Health inspection·August 24, 2022

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few illness diagnosis of schizophrenia. The MDS Nurse said if a PL 1 was inaccurate the resident would need a correction form completed. After reviewing Resident #153's diagnosis the MDS Nurse stated Resident #153's was not screened correctly for PASRR 1, and she would re-screen the resident. The MDS Nurse said possible negative outcomes for inaccurate PASRR Level 1 could be that residents would not receive the specialized services they qualified for through PASRR if the PL 1 was not completed correctly. She said the DON was her supervisor who monitored the PASRRs for accuracy. During an interview on 8/23/22 at 12:53 p.m. the DON said her expectation was for all PL1's to be completed by policy, accurately and timely on all residents. She acknowledged Resident #153's PL 1 did not indicate a diagnosis of mental illness and should have. She said the MDS Nurse was responsible for completing all things PASRR the PL 1 correctly and uploading it into the portal on all residents and would use any clinical documentation of diagnosis to review for mental illness in completing the PL 1 assessment. The DON said she was educated on PASRR and had not been monitoring the admission PASRR process but would put a plan in place to start monitoring for accuracy. The DON said the risk of a resident not having a correct PL 1 completed would possibly be not receiving needed and deserved services. The DON stated facility had no policy on PASRR and the facility used HHSC guidelines on completing PL 1. Record review of an undated and untitled bulleted list included in part: PASRR is required of each state's Medicaid program to ensure that those with Mental Illness (MI0/Intellectual or Developmental Disability (IDD) are cared for properly .review PL1 for potential MI, DD or ID and if positive the Local Authority completes PL2 . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676444 If continuation sheet Page 2 of 10 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 676444 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bonne Vie 8595 Medical Center Boulevard Port Arthur, TX 77640 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 - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 23 residents reviewed for care plans. (Resident #15) The facility did not care plan Resident #15 for diabetes (a high level of sugar in the blood) and insulin (a medication used to treat diabetes). This failure could place the residents at risk of not receiving care and services to maintain their highest practicable level of physical, mental, and psychosocial well-being. Findings included: Record review of physician orders dated August 2022 indicated Resident #15, admitted [DATE], was [AGE] years old with a diagnosis of diabetes. The orders indicated he was to receive Novolog insulin 100 units/ml two times a day per sliding scale (a scale amount of insulin administered that varies in accordance with the blood glucose reading [the main sugar found in your blood]) with a start date of 02/26/2022 and was to receive a diabetic snack every evening with a start date of 04/12/2022. Record review of the most recent quarterly MDS assessment dated [DATE] indicated Resident #15 had a BIMS of 10 (mental status moderately impaired), had impaired vision (can see large print only), required extensive assistance for personal hygiene and had a diagnosis of diabetes. Record review of care plans dated 08/24/22 indicated Resident #15 did not have a care plan for diabetes and/or insulin. During an interview on 08/22/22 at 09:26 a.m., Resident #15 said he was diabetic and took insulin per sliding scale, when he needed it. He said recently his blood sugar levels had been good and he did not have to take insulin. During an interview on 08/24/22 at 1:32 p.m., the DON said Resident #15 did not have a care plan for insulin or diabetes and should have. She said her expectations were for the resident to be care planned for insulin and diabetes. She said the negative outcome of not having a care plan could be the staff would not know how to take care of the patient. She said the LVN unit manager (unit manager B) was responsible for making sure the care plans were completed. During an interview on 08/24/22 at 1:38 p.m., Unit manager B said Resident #15 had been a diabetic since he came from their sister facility years ago. She said it was her responsibility to complete the care plan for the resident, she had not completed the care plan for the resident's diabetes and insulin, however, she had gone into the system just a minute ago and put the care plan in his chart after surveyor intervention. She said he did need to be care planned for diabetes and insulin and the possible negative outcome could be the staff would not know he was on insulin or to monitor it. Review of the Patient Care Management System policy, titled Assessments, dated November 2017 indicated . 3. Upon admission each patient/resident's diagnoses must be reviewed with the physician to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676444 If continuation sheet Page 3 of 10 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 676444 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bonne Vie 8595 Medical Center Boulevard Port Arthur, TX 77640 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 develop individualized care plan interventions, including the touchscreen daily care guide. The facility will use patient/resident observation, communication, family input and clinical history . 