Inspection·April 13, 2023

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview with the MDS coordinator on 04/13/23 at 1:00PM, she said she completed the form and sent it to the therapy department for completion. She said the therapy department was supposed to complete the NFSS forms and send them in through the LTC online portal. During an interview on 04/13/23 at 3:00PM, Therapy staff K said she resubmitted the NFSS on 04/05/23. She said the NFSS form was rejected the first time but Resident #75 continued receiving services. During an interview with Local authority staff on 04/13/23 at 4:50PM, she said the facility did not submit the NFSS within the allocated time frame and the NFSS would be rejected. She said the facility had to re-schedule another meeting for PASRR assessment with the local authority and Resident #75. During an interview on 04/13/23 at 5:20 PM, the facility Administrator said the facility followed guidlines set by PASRR. She provided PASRR's policy. Record review of PASRR requirement dated March 2021 Titled Companion Guide for Completing the Authorization Request for PASRR Nursing Facility Specialized Services (NFSS) Form Page 9 read in part . NFSS Request More Than 30-Calendar Days After IDT Meeting If the nursing facility is submitting the NFSS request more than 20 business days (Approximately, 30 calendar days) after the initial IDT or annual specialized services meeting, the nursing facility submitters will receive an error message to this effect. This is to notify the nursing facility submitters that they are out of compliance with the requirements in rule and may be subject to a follow-up visit by regulatory staff. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676490 If continuation sheet Page 2 of 19 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 676490 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sylan Shores Health and Wellness 3950 Underwood Rd LA Porte, TX 77571 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 0658 Ensure services provided by the nursing facility meet professional standards of quality. 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 ensure the services provided or arranged by the facility, as outlined by the comprehensive care plan meet professional standards of quality for 1 of 14 residents (Resident #61) reviewed for professional standards: Residents Affected - Few The facility failed to ensure Resident #61 had an active physician order for her Wander guard device. A Wanderguard is a safety device placed on an individual who is high risk for unsafe wandering that alerts the responsible party when that individual attempts to exit a building/designated area. This failure to meet professional standards of entering and following physician orders could place residents at risk for inadequate care or inadequate monitoring. Findings included: Record review of Resident #61's face sheet revealed that resident was a [AGE] year-old woman admitted to facility on 9/28/2022 with diagnoses of unspecified dementia (progressive loss of mental ability; thinking, decision making, memory), heart failure (decreased ability of heart to pump blood), sedative, hypnotic, anxiolytic dependence , cerebral infarction (stroke), and cognitive communication deficit (decreased ability to express thoughts/communicate effectively). Observed Resident #61 on 4/11/23 at 9:50am attempting to push emergency exit door on 400 hall. Alarm briefly sounded 1 time and resident immediately backed away from the door mumbling to herself. Observed Wander guard placed on Resident #61's left ankle. Record review of progress notes dated 4/12/23 revealed that Resident #61 successfully wandered out of the facility unattended on 4/12/23 around 4 am and was returned by a police officer at 4:20am on 4/12/23. She was assessed and had no injury. There was no progress note that documented that Resident #61 was trying to exit the facility on 4/11/23, and no other documentation that she had previously tried to leave ore successfully left the facility. Record review of Resident #61's physician orders revealed that she did not have an active order for the wander guard. Record review of Resident #61's assessments showed a positive Elopement Assessment (9/28/2022) indicating resident was at-risk for elopement. Record review of Resident #61's care plan identified Resident #61 as an elopement risk/wander r/t dementia, disoriented to place, history of attempts to leave facility unattended, impaired safety awareness, wander guard in place (date initiated 9/30/2022). Record review of Resident #61's MDS dated [DATE] showed BIMS score of 3. A BIMS score of 3 indicates severe cognitive impairment. Interview with the DON on 4/12/2023 at 1:06pm stated that Resident #61 has been admitted to the facility for longer than she (the DON) has been working there. She is aware that the resident is a wanderer and has a Wanderguard in place, but she never checked to make sure the order for it was entered in the computer. The DON stated that residents who are identified as elopement risk are to have the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676490 If continuation sheet Page 3 of 19 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 676490 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sylan Shores Health and Wellness 3950 Underwood Rd LA Porte, TX 77571 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 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Elopement Assessment. If deemed at risk, the resident's nurse should contact the physician for a Wander guard order, and then enter the order into the computer once approved. The DON said that she was not aware of there being a specific policy for Wanderguard, but would check with the Administrator. The DON said the nurses providing care for residents are responsible for entering, updating, or removing physician orders per professional standard of care, however, no one checks behind them. She said that failure to meet professional standards can cause harm because the resident may not get the appropriate treatment or care as ordered. Interview with the Administrator on 4/12/2023 at 1:15pm stated that she was unable to find a policy for Wander guard device. She confirmed that any device or treatment that a resident has should be in the care plan and have an active physician's order. She said that Resident #61 had the Wander guard in place on her ankle before her (the Administrator's) arrival to the facility and she did not think anything of it. Interview with the RP for Resident #61 on 4/12/23 at 2:50pm. He said that he was aware that the Wwander guard was in place because Resident #61 is high risk for wandering. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676490 If continuation sheet Page 4 of 19 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 676490 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sylan Shores Health and Wellness 3950 Underwood Rd LA Porte, TX 77571 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 0689 Level of Harm - Minimal harm or potential for actual harm Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Intake ID #418036\TX00453051 Residents Affected - Few Based on observation, interview, and record review, the facility failed to provide supervision to each resident to prevent accidents for 1 of 6 residents (Resident #61) reviewed as part of sample. The facility failed to ensure that all facility exit doors were secured to prevent unsupervised wandering of residents out of the facility. This failure could place wandering residents at risk for being lost or harmed. Findings included: Record review of Resident #61's face sheet revealed that resident was a [AGE] year-old woman admitted to facility on 9/28/2022 with diagnoses of unspecified dementia (progressive loss of mental ability; thinking, decision making, memory), heart failure (decreased ability of heart to pump blood), sedative, hypnotic, anxiolytic dependence , cerebral infarction (stroke), and cognitive communication deficit (decreased ability to express thoughts/communicate effectively). Record review of Resident #61's assessments showed a positive Elopement Assessment (9/28/2022) indicating resident was at-risk for elopement. Record review of Resident #61's care plan identified Resident #61 as an elopement risk/wander r/t dementia, disoriented to place, history of attempts to leave facility unattended, impaired safety awareness, wander guard in place (date initiated 9/30/2022). Record review of Resident #61's MDS dated [DATE] showed BIMS score of 3. A BIMS score of 3 indicates severe cognitive impairment. Observed Resident #61 on 4/11/23 at 9:50am attempting to push emergency exit door on 400 hall. Th Wanderguard was in place on her left ankle. The alarm briefly sounded 1 time and resident immediately backed away from the door mumbling to herself. The door did not open. LVN O approached resident and resident walked away from her and continued to walk down the hall to the nurses stationnurses station. Interview with LVN O on 4/11/23 at 9:50am stated Resident #61 wanders all throughout the facility all day and when she gets tired, she rests in the lobby area and sometimes takes a nap on the sofa. She said the resident can sit down and eat a meal with some encouragement. LVN O said that resident sometimes goes to activities, but the activities don't keep her attention long and resident gets up and starts walking again. LVN O said when resident #61 is seen at a door, she is redirected without a problem. LVN O said the emergency doors have alarms that go off if anyone attempts to open them. Record review of progress notes dated 4/12/23 revealed that Resident #61 successfully wandered out of the facility unsupervised on 4/12/23 around 4 am and was returned by a police officer at 4:20am on 4/12/23. Resident was assessed and had no injury. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676490 If continuation sheet Page 5 of 19 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 676490 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sylan Shores Health and Wellness 3950 Underwood Rd LA Porte, TX 77571 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview with CNA S on 04/12/23 at 12:54pm stated that Resident #61 walks independently. When CNA S arrived for her shift at 6am, resident was sleeping. CNA S stated that resident wears a Wander guard on her left ankle. CNA S unable to confirm when Resident #61's Wanderguard was last checked. Interview with CMA B (Certified Medication Aid) on 04/12/23 at 12:56pm stated that there are 5 emergency exits (1-100 hall, 1- 200 hall, 2- 300 hall, 1-400 hall), and additional exits at front and near kitchen. Interview with the DON on 04-12-23 at 12:58pm stated that the facility had not yet started the investigation on Resident #61's elopement . The DON was unable to provide information beyond reading nurses note that was already entered in the computer. The DON stated that prior to elopement, Resident #61 was last observed by nursing staff at 3:50am and resident was brought back to facility at 4:20am. A good Samaritan observed the resident wandering outside and called the police. The police found resident and brought her to facility door at 4:20 am. DON stated there are cameras that cover part of halls, main entryway, kitchen entrance, and part of nurses' station. As of 12:58pm, administration did not know how the resident got out of the building. The DON said the investigation had not yet started because the incident had just happened that morning, the resident was safe, and the exterior doors and alarms had been checked to ensure proper function. She said Administration needed time to regroup as this incident occurred during their recertification survey. Interview with RP for Resident #61 on 4/12/23 at 2:50pm. He said that he was notified by LVN N about resident's elopement at 4:30am right after she was returned to the facility. He was not told how resident eloped, only that she was okay. RP said that he was told the resident's Wander guard was not working as it did not alarm when she exited facility nor when she returned. He said that he was aware that the Wander guard was in place because Resident #61 is high risk for wandering. The RP did not know how long the Wanderguard had not been working. Interview with LVN G on 4/12/23 at 6:34pm stated that she was working the 10pm-6am shift on 100/200 halls going in and out of resident rooms. She said that she did not hear any alarm go off at any point. She stated that she was not working with Resident #61 and did not see her at all. She said that she is aware that Resident #61 wanders, but was working and did not notice her that night. Interview with CNA P on 4/12/23 at 6:38pm stated that she was making rounds during her 10pm-6am shift and providing care to the residents on 400 hall. CNA P is familiar with Resident #61 and said that she saw the resident making her usual rounds up and down 100 to 400 hall, then from television area near dining room, to lobby area near entrance. She said that it is common for Resident #61 to walk this path and that the resident is responsive to redirection after she has been allowed to walk her path 1-2 times. CNA P