removal on 04/18/2023 at 9:00PM was not observed. Record review of Resident #65's care plan revealed, Resident #65 had chronic pain, sore joints, Polyneuropathy (damage or disease affecting peripheral nerves). The resident was on Tylenol, Tylenol #3, Gabapentin, and Lidocaine patch. Date revised was 03/12/2023. Interventions included administer medication as per orders. Date revised was 11/01/2022. In an observation during medication pass on 04/19/2023 at 8:15AM, MA B removed the old patch on Resident #65's right shoulder. MA B asked the resident which shoulder she would like the new patch on. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676223 If continuation sheet Page 7 of 13 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 676223 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bayou Pines Care Center 4905 Fleming Street LA Marque, TX 77568 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident #65 stated she would like it on the right shoulder. MA B applied the Lidocaine 4% patch on Resident #65's right shoulder. In an observation and interview on 04/19/2023 at 11:35AM, MA B stated the night shift put on the Lidocaine patch for Resident #65. MA B checked Resident #65's electronic record and stated the night shift was supposed to remove it and that the patch she removed in the morning must have been the one she put on yesterday (04/18/2023). MA B stated she will notify the nurse. In an interview on 04/19/2023 at 2:00PM, Resident #65 stated they put the Lidocaine patch mainly on the left shoulder, but it was the right shoulder that has pain. In an interview on 04/19/2023 at 3:00PM, the DON stated the risk of leaving the Lidocaine patch on longer than ordered would be redness to the skin and maybe swelling. She stated the med aide should notify the nurse that the patch was left on. The DON stated she would write a medication error report and notify the MD. The DON stated she would do education with MA B. In an interview on 04/20/2023 at 10:10AM, MA B did not know why she put the Lidocaine patch on Resident #65's right shoulder because she would have to look at the order again. MA B stated leaving the patch over the same area could cause damage to the skin. MA B stated she put the patch on the same area because she got nervous. In an interview on 04/20/2023 at 9:00AM, the DON stated she expected the medication aid to follow the medication pass policy and follow the 6 rights of medication administration. The DON stated it was the DON and the ADON who was responsible to ensure nursing staff were educated on medication pass. The DON stated the pharmacy consultant helped with medication pass checklists. Resident #243 Record review of Resident #243's admission record dated 04/19/2023, revealed a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included heart attack, narrowed arteries in the heart, blood clot in the lungs, heart failure, diabetes, dependent on renal dialysis, pulmonary embolism (blood clot in the lungs), depression, anemia, hypothyroidism (underactive thyroid gland), hyperlipidemia (too many lipids(fats) in the blood), elevated blood pressure, shortness of breath and presence of heart valve replacement. Record review of Resident #243's admission MDS dated [DATE] revealed she made herself understood and had the ability to understand others. Her BIMS score was 10 out of 15, indicating she had mild cognitive impairment. She had no evidence of inattention, disorganized thinking or altered level of consciousness. She required extensive one-to-two-person assistance with most ADLs. She required supervision of one person for eating. She was occasionally incontinent of urine and frequently incontinent of bowel. Section I, Active Diagnoses revealed she had debility due to cardiorespiratory conditions. Section O, special treatments, procedures, and programs revealed she had dialysis and received oxygen therapy in the last 14 days. Record review of Resident #243's Order Summary Report dated 04/19/2023 at 4:12PM, revealed an active order for Sevelamer Carbonate 800mg tablet (medication to lower high blood phosphorus levels d/t severe kidney disease), give 2 tablets by mouth three times a day related to dependence on renal dialysis. Give two 800mg tabs equal to 160mg dose. Time changed for dialysis. Order date 04/10/2023. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676223 If continuation sheet Page 8 of 13 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 676223 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bayou Pines Care Center 4905 Fleming Street LA Marque, TX 77568 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 0755 Level of Harm - Minimal harm or potential for actual harm Record review Resident #243's hospital discharge medications list dated 04/05/2023 at 1:54PM, revealed an order for Sevelamer Carbonate (Renvela), 1600mg, oral, three times a day with meals. Record review of Resident #243's Baseline Care Plan, completed on 04/06/2023 revealed: section G. Physician Orders 1. See current MAR and TAR orders. Residents Affected - Few Record review of Resident #243's April 2023 MAR, revealed Resident #243 received Sevelamer 800mg give 2 tablets by mouth three times a day, at 12:00PM, 4:00PM and 8:00PM, starting 04/11/2023. Further review of the MAR order did not include Sevelamer to be given with meals. Record review of Resident #243's undated care plan revealed Resident #243 was on dialysis r/t renal failure. The resident was on Sevelamer. Further review of the care plan revealed interventions did not include to administer Sevelamer with meals. In an observation and interview on 04/19/2023 at 8:30AM, Resident #243 was in her room and had just completed breakfast. She stated that she did not receive the medication Sevelamer to take with breakfast. In an interview on 04/20/2023 at 9:40AM, MA C, stated Resident #243, only received Midodrine (medication to increase blood pressure) in the morning and was not due to get any more medications until noon. In an interview on 04/20/2023 at 9:45AM, LVN C, stated she had never seen Resident #243 take any medications with meals, but was unsure because the medication aides were the ones who gave oral medications. LVN C stated she understood the medication Sevelamer (Renvela) was to be taken with meals but could not recall what the medication was for. LVN C stated she would have to look it up. In an interview on 04/20/2023 at 10:00AM, the ADON stated he was responsible for entering