Inspection·April 2, 2025

F 0656 Level of Harm - Minimal harm or potential for actual harm Record review of CR #1's quarterly MDS dated [DATE] revealed he had a BIMS score of 13 (cognitively intact); CR #1 did not exhibit delusions or hallucinations; CR #1 did not exhibit behaviors related to rejection of care; CR #1 was wheelchair bound; CR #1 was dependent on staff for toileting hygiene, showers, dressing, and personal hygiene; CR #1 did not have a catheter; CR #1 was always incontinent of bowel and bladder; and CR #1 was diagnosed with neurogenic bladder (UTI - last 30 days was not checked). Residents Affected - Some Record review of CR #1's care plan, revised 03/24/2025 revealed no care area to address his recurrent UTI's. Record review of the facility's infection control tracking for January 2025, February 2025, and March 2025 revealed CR #1 was diagnosed with UTI on 01/20/2025 (Symptoms: AMS (a change in a person's mental function). Culture results: Pseumonas aeruginosa, staph spp, and staph aureus [types of bacteria]) and 03/07/2025. Record review of CR #1's UTI Panel collected on 01/14/2025 revealed it was positive for pseudomonas aeruginosa, staphylococcus spp, and staphylococcus aureus. Record review of CR #1's UTI Panel collected on 01/29/2025 revealed it was positive for staphylococcus aureus and staphylococcus spp. Record review of CR #1's UTI Panel collected on 03/13/2025 revealed it was rejected due to incorrect tube/specimen received. Missing specimen. Record review of CR #1's MAR for January 2025 revealed: * Cipro Oral Tablet. Give 1 tablet by mouth two times a day for UTI for 5 days. Start date: 01/20/2025. This medication was administered for five days until 01/25/2025. * Cephalexin Oral Tablet 500 MG. Give 1 tablet by mouth every 6 hours for infection for 5 days. Start date: 01/30/2025. Record review of CR #1's MAR for March 2025 revealed: * Cefdinir Oral Capsule 300 MG. Give 1 capsule by mouth two times a day for UTI for 6 days. Start date: 03/07/2025. This medication was administered six days. * Ciprofloxacin HCL oral tablet 250 MG. Give one tablet by mouth one time a day for UTI suppressive for 90 administrations. Start date: 03/22/2025. This medication was administered from 03/22/2025 until 03/24/2025 when CR #1 was sent out to the hospital. It was administered again 03/28/2025 and 03/29/2025 until he was sent out to the hospital. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676223 If continuation sheet Page 2 of 7 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 04/02/2025 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 0656 Record review of CR #1's nursing progress notes for March 2025 revealed: Level of Harm - Minimal harm or potential for actual harm * Residents Affected - Some On 03/06/2025, at 3:00 a.m., an unidentified nurse wrote, RN at hospital phoned report on CR #1 who will be returning around 4:00 p.m. Resident was also found to have a UTI and was given IV antibiotics at the hospital which will NOT be continued upon discharge. His treatment is complete . Resident has improved and will return this evening. * On 03/14/2025, at 10:30 a.m., an unidentified nurse wrote, Resident's family watching through tablet at bedside, phones facility to request resident be sent to ER. This nurse checked resident's vital signs and family was on tablet watching. Family then asked that resident be sent out. Resident has had a decline since returning from ER a week ago. Temperature - 100.3 (degrees Fahrenheit), blood pressure - 116/65, pulse - 85, respirations - 16, oxygen saturation - 90% . * On 03/21/2025, at 3:25 p.m., an unidentified nurse wrote, Resident arrived back to the facility in stable condition . He is very confused and is A&Ox2. He has a midline (a small, thin tube inserted into a vein in the upper arm, used for intravenous access) to his right upper arm and will be receiving IV Cefepime (injection used to treat bacterial infections) x 8 doses for the treatment of a UTI . He will also be on Cipro (antibiotic used to treat infections) 250 mg x 90 days for UTI suppression . His g-tube (a small, flexible tube surgically inserted through the stomach wall to provide access for feeding, hydration, or medication) is only to be used at this time for 250 cc's of water flushed 5 x's daily for increased hydration in order to prevent further UTI's . Record review of CR #1's physician progress notes dated, 03/24/2025 revealed, . Encounter Reason/Date: Nursing staff request for post hospitalization follow-up and evaluation and management of pyelonephritis (the medical term for kidney infection) . History of Present Illness: . The gastrostomy tube