12. The monthly Quality Assurance and Performance Improvement Meeting must include a review of the timely completion and updating of care plans, timely completion of nursing assessment, Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676444 If continuation sheet Page 4 of 10 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 676444 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bonne Vie 8595 Medical Center Boulevard Port Arthur, TX 77640 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 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation interview and record review, the facility failed to provide a therapeutic diet when ordered by the physician to maintain adequate nutritional status, to the extent possible to maintain acceptable parameters of nutritional status for 1 of 23 residents reviewed for weight loss. (Resident # 204) Residents Affected - Few The facility did not ensure Resident #204 received a health shake three times a day as ordered by the physician. This failure could place the residents at risk for not receiving care and services to maintain their highest practicable level of physical, mental, and psychosocial well-being. Findings included: Record review of physician orders dated August 2022 indicated Resident #204, admitted [DATE], was [AGE] years old with a diagnosis of protein calorie malnutrition. The resident had an order for health shakes with meals one time a day, which the physician discontinued on 08/3/22 and there was a new order dated 08/3/22 for the resident to receive a health shake with meals three times a day. Record review of the admission MDS assessment dated [DATE] indicated Resident #204 had a BIMS score of 8 out of 15 (mental status moderately impaired), required supervision (encouragement or cueing) for eating, had a diagnosis of protein calorie malnutrition and was on a therapeutic diet. Record review of the care plan dated 08/24/22 indicated Resident #204 received a therapeutic diet. The goal was for the resident to have adequate nutrition and fluid intake over the next 90 days. Interventions indicated to serve diet as ordered and monitor intake. Record review of Resident #204's weight worksheet indicated the resident refused to be weighed on the admission date of 7/6/22. The resident weighed 95.8 lbs. on 07/12/22 and 92.2 lbs. on 08/15/22. Record review of Resident #204's breakfast meal ticket dated 08/24/22 indicated there was no documentation the resident had house shakes ordered. During an interview on 08/22/22 at 11:23 a.m., Resident #204 said she was admitted to the facility because she had weight loss. She said she just kept losing weight During observations of Resident #204's meal service, there was not a health shake on the resident's meal tray for the following dates/times: * 08/22/22 at 12:48 p.m. * 08/23/22 at 8:58 a.m.; and * 08/24/22 at 8:26 a.m. During an interview on 08/22/22 at 12:50 p.m. with LVN C when asked if Resident #204 was on supplements for weight loss, LVN C said the resident was on supplement pass three times a day, which was administered during medication pass. He said the resident had lost weight from 95 lbs to 92 lbs since (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676444 If continuation sheet Page 5 of 10 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 676444 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bonne Vie 8595 Medical Center Boulevard Port Arthur, TX 77640 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 0692 admission. Level of Harm - Minimal harm or potential for actual harm During observation and interview on 8/24/22 at 8:27 a.m., after observation of Resident #204's meal tray, LVN D said the resident did not have a house shake on her meal tray. She said the orders did indicate the resident was supposed to receive a health shake three times a day with meals. LVN D said the resident could continue to lose weight if she did not receive the health shakes as ordered. Residents Affected - Few During an interview on 08/24/22 at 8:30 a.m. the ADON said Resident #204 should have received the health shakes three times a day as ordered. She said the negative outcome would be she could continue to lose weight if she did not receive the shakes. She said LVN D was the staff who wrote the order. She said at the time the order was written, Resident #204 was on Hall 300 where LVN D worked. She said if LVN D wrote the order, she would be the one who was responsible for delivering the order to the kitchen. She said her expectations were for the residents to receive their diet as ordered. During an interview and record review on 08/24/22 at 8:33 a.m., the DM said the house shakes do go to the residents from the kitchen. She said the nurse who writes the order brings the order to her and she puts the order in the computer so it can be implemented. After record review of Resident #204's meal ticket, she said the house shakes were not on the resident's ticket. The DM presented the resident's dietary order to the surveyor and said the resident did not have dietary orders for house shakes. She said the negative outcome of Resident #204 not receiving the house shakes as ordered would be the resident could possibly lose weight. During an interview on 08/24/22 at 8:54 a.m., LVN D said Resident #204 did have orders for health shakes three times a day. She said she did not remember if she had printed Resident #204's dietary order for the health shakes and/or sent them to the kitchen or not. She said once a dietary order was written it was supposed to be hand carried to the kitchen so they could add the new order to the resident's diet; it could not be sent electronically. She said the resident did not eat or drink well, so she got an order for health shakes. She said the negative outcome was the resident could continue to lose weight. During an interview on 08/24/22 at 8:57 a.m., the DON said when the orders were received for meals or health shakes, the order was supposed to be printed and walked to the kitchen. She said the nurse that took the order was responsible for writing the order and bringing it to the kitchen. She said her expectations were for the health shakes to be served to Resident #204 as ordered. She said the possible negative outcome would be the resident would lose weight. During an interview on 08/24/22 at 2:23 p.m., the corporate nurse said the facility did not have a specific policy related to following physician orders for nutrition/diet. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676444 If continuation sheet Page 6 of 10 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 676444 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bonne Vie 8595 Medical Center Boulevard Port Arthur, TX 77640 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 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 observation, interview and record review the facility failed to ensure all drugs and biologicals were stored in accordance with currently accepted professional principles in locked compartments for 1 of 23 residents (Resident #1) and permitted only authorized personnel reviewed for storage of medications. -The facility failed to ensure Resident #1 did not have medication, melatonin 10mg bottle at the bedside. This failure could place residents at risk for consuming unsafe medications and having access to unauthorized medication that could cause a decline in health status and possible drug diversion. The findings included: Record review of Resident #1's face sheet dated August 2022 indicated Resident #1, admitted [DATE], was a [AGE] year old male with diagnoses that included: gastro-esophageal reflux disease (occurs when stomach acid repeatedly flows back into the tube connecting your mouth and stomach/esophagus), heart disease, hypertension (high blood pressure) and insomnia (a common sleep disorder that can make it hard to fall asleep, hard to stay asleep, or cause you to wake up too early and not be able to get back to sleep). Record review of admission MDS ARD dated 8/16/22 indicated Resident #1 had clear speech, ability to understand and be understood by others, BIMS 9 of 15 indicating he had moderately impaired cognition. Record review of Resident #1's electronic record revealed there was no Care Plan addressing to keep medications at bedside and no care plan to self-administer medications. Further review of the electronic record inticated Resident #1 did not have a Self-Administration Medication Assessment initiated or completed for August 2022 Record review of resident #1's August 2022 physician orders indicated no orders for medication self-administration, Melatonin 10mg or to keep medications at bedside. Observation during initial tour, on 8/22/22 at 9:30 A.M. revealed Resident #1 was very hard of hearing, watching TV, sitting on a wheelchair in his room and the door was open. On his bedside table was an open and used bottle of Melatonin 10 mg tablets, with no pharmacy label. Observation on 8/22/22 at 11:30 A.M. revealed Resident #1 was watching TV, sitting on a wheelchair in his room and the door was open. On his bedside table remained the opened and used bottle of Melatonin 10 mg tablets, with no pharmacy label. In an interview and observation on 8/22/22 at 11:33 A.m. Resident #1 stated the Melatonin was his and he took 1 pill when he needed it to get to sleep. Resident #1 said he did not remember the last time he took it but believed it was some time last week. Resident stated he leaves the medication on his table in his room and he thought the nurses should be aware he had the medication because it was in plain eyesight on the bedside table and could be seen every time they walk in the room. He (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676444 If continuation sheet Page 7 of 10 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 676444 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bonne Vie 8595 Medical Center Boulevard Port Arthur, TX 77640 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 0761 Level of Harm - Minimal harm or potential for actual harm further stated he takes the Melatonin one-tablet at night for sleep but only when need it. Resident #1 stated his family member bought the medication for him, but he could not remember when or when was the last time he took it. Resident #1 said he did not need a doctor's order to take the medication because it was OTC over the counter and no doctor's prescription was necessary for it. On his bedside table was a Melatonin 10 mg bottle, opened and used with no pharmacy label. Residents Affected - Few Observation and interview on 8/22/22 at 12:58 P.M. with LVN C indicated on Resident #1's bedside table was a Melatonin 10 mg bottle, opened and used with no pharmacy label. LVN C stated he did not know when the medication bottle came or who may have brought it in to Resident #1. LVN C said he was the staff person assigned to Resident #1 for medication administration and while looking at the electronic record for Resident #1 LVN stated he did not see an order for Melatonin or any other sleep aide. LVN C said he makes observations on things like safety, cleanliness, and odors every day on his assigned hall and had not seen any medication at the bedside. LVN C said he would have removed the Melatonin bottle, because medication at the bedside that was not locked up can be dangerous if residents use it the wrong way. LVN C left the room with the Melatonin 10 mg tablets remaining on Resident #1's bedside table. Observation and interview with the DON on 8/22/22 at 1:30 P.M. revealed on Resident #1's bedside table was medication Melatonin 10 mg. The DON stated the resident did not have any sleeping problems that she was aware of or being treated with any sleep aid medication. The DON said she teaches staff on orientation and as needed that medications could not be left out unattended at the resident's bedside and staff assigned to resident were to look for medications and remove them . The DON said her expectation was for nursing staff to follow facility policy and procedure and not leave medications at the bedside. The DON said residents would need a doctor's order and medication self-administration assessment completed before they could be able to keep meds at the bed side and administer themselves but none of the residents had any because it was not allowed in the facility. The DON revealed Resident #1 did not have an order for mediation Melatonin 10 mg or to leave medications at bedside and no self-administer medication assessment had been done for Resident #1. The DON said leaving medications at the bedside puts residents at risk of not taking properly or giving it to someone else