denied hearing a door alarm go off at any point. She wasn't aware of Resident #61 trying to leave the facility, stated that the resident just wanders in the facility. Interview with LVN N on 4/12/23 at 6:43pm said that the resident wears a Wander guard. She was not aware of the Wanderguard not working, but does not know when it was last checked. LVN N said that she saw Resident #61 walking near the nurses' station as she was on her way to get G-tube feedings around 3:50am. LVN N said that she was walking towards the nurses station from the 300 hall when she saw a police officer come around the corner from the front entrance. LVN N said that she asked the officer how he entered the building as the doors should have been locked. LVN N said that the officer told her that he walked in through the front door and believed he had Resident #61. He found her outside in the grass near the facility sign and Resident #61 was able to tell him her name. LVN N states that Resident #61 re-entered the facility at 4:20am through the front doors with Wander guard in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676490 If continuation sheet Page 6 of 19 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 676490 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sylan Shores Health and Wellness 3950 Underwood Rd LA Porte, TX 77571 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few place on ankle, however, the device did not trigger the Wanderguard door alarm to sound as it should have. LVN N said that at no point did she hear an alarm go off. LVN N also stated that it was normal for Resident #61 to wander inside the facility, but did not recall the resident actually trying to leave the facility. Interview with 100 hall CNA F on 4/12/23 at 6:55pm said that she did see Resident #61 walking through the facility throughout her 10pm-6am shift but was also in and out of rooms providing care. She said that she did not hear an alarm go off. She said it is Resident #61's normal behavior to wander the facility, and when she see her on her hall, she redirects her back to the 400-hall where her room is. She said she was not aware of Resident #61 trying to leave the facility. Interview with MN on 4/13/23 at 8:45am said that he checks all the doors every morning upon his arrival and before he leaves for the day. He said he tests them by pushing them to make sure the alarm beeps, then pulls them to ensure they are closed. MN explained that the doors located on resident halls are emergency exits and that no one should use them as regular exit or entry points. He said that to unlock the door, you must enter a pin number or hold the push bar for 15 seconds. If the bar is pushed, then an alarm will sound at the door and alert the nurses' station. If the bar is held for 15 seconds, then it will unlock and open. MN said that the morning of Resident #61's elopement, he went around to check all the doors and did not find anything wrong with the emergency doors on resident halls. He said that an issue was corrected with the front door controller for access control which would allow receptionist to open door from her desk. He said this would allow the receptionist to unlock the front door by pressing a button from her desk and not have to get up and press the door code. He stated this should not impact whether the door was locked appropriately when it is closed all the way. He believed that administration reviewed camera footage and saw housekeeping let themselves in at 3:50am but did not ensure the front door was closed all the way. This is how the police officer was able to enter through the front door. He said door checks are part of his normal routine but is not documented. He said he does not test Wanderguards. Interview with the Administrator on 4/13/23 at 9am said that she reviewed camera footage and saw Resident #61 and Resident #71 pushing on the 100-hall door. She was aware that the timestamp would be off 2-3 hours and stated that is an IT issue that has not been resolved. She said the residents did trigger the alarm and backed away from the door, however, the footage did not show staff come to check the door to ensure that it was closed properly. Later, Resident #61 returned to the door which was still slightly open and was able to walk out of the door undetected. The Administrator said that the resident could have been harmed, but thankfully she wasn't. The Administrator said it is normal for the resident to wander in the facility but had never eloped or tried to elope from the facility. She stated that Resident #61's Wanderguard was replaced immediately after the incident that morning on 4/12/23 and Resident #61 is under close monitoring now with checks every 15 minutes. She said that staff would be trained on that day 4/13/23 on elopement, abuse, and neglect. Record review of Wandering and Elopement Policy (March 2019) reflected, The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676490 If continuation sheet Page 7 of 19 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 676490 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sylan Shores Health and Wellness 3950 Underwood Rd LA Porte, TX 77571 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 - Some 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 to meet the needs of each resident for 4 of 13 residents (Resident #6, Resident #72, Resident #78, and Resident #105) reviewed for pharmacy services. MA A failed to administer Morphine, a pain medication, to Resident #6 within the scheduled administration window. The facility failed to ensure the Medication Room did not contain expired IV medications for Residents #78 and #105. The facility failed to ensure the 400 hall nursing cart did not contain expired Insulin and supplements for Resident #72. These failures could place residents at risk of not receiving the therapeutic benefit of medications and/or adverse reactions to medications. Findings Included Resident #6 Record review of Resident #6's Face Sheet dated 04/12/23 revealed, a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included: motor and sensory neuropathy (nerve pain), opioid dependence, legal blindness and absence of right and left leg below the knee. Record review of Resident #6's Quarterly MDS dated [DATE] revealed, intact cognition as indicated by a BIMS score of 15 out of 15, supervision on most ADLs, always continent of bladder, always continent of bowel, received both scheduled and PRN pain medications, did not receive non-medication intervention for pain and received 3 days of opioid in the last 7 days. Record review of Resident #6's