was required for nutritional support, contributing to addressing recurrent UTI's through consistent hydration . Symptoms are suspect of ongoing issues with UTI's, coupled with complications in managing nutrition and comfort related to gastrostomy tube . Assessment and Plan: . There is discomfort associated with the gastrostomy tube and persistent concerns about nutrition and hydration adequacy, crucial for managing and preventing recurrent UTI's . Record review of CR #1's physician's orders for April 2025 revealed: * Perform bladder scan Q shift PRN urinating difficulties/retention every 8 hours as needed for urinary retention. Observation and interview with CR #1 at an acute care hospital on [DATE], at 8:40 a.m. revealed he was alert and oriented. He was observed drinking coffee from a Styrofoam cup. He had a g-tube. He said he lived at the nursing facility for almost ten years. He said the staff always made sure he was clean and dry. He said he had to tell staff when he needed incontinent care. He said the staff came quickly when he told them he needed to be changed. He said he got a lot of UTI's, and they just kept (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676223 If continuation sheet Page 3 of 7 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 04/02/2025 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 0656 on coming. Level of Harm - Minimal harm or potential for actual harm Resident #2 Residents Affected - Some Record review of Resident #2's face sheet dated 04/01/2025 revealed she was an [AGE] year-old female who was admitted to the facility on [DATE]. She was diagnosed with UTI, psychotic disturbance (a mental health condition characterized by a loss of touch with reality, leading to abnormal thoughts, perceptions, and behaviors), mood disturbance (a group of psychiatric conditions that can cause intense and persistent changes in mood, energy, and behavior), anxiety (a mental health condition characterized by excessive worry, fear, and nervousness), chronic atrial fibrillation (a heart rhythm disorder characterized by the upper chambers of the heart beating irregularly and rapidly for more than 12 months), venous insufficiency (improper functioning of the vein valves in the leg, causing swelling and skin changes), and atherosclerotic heart disease (damage or disease in the heart's major blood vessels). Record review of Resident #2's quarterly MDS dated [DATE] revealed she had a BIMS score of 11 (moderate cognitive impairment); Resident #2 did not exhibit behaviors related to hallucinations, delusions, or rejection of care; Resident #1 was wheelchair bound; Resident #2 was dependent on staff for toileting hygiene, showers, dressing, and personal hygiene; Resident #2 did not have a catheter; Resident #2 was always incontinent of bowel and bladder; and Resident #2 was diagnosed with UTI within 30 days of the assessment. Record review of Resident #2's care plan revised on 02/05/2025 revealed no care areas to address her reoccurring UTI's. Record review of the facility's infection control tracking for January 2025, February 2025, and March 2025 revealed Resident #2 was diagnosed with UTI on 01/30/2025 (Symptoms: altered mental status. Culture Results: e. faecalis, e. coli, staph. spp [types of bacteria]) and 03/07/2025 (UTI Panel results included in report: gram-positive staphylococcus spp). Record review of Resident #2's UTI Panel collected on 01/30/2025 revealed she was positive for enterococcus faecalis, escheria coli, and staphylococcus spp. Record review of Resident #2's MAR for January 2025 revealed: * Cipro Oral Tablet 500 MG. Give 1 tablet by mouth two times a day related to urinary tract infection for 7 days. Start date: 01/31/2025. Record review of Resident #2's MAR for March 2025 revealed: % Cipro Oral Tablet 500 MG. Give 1 tablet by mouth every 12 hours for UTI for 7 days. Start day: 03/09/2025. This medication was administered 03/09/2025 and 03/10/2025 until she was transferred to an acute care hospital on [DATE]. Record review of Resident #2's nursing progress notes revealed: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676223 If continuation sheet Page 4 of 7 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 04/02/2025 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 0656 * Level of Harm - Minimal harm or potential for actual harm On 03/14/2025, at 7:32 p.m., an unidentified nurse wrote, Resident returned at 6:50 p.m. via ambulance with two attendants. Resident seems confused and says she sees dust everywhere in the air . Diagnosed with septic shock with E. coli UTI . Residents Affected - Some Observation and interview with Resident #2 on 04/01/2025 at 11:40 a.m. revealed she was alert but answered some questions inappropriately. She said staff sometimes missed cleaning her (incontinent care), but it was up to her to make sure she got clean. She said the staff always came timely when she let them know she needed to be cleaned. She said she had a UTI a couple of weeks ago and she thought she possibly had another one. She could not say why she thought she had another UTI. She said she did not get a lot of UTI's and the one she had a few weeks ago was the first one. In a telephone interview with LVN A on 04/01/2025, at 11:18 a.m., she stated she had only worked at the facility for three weeks, but other staff told her CR #1 got frequent UTI's. She said CR #1's family member wanted him to have a g-tube for hydration related to frequent UTI's. She said CR #1 did not drink a lot of fluids and drank coffee instead of water. She said for residents who got frequent UTI's, they monitored urine output and made sure they got plenty of fluids. She said the CNAs were very good about providing incontinent care and that was another aspect of keeping CR #1 from getting UTI's. In an interview with LVN B on 04/01/2025, at 12:10 p.m., she stated she worked at the facility eight years, and she had been taking care of CR #1 for a long time. She said CR #1 had a stroke which caused him to have a neurogenic bladder and resulted in frequent UTI's. She stated nurses had to make sure CR #1 did not hold urine and got enough water to drink. She stated CR #1 got a feeding tube about two weeks ago for hydration because he kept going to the hospital for UTI's. She said CR #1 had a chronic problem with UTI's. She said they encouraged fluids and ensured proper peri-care for residents who got frequent UTI's. She said she checked CR #1's incontinent briefs frequently and made sure he received incontinent care as needed. She stated if any resident exhibited symptoms of a UTI, including dysuria (painful urination), pain, fever, and AMS, they would follow infection protocol, monitor, and call the doctor. In an interview with the DON on 04/01/2025, at 12:27 p.m., she stated she was familiar with CR #1 because he lived in the facility a long time. She said CR #1 was not good with drinking water and if CR #1's name was on the infection control tracking multiple times, it was for a new infection with each entry. She said UTI infections usually resolved completely after an antibiotic regimen. She stated she had not looked at CR #1's care plan, so she did not know what was listed related to his frequent UTI's. She stated there should have been care areas on CR #1's care plan related to frequent UTI's. She said if there were no care areas for UTI on CR #1's care plan, they could have been resolved (removed) on the care plan after he was treated. In a follow-up interview with the DON on 04/01/2025, at 2:10 p.m., she stated she reviewed CR #1's care plan and she did not see any mention of his recurrent UTI's. She said it may not be on CR #1's care plan because he had been in and out of the hospital so much recently. An attempt was made to contact CR #1's NP by phone on 04/02/2025, at 11:40 a.m. A voicemail message was left but the call was not returned. In a telephone interview with Resident #2's NP on 04/02/2025, at 11:42 a.m., she stated she treated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676223 If continuation sheet Page 5 of 7 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 04/02/2025 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Resident #2 for more than three years and she (Resident #2) got recurrent UTI's at least 1-2 times per year. She said Resident #2 was recently sent out to the hospital and was diagnosed with sepsis from a UTI. She said Resident #2 started antibiotics for the UTI two days before she went to the hospital. She said she would expect the facility to address interventions on Resident #2's care plan and implement the interventions regularly. She said she would expect all facility staff to be ware of the interventions on Resident #2's care plan. She said not providing incontinent care or encouraging fluids could contribute to UTI. In an interview with the DON on 04/02/2025, at 12:17 p.m., she stated the MDS nurse would be responsible for updating residents' care plans. She stated the purpose of a care plan was the same as the purpose for physician's orders, to give orders on how to take care of the patients. She said the orders told staff what to do and so did the care plan. She said the orders and the care plan were one in the same. She said a care plan gave goals and interventions and was more of a long-term