Health inspection·September 16, 2025

F 0583 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete to see her screen unless they were on the floor. She said the harm in leaving the screen up would be someone viewing another's personal information and residents should not be able to see the information either. She stated that sometimes she noticed nurses at the nurse's station would leave their computer screen unlocked, but they didn't realize that there was a screen they could click that would hide the information if they needed to walk away. The policy was to keep personal information hidden while you were not at your laptop or computer at the nurse's station. Event ID: Facility ID: 676223 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 676223 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/16/2025 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 0755 Level of Harm - Immediate jeopardy to resident health or safety 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 (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of 1 (Resident #1) of 5 residents reviewed for pharmaceutical services. The facility failed to ensure Resident #1 received her Carbamazepine as prescribed due to her medication being placed in a bin for destruction instead of administered resulting in Resident #1 experiencing a seizure. The facility failed to ensure allegations of Resident #1's medications not being administered and being set aside or destruction were thoroughly investigated resulting in Resident #1's medication being destroyed instead of administered. The facility failed to ensure there was a system in place to document and track all medications being destroyed, including Resident #1 Carbamazepine. An IJ was identified on 9/15/25 at 1:48 pm. The IJ template was provided to the facility on 9/15/25 at 2:12 pm. While the IJ was removed on 9/16/25, the facility remained out of compliance at a scope of isolated and severity level of no actual harm with potential for more than minimal harm that is not IJ, due to the need for the facility to evaluate the effectiveness of the corrective action. This failure could place residents at risk for adverse side effects, illness, and possible hospitalization. Findings included: Record review of Resident#1's face sheet revealed a [AGE] year-old woman who was admitted to the skilled nursing facility on [DATE]. Her admitting diagnoses were cerebral palsy (brain damage that effects movement and posture), profound intellectual disabilities, and epilepsy (chronic neurological condition causing seizures). Record review of Resident #1's care plan disclosed that she utilized a feeding tube for meals and all medication was to be administered by way of g-tube (gastrostomy tube - a feeding tube that enters the stomach through a small opening in the abdomen to deliver nutrition, fluids, and medication). The care plan revealed that seizure medications should be administered as ordered. Record review of Resident #1's orders dated 11/07/2023 revealed she was to receive 1 Carbamazepine 200MG tablet (treated for epilepsy) via g-tube every 12 hours. Record review of Resident #1's TAR for August 2025 revealed that on 8/12/25 Carbamazepine 200 MG was marked given on the 7 pm- 7 am shift by LVN D and was marked given during the 7 pm- 7 am shift on 8/18/25 by LVN E. Record review of a progress note dated 8/9/25 at 7:11 am by LVN C revealed, Resident, non-verbal at baseline, history of seizures, observed to have two brief seizure episodes involving the upper extremities, each lasting approximately 10-15 seconds, during this shift. Resident returned to baseline alertness afterward, vitals stable. Attempted to Notify Provider at 7:10 am of observations and concern regarding possible sub-therapeutic seizure medication effect. Communicated with day shift (RN B) to Requested order for seizure medication therapeutic level lab draw for further evaluation will provider calls back. Record review of Resident #1's MDS (minimum data set) revealed that her baseline was at 0 and was severely impaired. There were functional limitations in her upper and lower extremities, she required the use of a wheelchair, and was dependent on staff for needs. Resident #1 also utilized a feeding tube and received anticonvulsant medication. In an interview on 8/21/25 at 11:52 am, RN A explained that Resident #1 had cerebral palsy, utilized a g-tube, was non-verbal, and was not alert and oriented. She explained that in the past, she would find medication packets of Carbamazepine 200 MG dated for the previous days that she was not on shift in the medication cart. She said she did not know why they were there, but she would take them out of the medication cart and place them in the cabinet inside of the locked medication room. She informed the DON in July 2025 regarding the found medication packets, and the DON responded, I'll deal with it. She stated that she had never seen Resident #1 have a seizure, but there was an (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676223 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 676223 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/16/2025 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 0755 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few issue with communication between the night shift and day shift at the facility. She stated the last time she found a medication packet was a week or 2 prior to 8/21/25. In an observation and interview on 8/21/25 at 12:28 pm, the DON showed the investigator a bucket of medication inside of a storage closet inside of her office. In the bucket, two packets of medication were found for Resident #1 that contained Carbamazepine 200 MG dated for 08/12/25 at 9:00 pm and 08/18/25 at 9:00 pm. The DON stated that those medication packets came from the facility's medication room and she collected and stored them in her storage room inside her office until the monthly destruction date (8/25/25). The DON explained that the facility utilized a pharmacy service that delivered pre-packaged medications daily, which included medication packets for up to 2 days in advance. The DON stated that for example, if the delivery was made today on 8/21/25, it