undated Care Plan revealed, focus- potential for pain and tenderness in the joints; intervention- administer medications per MD orders. Record review of Resident #6's Physician's Orders dated 03/08/23 revealed, Morphine ER 15 mg- give 1 tablet 2 times a day for chronic pain do not crush scheduled for 09:00 AM. An observation and interview on 04/12/23 at 08:50 AM revealed, Resident #6's MAR was yellow indicating he had not yet received his Morphine. MA A said medications can be administered 1 hour before up until 1 hour after it is scheduled and she had administered the medication to Resident #6 at 07:30 AM but did not document it because it was outside of the medication administration window. She said she knew she was not supposed to give Resident #6 his morphine that early but the resident waits in the halls for his medications and when he does not receive it he gets irate, creates a ruckus and says he will report the staff to the state. MA A was observed to document administration of Morphine 15 mg to Resident #6 at 08:52 AM, 1 hour and 22 minutes after it was actually administered (07:30 am). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676490 If continuation sheet Page 8 of 19 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 676490 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sylan Shores Health and Wellness 3950 Underwood Rd LA Porte, TX 77571 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 400 Hall Nursing Cart Level of Harm - Minimal harm or potential for actual harm Resident #72 Residents Affected - Some Record review of Resident #72's Face Sheet dated 04/12/23 revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included: Alzheimer's Disease, type 2 diabetes and heart failure. Record review of Resident #72's MDS dated [DATE] revealed, intact cognition as indicated by a BIMS score of 13 out of 15, limited assistance with most ADLs, use of a wheelchair and frequently incontinent of both bladder and bowel. Record review of Resident #72's undated Care Plan revealed, focus- diabetes with unstable blood sugars; intervention- diabetes medication as ordered by doctor. Record review of Resident #72's Physician's Order dated 12/13/21 revealed, Basaglar insulin- inject 5 units under the skin once daily for diabetes. Hold if BG is less than 80. An observation and interview on 04/12/23 at 10:59 AM, inventory of the 400 Hall Nursing Cart with LVN A revealed: - an open, in use and expired Basaglar insulin pen for Resident #72 with an open date of 03/02/23. - an open and in use bottle of Zinc 50 mg with a manufacturer's expiration date of 03/2023. - an open and in use bottle of Ascorbic Acid (Vitamin C) with a manufacturer's expiration date of 01/2023. LVN A said this was her first day working on the hall but nursing staff are expected to check their carts daily as used for expired medications. She said insulin pens typically expire after 28 days (03/30/23 for Resident #72's Basaglar), after which they become less efficacious. She said since the Basaglar was expired it could no longer be used and must be discarded in the drug disposal bin located in the medication room. She said the use of expired insulin could place residents at risk for uncontrolled blood sugars, while the use of the expired dietary supplements could place residents at risk of inadequate supplementation. Medication Room Resident #78 Record review of Resident #78's Face Sheet dated 04/12/23 revealed a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included: osteomyelitis (bacterial bone infection), type 2 diabetes and hypertension (high blood pressure). Record review of Resident #78's MDS dated [DATE] revealed, no documented BIMS score or cognitive skills for daily decision making, extensive assistance for most ADLs, active diagnoses of pneumonia and septicemia (blood infection) in the last 7 days, 3 days of antibiotic use in the last 7 days, an indwelling urinary catheter and always incontinent of bowel. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676490 If continuation sheet Page 9 of 19 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 676490 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sylan Shores Health and Wellness 3950 Underwood Rd LA Porte, TX 77571 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 of Resident #78's Order Summary dated 04/12/23 revealed, Meropenem IV solution- use 500 mg intravenously every 8 hours related to osteomyelitis. The start date was 04/11/23 and the end date was scheduled for 04/26/23. Resident #105 Residents Affected - Some Record review of Resident #105's face sheet revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included: Bacteremia (bacterial infection of the blood), altered mental status, hypertension and type 2 diabetes. Record review of Resident #105's MDS dated [DATE] revealed, MDS was not completed. Record review of Resident #105's undated Care Plan revealed, Focus- endocarditis (bacteria heart infection) secondary to Osteomyelitis and MSSA bacteremia; intervention- administer IV antibiotic as per MD orders. Record review of Resident #105's Order Summary dated 04/12/23 revealed, Nafcillin- use 2 grams intravenously every 4 hours for endocarditis secondary to osteomyelitis- MSSA bacteremia. The start date was 04/03/23 and the scheduled end date was 05/16/23. An observation and interview on 04/12/23 at 11:12 AM, inventory of the Medication Room with LVN A revealed: - 9 bags of expired IV meropenem for Resident #78 with a pharmacy expiration date of 04/08/23. - 6 bags of expired IV Nafcillin for Resident #105 with a pharmacy expiration date of 04/09/23. - 17 bags of expired IV Nafcillin for Resident #105 with a pharmacy expiration date of 04/11/23. LVN A said she did not know who was responsible for checking the Medication Room for expired medications and both residents were still in the facility. She said use of expired IV antibiotics could place residents at risk for untreated health conditions and worsening of infections. In an interview on 04/12/23 at 11:16 AM, the DON said that all nurses and MAs are responsible for checking the medication room for expired medications. The DON said she was new to the facility so a schedule assigning nursing staff to check the medication room for expired medications had not been created yet but she went through the medication room last week. She said all expired medications should be pulled from the medication room and medication carts daily and disposed of in the drug disposal been. The DON said when medication expires it becomes ineffective and use could lead to untreated disease states, or uncontrolled blood