Health inspection·December 11, 2025

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to label drugs and biologicals used in the facility in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for two medications cart (300 hall nurses cart and 300 hall Medication Aides cart) of the facility's four medication carts reviewed for medication storage. The facility failed to ensure IV fluids were labeled and dated before administering the fluids to Resident#1.The facility failed to ensure that an opened bottle of acidophilus was dated and stored in the refrigerator.The facility failed to ensure that an opened bottle of vitamin B 1 100mg was dated after opening and before storing in the 300-hall nurses medication cart. The facility failed to ensure that an opened of vitamin B 12 500mg was dated after opening and before storing in the 300-hall medication cart.The facility failed to ensure that an opened of vitamin B 12 1000mg was not dated after opening and before storing in the 300-hall medication cart.These failures had the potential to result in compromised medication efficacy, unsafe administration, and increased harm to residents. The findings included:Review of Resident #1's Quarterly MDS Assessment, dated 11/24/2025 reflected the Resident #1 was a [AGE] year-old female and had a BIMs score of 15, indicating her cognitive function was intact. The resident had diagnoses which included cancer, anemia (a condition where your blood lacks enough healthy red blood cells to carry adequate oxygen to your body, causing fatigue, weakness, pale skin, and shortness of breath), and hypertension (means the force of blood pushing against your artery walls is consistently too high). Review of Resident #1's Comprehensive Care Plan, dated Date Initiated: 11/26/2025 Revision on: 11/26/2025, reflected The resident has potential nutritional problem r/t lung CA, brain CA Monitor/record/report to MD PRN s/sx of malnutrition: Emaciation (Cachexia),muscle wasting, significant weight loss: 3lbs in 1 week, >5% in 1 month, >7.5% in 3months, >10% in 6 months. Date Initiated: 11/26/2025 Obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated. Date Initiated: 11/26/2025Review of Resident #1's active physicians orders date 12/09/2025 at 10:15am reflected 0.9 NS at 100cc/hr IV x1HR. Review of Resident #1's notes dated 12/09/2025 at 12:20pm Health Status Note. Note Text: MA reported to this writer that resident blood pressure was low. assessment was done and PRN midodrine was given. Resident B/P reassessed B/P - 87/39, P-78. NP notified of the change in BP after PRN medication. New orders received FOR 0.9% NS at 100CC/HR IV X 1Lts and CBC, BMP, Resident and POA was notified of changes.0.9% NS was taken from pyxis (medication dispensing system). IV fluids was hanged at 10:15am. Labs was draw at 10:37am. This writer assessed resident at 11:40am. Vital signs obtained B/P-126, P-78. Lab results was given to NP. No new orders at this time. [sic] The entry was written by LVN C. Observation of Resident#1 on 12/09/25 at 1:42 PM revealed she was receiving Intravenous fluids. The fluids were not labeled with the Page 1 of 3 676282 676282 12/11/2025 Bayou Manor 4141 S Braeswood Blvd Houston, TX 77025

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few type of fluid, Residents name, date of administration, rate of the fluid, or initial of the nurse administering the fluid.Interview on 12/09/25 at 1:45 PM with the DON revealed that Resident #1 was receiving normal saline fluids because her blood pressure was low.Observation on 12/09/25 at 2:08 PM with MA A and MA B on the 300-medication cart revealed one bottle of vitamin B 1 100mg that was open but not dated, one bottle of vitamin B 12 500mg that was open but not dated, and one bottle of vitamin B 1 1000mg was open and not dated. Interview on 12/09/25 at 2:12 PM with MA A and MA B revealed that they did not know that the medication bottles were not labeled. MA A and MA B stated all multi dose medication should be dated when opened. MA A and MA B both stated the risk to the residents was administering medication that was beyond the manufacturers' recommendations that might not be therapeutic. They stated that they had been in-serviced on medication storage.Observation on 12/09/25 at 2:21 PM with LVN C on the 300 nurses medication cart revealed one opened bottle of acidophilus in the cart (not refrigerated) with no open date.Interview on 12/09/25 at 2:25 PM with LVN C revealed that she opened the acidophilus bottle but forgot to label it and did not realize that it was supposed to be refrigerated. She stated she administered Resident #1's IV therapy. She stated the fluid (0.9% normal saline 1 liter) was from the emergency kit, which was why it was not labeled, and she forgot to label it. She stated that all IV fluids should have the resident's name, the fluid infusing, the rate, date, time, and initials of the person that administered the IV. She stated the risk to the resident receiving the wrong medication. She stated that she had been in-serviced on medication storage and IV administration.Interview on 12/11/2025 at 3:13 PM with the DON revealed that all medications including IV fluids should be labeled. She stated her expectations were the nurses and MAs did the medication rights before administering any medication. The risk of unlabeled IV fluids to the residents was it would be impossible to know what was infusing, and at what rate in case adjustments were to be made. The DON stated that the nurses and MAs were responsible for ensuring the medication carts were clean, all medications were within date, no medications were expired and all over the counter medications were dated when they opened. She stated that the MAs and nurse had been in-serviced on medication labeling and storage, and the nurse had been in-serviced on IV administration. Review of the facility policy titled Medication Storage in the Facility revised on 01/2018 reflected: Medication and biologicals are stored safely, securely, and properly, following manufacturers recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel or lawfully authorized to administer medications. Medication requiring refrigeration are kept in a refrigerator at temperatures between 36 degrees Fahrenheit and 8 degrees Fahrenheit with a thermometer to allow temperature monitoring. Medication requiring cool place are refrigerated unless otherwise directed on the label.When the original seal of the manufacturer's container or vial is initially broken, the container or vial will be dated.The nurse shall place a date opened sticker on the medication and enter the date opened and new date of expiration (NOTE: the best stickers to affix contain both a date opened and expiration notation line). The expiration date of the vial or container will be 30 days unless the manufacturer recommends another date or regulations required different dating (See APPENDIX 28 - MEDICATIONS WITH SHORTENED EXPIRATION DATES).Infusion Therapy Storage and LabelingFacility should ensure the infusion therapy labels include:1)Residents Name2)Volume, infusion rate3)Name and quantity of each additive,4) Initials of the Pharmacist5) Date and time of administration6)Initial of person administering the medication7) Ancillary labeling8) Expiration date Policy Interpretation and Implementation1. Medication and biologicals are stored in the packaging, containers, or other dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer medications between containers.2. The nursing staff is responsible for maintaining 676282 Page 2 of 3 676282 12/11/2025 Bayou Manor 4141 S Braeswood Blvd Houston, TX 77025

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few medication storage and preparation areas in a clean, safe, and sanitary manner.3. Medication requiring refrigeration are stored located in the medication room at the nurses' station or other secured location. Medications are stored separately from food and are labeled accordingly.are separately locked in permanently affixed compartments, except when using single unit package drug distribution system in which the quantity stores is minimal and a missing does cane be readily detected.Medication Labeling1.Labeling of medication and biologicals dispensed by the pharmacy is consistent with applicable federal and state requirements and currently accepted pharmaceutical practices.The medication label includes, at a minimum: Medications name.prescribed name.prescribed dose.Strength.Expiration date, when applicable.Residents name.Route of administration; andAppropriate and precautions.If medication containers are missing, incomplete, improper, or incorrect labels contact the dispensing pharmacy for instructions regarding returning or destroying these items. 676282 Page 3 of 3