would include medications for 8/22/25 and 8/23/25 as well. Each of the medication packets indicated the date and time the medication should be administered to each resident based off their physician's order. She could not explain why there were extra bags of medication for Resident #1 and stated that sometimes the pharmacy made mistakes and perhaps they sent extra. The DON stated that she was responsible for making sure meds were given and reviewing the MAR if there was anything missed. In an interview on 8/21/25 at 1:17 pm, LVN C stated that she had noticed unopened medication packets of Carbamazepine 200 MG for Resident #1 on several occasions during the month of July 2025 and August 2025. She explained that after a few times of noticing the medication packets, she confronted RN B about the packets. RN B stated that she may have grabbed the incorrect dated packet and administered it. LVN C also informed the DON about the unopened medication packets sometime in July (exact date unknown) and she stated that she would handle it. LVN C explained that there should be several unopened medication packets for Resident #1 and she felt confident that she was not receiving medications because she had an increase in seizures, which she documented on 8/9/25. She stated that some people only identified a seizure as a person flopping around, but Resident #1's eyes would get really big and she would get stuck. Another nurse was called to confirm (name unknown) if she was having a seizure and she agreed, but they did not send her out because she was care planned for them. In an interview on 8/21/25 at 3:17 pm with the Pharmacy's Corporate Nurse, she explained that pharmacy deliveries were made daily and they supplied the medication for up to two days in advance. She denied any request made by the facility for additional packs of medication and stated they only sent the medication that was prescribed, which was filled by a machine inside the pharmacy. Pharmacy Corporate Nurse stated that the pharmacy never sent extra packets of medication for Resident #1. In an observation and interview on 8/22/25 at 10:27 am with the DON, she was informed that 2 medication packs were found amongst her storage for discontinued/unused medications. One pack was dated for 8/12/25 at 9pm and filled on 8/10/25 and the other pack was dated 8/18/25 at 9pm and filled on 8/16/25. The DON stated that in July a nurse had bought it to her attention that RN B had not administered medication to Resident #1, evidenced by the unopened medication pack. She stated that RN B denied the allegation and because it was signed given in the MAR, she did nothing further. The DON believed that Resident #1 had received Carbamazepine and stated that I would know if she had not received her medication because she would have had a seizure, and she had not had a seizure in a while. The DON stated she was unaware that Resident #1 had a seizure on 8/9/25. In an interview on 8/22/25 at 9:23 am with RN B, she denied not administering medications to Resident #1. She stated she knew she was supposed to administer the medication as dated, but sometimes she would grab a medication packet with the correct medication in it, but it would be labeled with the wrong time/date and administer it. She could not answer why there were unopened packets of medication found. She had no knowledge of Resident #1's seizure episode on 8/9/25 and stated that she was getting (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676223 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 676223 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/16/2025 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 0755 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few older and only did the best she could. In an interview on 8/22/25 at 9:59 am, the NP explained that if a nurse wanted to request extra medication, they would do it through the pharmacy. She stated that it was important Resident #1 received her seizure medication as ordered because it helped to treat seizures and lowered the threshold of a seizure occurring. Without her seizure medication, it would put her at risk of an episode. She stated that she was unfamiliar of Resident #1 having a seizure on 8/9/25 and she did not receive a phone call from the nurse because it happened over the weekend, and she would have been unavailable because she worked Monday through Friday. The NP stated that she did not recall a seizure episode occurring from Resident #1 in a very long time. She explained that if the Carbamazepine medication was missed and a seizure occurred, she would have ordered a lab to check her therapeutic levels. The pharmacy usually would put in a standing order for Carbamazepine levels to be checked every 3-6 months or she would order one if there was a change in condition. An interview attempt was made to LVN E on 8/22/25 at 11:21 am and 8/28/25 at 2:48 pm. LVN E did not answer or return calls. Voicemail was left for callback. In an interview with LVN D on 8/28/25 at 2:39 pm, she stated that she worked from 7pm7am and was responsible for administering all nighttime medications. She stated that she had never noticed Resident #1 having a seizure, but she had noticed unopened packets of medications for Carbamazepine 200 MG and Pepcid 20 MG for different dates in the medication cart. When that occurred, she removed the packets and placed them in the medication room. She did not report the unused medication and she denied not administering medication to Resident #1. On 9/12/25 at 2:33pm, documentation was requested for non-controlled medications destroyed in July 2025. The DON stated she did not keep a list because the facility was no longer required to and she was not able to provide any documentation. Record review of the facility's policy titled Medication Errors dated 07/01/24 revealed: Medications are administered to residents according to all Federal and State requirements. The facility follows all acceptable standards of care to ensure that medication errors of five percent or greater do not occur. Procedures are established to assure that significant medication errors that cause the resident discomfort or jeopardize his/her health or safety