sugars. In an interview on 04/12/23 at 01:53 PM, the DON said that medications are to be administered up to 1 hour before and 1 hour after they are scheduled. She said medications should not be given outside of the scheduled administration window and administering pain medications like morphine earlier than ordered could place residents at risk of breakthrough pain, decreased respirations and overdose. Record review of the facility policy titled Administering Medications revised 04/2019 revealed, Medications are administered in accordance with prescriber orders, including any required time frame. The individual administering the medication checks the label to verify the right resident, right (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676490 If continuation sheet Page 10 of 19 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 676490 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sylan Shores Health and Wellness 3950 Underwood Rd LA Porte, TX 77571 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 - Some medication, right dose, right time and right method (route) of administration before giving the medication. The expiration/beyond use date on the medication label is checked prior to administering. When opening a multi-dose container, the date opened is recorded on the container. Record review of the facility policy titled 'Storage of Medications' revised 11/2020 revealed, 4- Drug containers that have missing, incomplete, or improper, or incorrect labels are returned to the pharmacy for proper labeling before storing. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. Record review of Basaglar Highlights of Prescribing Information revised 07/2021 revealed, In-use Basaglar prefilled pens must be used within 28 days or discarded, even if they still contain Basaglar. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676490 If continuation sheet Page 11 of 19 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 676490 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sylan Shores Health and Wellness 3950 Underwood Rd LA Porte, TX 77571 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 0759 Ensure medication error rates are not 5 percent or greater. 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 ensure that the medication error rate was not five percent (%) or greater. The facility had a medication error rate of 22 percent based on 8 errors out of 36 opportunities, which involved 4 of 8 residents (Resident #24, Resident #39, Resident #60 and Resident #69) reviewed for medication errors. Residents Affected - Some - MA B failed to administer medication as ordered to Resident #60 by administering Artificial Tears containing Glycerin, Hypromellose and Polyethylene Glycol instead of Artificial Tears containing Carboxymethylcellulose. - MA B failed to administered medication as ordered to Resident #24 by administering Lidocaine 4% Patch, a patch used for pain, instead of Lidocaine 5% and applied the patch to the right knee instead of right rib cage. - MA A failed to administer Resident #69's blood pressure medications Hydrochlorothiazide, Losartan and Acebutolol even though the resident's BP fell within acceptable parameters. - MA A failed to administer medication as ordered to Resident #39 by administering an extra drop of Dorzolamide/Timolol, an eye drop for glaucoma, at the resident's request, failed to administer a full dose of Brimonidine 0.2% eyedrops and administered Carafate (Sucralfate) 1 gm, a medication that coats the stomach and is used to treat ulcers, with 5 other oral medications. Findings Included: Resident #60 Record review of Resident #60's Face sheet dated 04/12/23 revealed, a [AGE] year-old female who admitted to the facility on [DATE] with a diagnosis of dry eye syndrome. Record review of Resident #60's undated Care Plan revealed, focus- impaired visual function; interventiongive medications as ordered. Record review of Resident #60's Physician Order dated 03/21/23 revealed, Artificial Tears (Carboxymethylcellulose)- 1 drop on both eyes two times a day for dry eye. An observation at 04/12/23 at 07:46 AM revealed, MA B preparing for eye drop administration to Resident #60. She retrieved a bottle of Artificial Tears containing Glycerin, Hypromellose and Polyethylene Glycol instead of Artificial Tears containing Carboxymethylcellulose, entered into Resident #60's room, and administered 1 drop into each eye of the resident. Resident #24 Record review of Resident #24's Face Sheet dated 04/12/23 revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of: c/compression fracture and muscle wasting. Record review of Resident #24's Quarterly MDS dated [DATE] revealed, moderately impaired cognition (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676490 If continuation sheet Page 12 of 19 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 676490 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sylan Shores Health and Wellness 3950 Underwood Rd LA Porte, TX 77571 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 0759 Level of Harm - Minimal harm or potential for actual harm as indicated by a BIMS score of 09 out of 15, extensive assistance for most ADLs, use of a wheelchair, always incontinent of bladder and always incontinent of bowel. Record review of Resident #24's undated Care Plan revealed, focus- potential for pain related to a lumbar (lower back) fracture and chest pain; intervention- administer pain medication as per orders. Residents Affected - Some Record review of Resident #24's Physician Orders dated 03/08/23 revealed, Lidocaine 5%- apply to right rib cage under axilla (armpit) one time a day for pain. In an observation on 04/12/23 at 07:51 AM, MA B retrieved 1 Lidocaine 4% patch, labeled it with the date and initials and entered into Resident #24's room. She asked Resident #24 where she would like the patch applied to which the resident finally answered as to the right knee. MA B applied the Lidocaine 4% patch to Resident #24's right knee and then exited the room. In an interview on 04/12/23 at 01:43 PM, MA B said that prior to administering medications nursing staff should verify the patients name against the chart and then verify the medication including the strength to be administered against the physician's order in the MAR. She said staff must check the resident's vitals and if they are within parameters the medication can be administered. MA B said she administered Lidocaine 4% to Resident #24 but she didn't notice that the order was for Lidocaine 5%. She said Lidocaine 4% and Lidocaine 5% were not the same and she would notify her