to take. The DON stated she would make sure the medication was removed and the doctors called to see about getting an order to administer the Melatonin. Record review of facility policy Storage of Medications for patient that Self-Administer, dated March 2016 read in part: . Policy . Storage of medications for self-administration remains the responsibility of nursing staff. In accordance with state and federal laws, the facility must store all drugs in locked storage area and permit only authorized individuals to have access to the keys. Procedure: All medications for self-administration will be stored in the Facility's locked medication carts or other locked storage areas. Record review of facility policy Self-Administration of Medications dated March 2016 read in part: . Procedure: An Assessment for Self-Administration of Medications (see [NAME] Form CFS 1-14HH) must be completed on each Patient requesting to self-administer medications and quarterly thereafter. An Assessment for Self-Administration of Medications is kept with the Patient's medical record under the Assessment tab. If it has been determined the Patient is capable of self-administering his/her medications, a physician order must be obtained, a care plan formulated, and staff in-serviced . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676444 If continuation sheet Page 8 of 10 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 676444 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bonne Vie 8595 Medical Center Boulevard Port Arthur, TX 77640 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 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and record review, the facility failed to prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen. Residents Affected - Some The facility failed to ensure kitchen equipment was clean and staff used sanitary measures while preparing food. This failure could place the residents at risk of food borne illnesses. Findings included: During initial observations of the kitchen on 08/22/22 at 8:38 a.m., the following were noted: *There was a brown splattered substance on the surface area surrounding the coffee dispenser spigots; and *There was a buildup of black substance to the surrounding surface area of the juice dispenser spigots. During observation and interview on 08/22/22 at 8:40 a.m., the DM said the coffee and juice machines were not clean and she began wiping the surrounding area of the juice machine spigots off with a white towel she had in her hand. After wiping the juice machine, the white towel had a black substance smeared on it. The DM said the coffee and juice machines were dirty and should be kept clean. She said the possible negative outcome would be contamination. During an observation on 08/22/22 at 8:49 a.m., there were multiple wet, beige, and brown particles on the top front left of the dish machine down to the top back of the dish machine. The particles in the back under the electrical wiring were stuck to the top of the dish machine. During an interview on 8/23/22 at 8:52 a.m., the DM said the food from the dish machine splashed up on top of the dish machine when it was in use, and it needed to be cleaned. She said the staff dishwasher was responsible for making sure the dish machine was clean, but she was on vacation. She said it should be cleaned even when the staff dishwasher was out on leave. She said the staff persons who were responsible for keeping the coffee and juice machines clean were also out on either sick or on vacation at this time. She said the kitchen equipment should be kept clean according to the cleaning schedule to prevent contamination. During observation of the steam table preparation for the noon meal on 08/23/22 at 12:01 p.m., [NAME] A, without washing her hands, walked from the steam table, retrieved her personal thermal cup from a prep table, walked over to the facility ice machine and scooped up a cup of ice using her thermal cup, shut the door, and walked off. During an interview on 08/23/22 at 12:02 p.m., [NAME] A said she did not wash her hands and she should not have put her cup in the facility ice machine to retrieve the ice. She said she knew she was supposed to wash her hands and use the scoop to retrieve ice from the machine. When asked if she was trained on kitchen sanitation, she said she had been in food service for years and no one had to teach her that. She said the negative outcome would be cross contamination. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676444 If continuation sheet Page 9 of 10 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 676444 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bonne Vie 8595 Medical Center Boulevard Port Arthur, TX 77640 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an observation and interview on 08/23/22 at 12:08 p.m., the DM said the cook knew better than to put her cup down in the ice machine. She said she would have to drain the ice machine and then she walked over and unplugged the machine. She said the staff should always wash their hands and use the scoop to retrieve ice and should not use their personal cups. She said the possible negative outcome would be contamination of the ice. She said she expected the staff to always use the scoop and to wash their hands before getting into the ice machine bin. Review of the cleaning schedule dated August 2022 indicated each day Monday through Sunday, there were 2 allotted spaces for kitchen staff to initial the coffee machine, juice machine and dish machine were cleaned. The dish machine column indicated there were no initials in 6 allotted spaces. The juice machine column indicated there were no initials in 7 allotted spaces. The coffee machine column indicated there were no initials in 37 allotted spaces. Review of the General Sanitation of Kitchen policy dated November 3, 2004 indicated: The staff shall maintain the sanitation of the kitchen through compliance with a written comprehensive cleaning schedule. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676444 If continuation sheet Page 10 of 10