the medications for new admissions. He stated he was not too familiar with the medication Sevelamer. He stated when he changed the Sevelamer order to accommodate Resident #243's dialysis times, the instructions must have fallen off. He stated the instructions for Sevelamer to be given with meals was on the original order. The ADON showed the surveyor the original order from the computer. He stated this was the original order even though it was dated 04/20/2023. The ADON stated he was not familiar with the drug to know what the risks to the resident would be, if the Sevelamer were not given with meals. In an interview on 04/20/2023 at 12:15PM, the ADON stated he got the Sevelamer order for Resident #243 from the hospital discharge summary. He stated he then reviewed the orders with the NP. In a telephone interview on 04/20/2023 at 12:49PM, the NP stated Resident #243 was supposed to get 2 pills of Sevelamer by mouth with meals and the reason was to bind with the phosphorous in the food. The NP stated the Sevelamer would not be as effective if the resident did not get the binders and the phosphorous would be higher from not getting the binding power of the medication. In an interview on 04/20/2023 at 1:27PM, the Administrator stated he expected nursing staff to follow the orders as written by the physician and not deviate from the orders. The Administrator stated if changes needed to be made, the physician should be contacted first and then get an order for the change. Record review of the facility's policy and procedure for Administration Procedures for all (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676223 If continuation sheet Page 9 of 13 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 676223 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bayou Pines Care Center 4905 Fleming Street LA Marque, TX 77568 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 0755 Level of Harm - Minimal harm or potential for actual harm Medications, Pharmacy Services for Nursing Facilities, 2006 American Society of Consultant Pharmacies and MED-PASS, Inc. (Revised January 2018) and effective date: February 2019 read in part: Policy, to administer medications in a safe and effective manner. Procedures: .C. Review 5 Rights (3) times: 1) .a. Check MAR/TAR for order .c. If unfamiliar with the medication, consult a drug reference, manufacturer package insert, or pharmacist for more information . Residents Affected - Few Record review of the facility's policy and procedure for Transdermal Drug Delivery system (patch) Application, Pharmacy Services for Nursing Facilities, 2006 American Society of Consultant Pharmacies and MED-PASS, Inc. (Revised January 2018) and effective date: February 2019 read in part: Purpose: To administer medication through the skin through proper placement of the patch and care of the application site(s) .Equipment Required .E. Medication Administration Record (MAR) .Procedures: .B. Identify the location on the body for patch placement. Always rotate application sites to prevent irritation . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676223 If continuation sheet Page 10 of 13 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 676223 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bayou Pines Care Center 4905 Fleming Street LA Marque, TX 77568 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. The facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. This failure could diminish resident's quality of life. Findings included: Record review of Bayou Pines Care Center Sanitation Assurance Procedures and Process reveals, disinfecting contact surfaces, detail bathroom, tile faucets chrome using tub and tile, order removal using Enzap and [NAME]. Spray Enzap where an odor or bacterial will grow. Do not wipe. Spray [NAME] on AC duet and privacy curtains. Empty trash containers, and detail clean and remove heavy soils. During an observation on 4/18/2023 at 9:50a.m., staff noticed an odor that reeked of urine. The surveyor went inside the resident's room and noticed that some of the rooms and hallways smelled like urine. room [ROOM NUMBER]B where Resident #1 reside, smelled like urine and feces. The surveyor reported the smell to LVN A and LVN said the resident had just been changed. LVN sprayed disinfected spray into the room and hallways. Surveyor observed that the smell of urine was consistent throughout the building even at till the end of the shift. During an Interview on 4/19/2023 at 11:08a.m. with CNA B, said normally the smell comes from night shift not changing the residents like they are supposed to. She said she knows the smell comes from night shift because she arrives to work at 6:45a.m. and she does a room check. She said she will ask night shift to change the residents before they leave, and they will not do it. She said the smell can come from the diaper in a trash can, inside of the room. She said they are supposed to take the diaper and trash out of the rooms, but they will sometimes forget to take the trash out. She said night shift comes in is 7:00p.m. and leaves at 7:00a.m. She said the night shift supervisor would tell her to do rounds with the person on her hall, but she cannot find that person sometimes and she would have to do it her by herself. She said it will slow her down from getting the residents up in the morning. She said she works from 7:00a.m. to 7:00p.m. She said she wipes beds down. She said she cannot use pine sol or Lysol because a lot of people do not like the smell, so she uses a disinfect spray. She said sometimes they are short staffed. She said sometimes they will pull staff from another hall to help assist with care. Interview on 4/19/2023 at 11:17a.m. with the DON, said the policy is that they are to change the residents as needed or every three to four hours. She said the smell can come from the garbage, or from the linen not taken out of the shower room. She said there are residents with a colostomy in the building as well. She said they put the diapers in the trash, and they are supposed to bring everything out. She said she hasn't had any residents complain about not being changed in a timely manner, and they haven't complained about the smell. She said a resident can have a skin break down if they are sitting in their urine for a long period of time. During observation and Interview on 4/19/2023 at 2:11p.m. with CNA A, said she checks on the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676223 