nurse to clarify the strength Resident #24 should be receiving as well as update the order. MA B said she did not notice that the Artificial Tears she administered had a different ingredient than Carboxymethylcellulose which was written on Resident #24's order. She said Artificial tears containing Hypromellose, Polyethylene Glycol and Glycerin was not interchangeable with Artificial Tears containing only Carboxymethylcellulose so she would contact her nurse for clarification on the order. MA B said failure to administer the correct medication or strength as ordered could place residents at risk of not receiving enough treatment or adverse reactions. Resident #69 Record review of Resident #69's Face Sheet dated 04/12/23 revealed a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included: type 2 diabetes, depression, type 2 diabetes, bipolar disorder, GERD, and heart failure. Resident #69 did not have a diagnosis of hypertension (high blood pressure). Record review of Resident #69's Quarterly MDS dated [DATE] revealed, impaired vision, use of corrective lenses, moderately impaired cognition as indicated by a BIMS score of 11 out of 15, supervision on all ADLs, occasionally incontinent of bladder and always continent of bowel. Record review of Resident #69's undated Care Plan revealed, focus- congestive heart failure; interventiongive cardiac medications as ordered. Record review of Resident #69's Order Summary dated 04/12/23 revealed: - Glimepiride 1 mg - 1 tablet by mouth one time a day for diabetes - Lactobacillus- 1 capsule one time a day for GI health - Omeprazole 40 mg DR- 1 capsule by mouth one time a day for GERD (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676490 If continuation sheet Page 13 of 19 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 676490 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sylan Shores Health and Wellness 3950 Underwood Rd LA Porte, TX 77571 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 0759 - Tamsulosin 0.4 mg- 1 capsule for BPH (enlarged Prostate). Level of Harm - Minimal harm or potential for actual harm - Acebutolol 200 mg- 1 capsule by mouth two times a day for high blood pressure with order date of 06/28/22. There were no parameter to hold for a low SBP. Residents Affected - Some - Hydrochlorothiazide 25 mg- ½ tablet by mouth two times a day for HTN, with order date of 06/28/22. There were no parameter to hold for a low SBP. - Losartan 50 mg- 1 tablet by mouth two times a day for HTN, with order start date of 06/28/22. There were no parameter to hold for a low SBP. An observation and interview on 04/12/23 at 09:01 AM revealed, MA A preparing medication for administration for Resident #69. She entered into the resident's room to check vitals and Resident #69's blood pressure was measured at 106/68 with a pulse of 62. MA A exited the resident's room and said she would not be administering Resident #69 any blood pressure medication because his blood pressure was too low. She retrieved and administered Resident #69's Glimepiride, lactobacillus, metformin, omeprazole and Tamsulosin. She did not administer Hydrochlorothiazide, Acebutolol and Losartan to Resident #69. An observation on 04/12/23 at 09:22 AM revealed, Resident #69's Losartan 50 mg blister pack directions read take 1 tablet by mouth twice daily; there were no BP parameters. Acebutolol 200 mg blister pack directions read take 1 capsule by mouth twice daily; there were no BP parameters. Hydrochlorothiazide 12.5 mg blister pack directions read table 1 tablet by mouth twice daily; there were no BP parameters. In an Observation and interview on 04/12/23 at 09:22 AM, MA A said that prior to medication administration nursing staff must ensure the resident is within parameters set by the prescribing MD so they must check vitals. She said the facility has a set SBP parameter of 110, and if a resident's SBP is less than that the medication is not given. After reviewing the order and the blister pack, MA A said Resident #69 did not have any parameters for his Acebutolol, hydrochlorothiazide and losartan and he should have received the medications. She said she should have consulted her nurse if she had questions about a medication with no parameters. She said failure to administer medications as ordered could place residents at risk for having untreated disease states. Resident #39 Record Review of Resident #39's face sheet dated 04/12/23 revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included: type 2 diabetes, legal blindness, heart failure, hypertension and retention of urine. Record review of Resident #39's admission MDS dated [DATE] revealed, severely impaired vision, limited assistance for most ADLs and frequently incontinent of both bladder and bowel. Record review of Resident #39's undated care plan revealed, focus- altered cardiovascular status r/t CHF, high cholesterol and hypertension; intervention- administer medications Per MD orders. Focus- diabetes with potential for abnormal blood levels, poor wound healing and pain; intervention- diabetes medications as ordered by doctor. Focus- receives eye drops r/t glaucoma; intervention- administer eye drops wherever Resident #39 is in the facility if not offensive to anyone. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676490 If continuation sheet Page 14 of 19 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 676490 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sylan Shores Health and Wellness 3950 Underwood Rd LA Porte, TX 77571 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 0759 Record review of Resident #39's Order Summary dated 04/12/23 revealed,: Level of Harm - Minimal harm or potential for actual harm - Brimonidine 0.2%- 1 drop in both eyes three times a day for glaucoma. - Dorzolamide/Timolol 2-0.5%- 1 drop in both eyes two times a day for glaucoma. Residents Affected - Some - Tamsulosin 0.4mg- 1 capsule by mouth one time a day for urine retention. - Hydralazine 25 mg- 1 tablet by mouth three times a day for HTN. - Carvedilol 6.25 mg- 1 tablet by mouth two times a day for HTN. - Docusate 100 mg- 1 capsule by mouth two times a day for constipation. - Potassium Chloride ER 8 mEq- 1 capsule 1 time a day for low potassium - Sucralfate 1 gm- 1 tablet by mouth before meals for gastric protection. An observation and interview at 04/12/23 starting at 09:07 AM revealed, MA A retrieved a bottle of Dorzolamide/Timolol eyedrops and entered into Resident #39's room. She administered 1 drop to Resident #39's right eye and 1 drop to Resident #39's left eye. Resident #39 asked MA A for an addition drop to her right