do not occur. In addition to reviewing each resident's drug regimen a qualified pharmacist shall review medication administration procedures on a regular basis. Policy review titled Medication Disposal and Return effective 6/21/2027 documented nursing staff was responsible for removing discontinued medications from the medication cart and a full chain of custody should be documented to clearly indicate the removal of the medication. The ADM and DON were notified on 9/15/25 at 2:12 pm that an IJ had been identified and an IJ template was provided. The following POR was approved on 9/16/25 at 8:53 am: PLAN OF REMOVAL 9/16/2025- F755Issue identified by surveyor:The facility failed to provide pharmaceutical services (including procedures that ensure accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of Resident #1 reviewed for pharmaceutical services. Corrective Actions: 1. The nurse (RN B) was terminated 8/29/25 and no longer employed at facility. 2. Medication Administration policy was reviewed by RN- Nurse Account Manager with Pharmacy on 9/15/25. No change to the policy was made. However, the practice of investigating extra medication was initiated. 3. On 9/15/25, COO educated Director of Nursing on investigating all unopened medication packets and completing a thorough investigation of concerns voiced regarding missing medication. Ex- interviewing residents/staff and notifying physician of concern. 4. By 9/15/25 licensed staff were interviewed to see if they had witnessed any seizure activity within the last 30 days. Completed 9/15/25. No activity has been noted. No one was found to have an issue. 5. By 9/15/25 DON (RN), ADON (LVN), and Social Services Director (LVN) in-serviced all Charge Nurses (LVN and RN) and Medication Aides on following physicians' orders regarding delivering medication and what to do if (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676223 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 676223 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/16/2025 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 0755 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete seizure activity is witnessed. In the event of a seizure, the physician will be informed and will follow physician recommendations. Documentation of calling MD and recommendations will be entered into medical records. Any new employee will be educated prior to start of shift. Staff will not be allowed to provide direct care until the training is completed. 6. On 9/15/2025 safe surveys were completed with residents by DON (RN), ADON (LVN), Social Services Director (LVN), and Administrator regarding receiving medications as ordered. No resident identified an issue with receiving or delivery. 7. As of 9/15/2025 Director of Nursing or Assistant DON will monitor unadministered medication prior to clinical meeting to determine why it was not administered (i.e. hospital, hospice, dc'd medication, extra). If it is determined it is extra, investigation will be initiated and pharmacy notified. A detailed list of any extra medication will be kept by the DON starting 9/15/25. This is a new practice that is not written in the Medication Administration Policy but will be an ongoing practice of the facility. 8. On 9/15/25, Medical Director declined to add new orders for Resident #1 to regularly monitor Carbamazepine level. 9. On 9/15/25 Ad Hoc QAPI was conducted with the Medical Director to review the plan of action and will be reviewed monitoring results will be reviewed monthly X 3 months in monthly QAPI. The Surveyor monitored the POR on 9/16/25 as followed: Review of an in-service titled Extra Medication conducted 8/22/25 documented that the COO educated the DON and ADON on investigating extra medication and conducting thorough investigations regarding all medication concerns. DON explained in an interview on 9/16/25 at 11:30 pm that she was to investigate where extra medications came from by investigating if the resident was on hospice, in the hospital, or discharged . She created a spreadsheet that she would update daily that included the date, resident name, medication, and reason missed. This would help her track and trend all medication concerns. Review of the in-service dated 9/15/25 educated all nursing staff and medication aids on what to do if they discovered additional medication packets on the medication cart. During interviews on 9/16/25 between 11:00 am- 2:00pm, Nurses (9 LVN's, 3 RN's, 2 medications aides) stated that they were to document the reason medication was not administered, write the reason why medication was not administered on all extra medication packets, and store those packets in the locked cabinet inside of medication room. On 9/15/25, an in-service dated 8/22/25 reflected that all nursing staff were educated seizure protocols and what do if a resident was having a seizure. During interviews on 9/16/25 from 11:00 am - 2:00 pm, nurses from the 7 am-7 pm and 7 pm-7 am shift were asked to review what was covered during their in-services. Nurses stated that if a resident was experiencing a seizure, they were to make sure the resident was safe, PRN medication was checked, and the NP or doctor was contacted on what recommendations to implement. Each seizure should be documented appropriately and additional notification should include the DON and family. Review of the Safety Rounds Checklist completed 9/12/25 with all cognizant residents concluded that residents felt safe at the facility and had no issues with receiving medications. An interview attempt was made on 9/16/25 with Medical Director but he could not be reached. Record review of POR and in-service dated 09/15/25 documented a signature of agreement from Medical Director. RN B was terminated on 8/29/25. Review of the Employee Counseling Disciplinary Report documented that the reason for termination was substandard care and falsifying documentation. The ADM and DON were notified on 9/16/25 2:18 pm that the IJ had been removed. While the IJ was removed, the facility remained at a level of no actual harm at a scope of isolated that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. Event ID: Facility ID: 676223 If continuation sheet Page 6 of 6