If continuation sheet Page 11 of 13 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 676223 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bayou Pines Care Center 4905 Fleming Street LA Marque, TX 77568 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some residents every hour in a half or two hours. She said she has not noticed a smell on 400 halls, but she does notice a smell on 200 halls. She said it smells like urine. She said the smell can come from not changing the residents and leaving things in the trash can. She said she has noticed the smell since she started working at the facility six months ago. She said the smell happens at night. She said when she comes into the facility in the mornings, she notices the smell. She said she has not had any residents come to her complaining about not being changed on time. She said she believes they are short of staff. She said when she started working at the facility there were three aides per hall and now there are two. She said they just got three aides on her hall last week. She said she feels they are short of staff because a lot of staff put their two weeks' notice in last week. She said when they have only two aides, they teamwork the hall. She said on the other halls there isn't a lot of teamwork. During an interview on 4/19/23 at 5:59pm CNA E, said she has been working at the facility since June, when [NAME] Park was transferred. She said she like working at this facility and she enjoys the residents. She said she work the 200 hallways. She reported she usually float in between 200, 300 and 400 hallways. She said on her matrix they are showing full staff. She said if another worker does not show up for their shift that is when it is required for the staff to float to other hallways, to provide the coverage. She said it just recently happened where coverage is needed in other areas. She said she has noticed a urine smell at the facility. She said there are certain rooms that carry a urine smell, like room [ROOM NUMBER]A and 209B. She said in room [ROOM NUMBER]B, Resident #81 tends to throw urine briefs in the trash can. She said they replace the trash can with a bedside toilet. She said the bedside toilet was placed on the side of his bed to keep him from urinating on the floor. She said room [ROOM NUMBER]B carpet was cleaned. She said the urine is not as strong, but they do not know if he is peeing somewhere else. She said in room [ROOM NUMBER]A, Resident #38 urine has a strong smell. She reported that Resident #38 likes to hide his diaper in the trash can and hide the diaper under the trash bags. She said she has washed the trash can and placed a lot of trash bags in the trash can to keep the resident from emptying the trash can. She said now the resident places his diaper in a bag. She said mainly you smell the 400 hallways after the CNAs have completed their rounds. She said rounds are completed every two hours. During an interview on 4/19/23 AT 6:25p.m. with interview with CMA P, said she has been working for this facility for a year. She reported its cleaner than any facility she has ever worked at. She reported she work number 100 hallways. She reported room [ROOM NUMBER]B does not want anyone to know she cannot hold her urine. She reported this resident like to put her briefs in bags to the side of her bed. She reported the resident does not like to shower especially in her bottom area. She reported they must call her daughter to assist in getting the resident to take a shower. She reported she hasn't not noticed any other displeasing odors in other hallways. She reported the call lights are answered during meals are when medication is being passed. She reported she have not witnessed any employees turning off the call light without answering or taking care of what the resident is requesting at that time. She reported as the medication is being passed and the resident briefs must be changed, she informs a CNA or a nurse. She said she has not worked at a facility where the residents did not complain about the food. She reported sometimes second shift may have a shortage because the staff is calling out. She reported she normally work only 100 hallways. During observation and interview on 4/19/23 at 7:00p.m. with CNA D, said she he has been working for this facility for approximately seven months. She said she changed shifts because she is going for her BSN in nursing. She said she enjoys working at night. She said she has noticed a shortage at night on both matrixes. She said she work the back of 100 halls, but sometimes she works all the halls where the need is required. She said she noticed a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676223 If continuation sheet Page 12 of 13 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 676223 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bayou Pines Care Center 4905 Fleming Street LA Marque, TX 77568 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some urine smell. She said room [ROOM NUMBER]B was always smelling like urine. She said room [ROOM NUMBER]B usually smell like urine. She said the resident does not like to get help and refuses care. She said the resident get their snacks around 8:00p.m. and sometimes snack is provided later if the nurse approved that Resident #58 can have more. She said the nurse would give them the names of the resident who should be up and ready for their transportation. She said she has not had a resident refuse to wake up and prepare for their appointment. During an interview on 4/20/2023 at 10:45a.m. with Housekeeping A said she has been working at the facility for a year. She said she is responsible for cleaning the resident's rooms. She said she cleans their tables, sweep, and mop the floors, vacuum and clean their bathrooms. She said she feel like there is enough staff to assist her with the job. Record Review of the facility's policy titled Physical Environment revised on 12/2022 read in part . The facility recognizes the individuality and autonomy of each resident. The facility provides a safe, clean, comfortable, and homelike environment and provides safety in treatment and support for a daily living in an environment that maximizes resident independence. Housekeeping and maintenance services necessary to maintain a sanitary, orderly and comfortable environment . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676223 If continuation sheet Page 13 of 13