eye and MA A agreed administering 1 additional drop of Dorzolamide/Timolol to the right eye. Resident #39 received a total of 2 drops to the right eye and 1 drop to the left eye. MA A returned to her medication cart and retrieved 1 tablet of Sucralfate 1 gm from a blister pack with an accessory label that read Take this product At Least 2 Hours Before or 2 Hours After Other Medications., 1 tablet of Carvedilol 6.25 mg, 1 tablet of Hydralazine 25 mg, 1 capsule of Tamsulosin 0.4mg, 1 capsule of KCL 8 mEq, 1 capsule of docusate 100 mg and administered the oral medications to Resident #39. At 09:17 AM MA A then retrieved a bottle of Brimonidine 0.2% eye drops and entered into Resident #39's room, she held the eye drop above the resident's left eye and pressed the bottle. A single drop was observed to hit Resident #39's upper eye lid with some of the liquid running down the side of her eye lid and into the corner of the Resident's eye, the resident did not receive the full dose into her left eye. MA A then administered 1 drop into Resident #39's right eye. MA A said that medications should be administered as ordered and she typically has difficulty administering eye drops to Resident #39 due to the positioning of the resident's head and she did not want to force the resident's head back. She said Resident #39 wanted an extra drop of her Dorzolamide/Timolol so she gave it but it was not appropriate to administer additional doses. MA A said she did not notice the Brimonidine first hit Resident #39's upper eye lid and since the resident did not get the full dose she must notify her nurse to determine what action should be taken. She said failure to administer medications as ordered could place residents at risk for untreated disease states and adverse reactions. In an interview on 04/12/23 at 01:53 PM, the DON said prior to administering medications nursing staff are expected to check the resident's vitals and document them in the EMR. She said if the resident's vitals are within the MD set parameters the medication can be administered and if they are outside of the parameters the dose should be held and the MD notified. The DON said its incorrect to hold a medication that has no parameters and if a MA had a question about a resident's vitals they should notify their nurse. The DON said nursing staff must then verify the patient information, drug information against the MAR and the prescriptions. She said when staff are selecting the medication to be administered, they must follow MD orders ensuring both the drug, strength and location of application were accurate. The DON said eye drops should be administered as ordered and since the eye drop (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676490 If continuation sheet Page 15 of 19 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 676490 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sylan Shores Health and Wellness 3950 Underwood Rd LA Porte, TX 77571 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 0759 Level of Harm - Minimal harm or potential for actual harm hit Resident #39's eye prior to entering her eye the resident did not receive the full dose; she said that MA A should not have administered additional eyedrops upon Resident #39's request. She said that administering Sucralfate could impact the efficacy of the other medications since it coats the stomach so it should be administered as ordered. The DON said failure to administer medications as ordered could place residents at risk for inadequate therapy and adverse reactions Residents Affected - Some Record review of the facility policy titled Administering Medications revised 04/2019 revealed, Medications are administered in accordance with prescriber orders, including any required time frame. The individual administering the medication checks the label to verify the right resident, right medication, right dose, right time and right method (route) of administration before giving the medication. Record review of the facility policy titled Medication Errors revised 04/2014 revealed, 5- a medication error is defined as the preparation or administration of drugs or biological which is not in accordance with the physician's orders, manufacturer specifications, or accepted professional standards of the professional(s) providing services. 6- examples of medication errors include: a) omission- a drug is ordered but not administered; b) unauthorized drug- a drug is administered without a physician's order; f) wrong drug; g) wrong time. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676490 If continuation sheet Page 16 of 19 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 676490 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sylan Shores Health and Wellness 3950 Underwood Rd LA Porte, TX 77571 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 - Some 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 drugs and biologicals used in the facility were labeled in accordance with professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable for 2 of 3 medication carts (400 Hall Nursing Cart and 200 Hall Nursing Cart) reviewed for medication storage. - The facility failed to ensure the 400 Hall Nursing Cart did not contain insulin pens with no open date - The facility failed to ensure the 200 Hall Nursing Cart did not contain insulin pens with no pharmacy labels. This failure could place residents at risk of adverse medication reactions. Findings Included: 400 Hall Nursing Cart Resident #18 Record review of Resident #18's Face Sheet dated [DATE] revealed, a [AGE] year-old male admitted on [DATE] with diagnoses which included: type 2 diabetes and depression. Record review of Resident #18's Quarterly MDS dated [DATE] revealed, intact cognition as indicated by a BIMS score of 13 out of 15, extensive assistance with most ADLs, occasionally incontinent of bladder and always incontinent of bowel. Record review of Resident #18's Physician Order dated [DATE] revealed, Basaglar Insulin- inject 90 units under the skin at bedtime. Resident #37 Record review of Resident #37's Face Sheet dated [DATE] revealed, a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included: type 2 diabetes. Record review of Resident #37's Quarterly MDS dated [DATE] revealed, moderately impaired cognition as indicated by a BIMS score of 12 out of 15, extensive assistance with most ADLs, an indwelling urinary catheter and frequently incontinent of bowel. Record review of Resident #37's undated Care Plan revealed, focus- diabetes with potential for abnormal blood sugar levels; intervention- diabetes medications as ordered by doctor. Record review of Resident #37's Physician Orders dated [DATE] revealed, NovoLog Insulin- inject as per sliding scale. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676490 If continuation sheet Page 17 of 19 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 676490 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sylan Shores Health and Wellness 3950 Underwood Rd LA Porte, TX 77571 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 An observation and interview on [DATE] at 10:59 AM, inventory of the 400 Hall Nursing Cart with LVN A revealed: Level of Harm - Minimal harm or potential for actual harm - an open and in use Basaglar Insulin pen for Resident #18 with no open date. Residents Affected - Some - an open and in use Novolog Insulin pen for Resident #37 with no open date. LVN A said nursing staff are expected to check their carts daily for expired or inappropriately labeled medications. She said Insulin pens should be labeled with the date they are opened in order to track the expiration date. LVN A said after insulin expires it becomes less effective and since the expiration dates on the pens could not be established they must be discarded in the drug disposal bin. She said use of expired insulin could place residents at risk for un-controlled blood sugars. 200 Hall Nursing Cart An observation and interview on [DATE] at 11:23 AM, inventory of the 200 Hall Nursing Cart with LVN B revealed: - an open and in use Humalog Insulin Pen with no pharmacy label or open date. - an open and in use Novolog Insulin Pen with no pharmacy label or open date. LVN B said nursing staff are expected to check their carts every day as used for inappropriately labeled medications. She said all medications should have pharmacy labeling which includes: patient name, dose, route and prescription information. She said since the insulin pens did not have any patient identifiers they must be discarded in drug disposal bin and use of unlabeled insulin pens could lead to cross contamination if used on different patients. In an interview on [DATE] at 11:16 AM the DON said, nursing staff are expected to check their carts daily as used for inappropriately labeled medications. She said Insulin pens should have a pharmacy label as well as an open date which is used to track the expiration date. The DON said Insulin loses its efficacy after they expire and use could lead to untreated disease states, or uncontrolled blood sugars. She said all inappropriately labeled medications should be discarded in the drug disposal bin in the med room. Record review of the facility policy titled Insulin Administration revised 09/2014 revealed, 4- check expiration date, if drawing from an opened multidose vial. IF opening a new vial, record expiration date and time on the vial (follow manufacturer recommendations for expiration after opening. Record review of the facility policy titled Labeling of Medication Containers revised 04/2019 revealed, 2any medication packaging or containers that are inadequately or improperly labeled are returned to the issuing pharmacy. 3- Labels for individual resident medications include all necessary information. Such as: a) the resident's name; b) the prescribing physician's names; i- directions for use. Record review of the facility policy titled Storage of Medications revised 11/2020 revealed, 4- Drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676490 If continuation sheet Page 18 of 19 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 676490 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sylan Shores Health and Wellness 3950 Underwood Rd LA Porte, TX 77571 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain medical records on each resident, in accordance with accepted professional standards and practices, which were complete and accurately documented for 1 of 15 residents (Resident #6) whose records were reviewed. - MA A failed to document administration of Morphine ER 15 mg, an opioid used to treat pain, until 1 hour and 20 minutes after administration. These failures could place residents at risk for inadequate errors leading to medication errors and adverse reactions. Findings Included: Record review of Resident #6's Face Sheet dated 04/12/23 revealed, a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included: motor and sensory neuropathy (nerve pain), opioid dependence, legal blindness and absence of right and left leg below the knee. Record review of Resident #6's Quarterly MDS dated [DATE] revealed, intact cognition as indicated by a BIMS score of 15 out of 15, supervision on most ADLs, always continent of bladder, always continent of bowel, received both scheduled and PRN pain medications, did not receive non-medication intervention for pain and received 3 days of opioid in the last 7 days. Record review of Resident #6's undated Care Plan revealed, focus- potential for pain and tenderness in the joints; intervention- administer medications per MD orders. Record review of Resident #6's Physician's Orders dated 03/08/23 revealed, Morphine ER 15 mg- give 1 tablet 2 times a day for chronic pain do not crush. An observation and interview on 04/12/23 at 08:50 AM revealed, Resident #6's MAR was yellow indicating he had not yet received his Morphine. MA A said she had administered the medication to Resident #6 at 07:30 AM but did not document it because it was outside of the medication administration window. MA A was observed to document administration of Morphine 15 mg to Resident #6 at 08:52 AM, 1 hour and 22 minutes after it was actually administered (07:30). In an interview on 04/12/23 at 01:53 AM, the DON said that nursing staff are expected to document immediately after medication administration. She said failure to document administration of pain medications on time could lead to duplication of administration, if another nurse did not know the medication was previously administered. She said failure to document the administration of pain medication on time could place the resident as risk of decreased respiration and overdose if a duplicate administration occurs. Record review of the facility policy titled Administering Medications revised 04/2019 revealed, the individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next one. As required or indicated for a medication, the individual administering the medication records in the resident's medical record: the date and time the medication was administered The signature and title of the person administering the drug. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676490 If continuation sheet Page 19 of 19