plan. She said UTI's should be on care plans to inform staff of interventions. She said when residents arrived from the hospital, the facility received clinical records and the nurses received report on resident needs every morning during the staff morning meeting, so the MDS nurse knew everything that was going on in the building. She said a benefit of having care areas listed on the care plan was that the care plans were linked to the [NAME]'s (a quick-reference system used by nurses to summarize key patient information, including medications, treatments, and care plans, for easy access and efficient patient care). She said the [NAME] contained resident orders, tasks, and care plans that all staff could see. She said the nurses would review a resident's orders before they saw the care plan, but the CNAs would see the care plans. She stated Resident #2 also experienced recurrent UTI's, but it was not listed on her care plan. She stated she did not know that there would be a negative effect for not listing recurrent UTI's on a care plan because they followed physician's orders. In an interview with MDS RN C and MDS LVN D on 04/02/2025, at 12:30 p.m., MDS LVN D said she was new to the building. MDS RN C said she was responsible for updating residents' care plans. MDS RN C said she received information about residents from morning meetings, the charge nurses, and from hospital discharge information. She stated she had not been updating resident care plans related to UTI's but that should be something she did, especially if they were on preventative medication. MDS LVN D said they should always update residents' care plans for recurrent UTI's. MDS RN C said they updated care plans to keep information current and up to date. MDS LVN D said they also updated residents' care plans so they could keep up with the level of function and level of care. MDS LVN D said the negative effect of not updating the care plan would be that the nurses would not know the resident had recurrent UTI's, they would not know the resident's history, and new staff would not know how to care for the resident. MDS RN C said updating the care plans also updated the [NAME], which all staff had access to. In an interview with LVN A on 04/02/2025, at 12:45 p.m., she stated nurses reviewed each resident's physician's orders and their care plan. She said if a resident had recurrent UTI's, the physician's orders detailed what the doctors wanted them to do. She said the nurses would also look at the care plan to see what interventions were in place for them and the CNAs. She said it was important for staff to look at both. She said she thought CR #1 did have interventions in place on his care plan related to UTI's. She said they pushed fluids, monitored for symptoms, and provided timely incontinent care for all of their residents. She said negative effects of not updating residents' care plans would be that the nurses and CNAs would not know how to treat the resident for a certain condition. In an interview with CNA E on 04/02/2025, at 1:15 p.m. she stated CNAs had access to resident [NAME]'s, which showed them resident care plans, but not physician's orders. She said they looked at care (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676223 If continuation sheet Page 6 of 7 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 04/02/2025 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 0656 plans to see what condition residents had and their specific interventions. Level of Harm - Minimal harm or potential for actual harm Record review of the facility's policy titled, Urinary Tract Infections/Bacteriuria - Clinical Protocol revised April 2018 revealed, Assessment and Recognition. 1. The physician and staff will identify individuals with a history of symptomatic urinary tract infections, and those who have risk factors for UTI's. 2. The staff and practitioner will identify individuals with possible signs and symptoms of a UTI . b. Nurses should observe, document, and report signs and symptoms in detail and avoid premature diagnostic conclusions . Monitoring . 2. When a resident has a persistent or recurrent urinary tract infection after treatment with antibiotics, the physician will review the situation carefully with the nursing staff and consider other additional issues before prescribing additional courses of antibiotics . Residents Affected - Some Record review of the facility's policy titled, Care Planning - Interdisciplinary Team revised September 2013 revealed, Policy Statement. Our facility's Care Planning/Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676223 If continuation sheet Page 7 of 7