Bayou Pines Care Center

F-F285), Subpart C, Preadmission Screening and Annual Review of Mentally Ill and Mentally Retarded Individuals . Facility staff will coordinate with referring entities to ensure that any individual seeking admission to a Medicaid-certified facility receives a PASRR Level 1 screening for an intellectual disability (ID), developmental disability (DD) or mental illness (MI) before or upon admission .If the PASRR LEVEL 1 screening indicates the individual may have an ID, DD or MI, staff will .coordinate with the local mental health authority (LMHA) to ensure the individual receives a PASRR Level II evaluation.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 10 676223 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 676223 B. Wing 07/31/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Bayou Pines Care Center 4905 Fleming Street LA Marque, TX 77568

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 26244

Residents Affected - Few Based on observation, interview and record review, the facility failed to develop and implement a comprehensive care plan that included measurable objectives and timetables to meet the resident's medical, nursing, and psychological needs that were identified in the comprehensive assessment for 1 of 19 residents reviewed for care plans (Resident #138), in that:

Facility failed to have Resident #138's care plan for PTSD, with goals and interventions to address cognitive behavioral therapy.

This failure placed residents at risk of not having accurate care plans to address psychological care.

Findings include:

Resident #138

Record review of Resident #138's clinical chart revealed admitted [DATE REDACTED] with diagnoses including heart disease with congestive heart failure (reduction in ability of heart to pump blood), Diabetes (the body does not produce enough insulin, PTSD (mental health condition triggered by a traumatic event), Osteoarthritis (breakdown of joint tissues over time).

Record review of Resident #138's MDS dated [DATE REDACTED] revealed a BIMS score of 14, indicating no impairment of cognitive skills, ability to understand and be understood, assistance required for ADLs, and active diagnosis of PTSD.

Record review of the physician's orders dated for July 2024 revealed Goal: manage PTSD symptoms to improve quality of life and maximize functioning; Plan: continue Citalopram 40 mg (to treat depression), Buspirone 15 mg (to treat anxiety disorders), Clonazepam 1mg (to treat panic disorders and anxiety), establish care with psychology for cognitive behavioral therapy.

Record review of the undated care plan for Resident #138 revealed no care plan for PTSD, with goals or interventions for cognitive behavioral therapy.

Observation of Resident #138 on 7/29/24 at 9:10am revealed she was in her room, dressed, standing by her bed with her walker, talking to her roommate. She said she was doing well here and has meetings with the therapist every week which helps her feel better.

Record review of Resident #138's therapy provider Diagnostic assessment dated [DATE REDACTED] revealed cognitive behavioral therapy sessions to be conducted 4 times a month for 4 months, for making and implementing a treatment plan to address coping strategies for anxiety, depression and nervousness/worried mood, and monitoring depression severity.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 10 676223 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 676223 B. Wing 07/31/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Bayou Pines Care Center 4905 Fleming Street LA Marque, TX 77568

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Record review of Resident #138's therapy provider progress notes dated 7/15/24, revealed continued cognitive behavioral therapy sessions with emphasis on the treatment plan developed during the diagnostic Level of Harm - Minimal harm or assessment, including supportive interventions, discussion of coping skills related to adjustment to potential for actual harm placement, participation in activities and therapy, and reinforced adaptive cognitive behaviors related to previous threats by family member. Residents Affected - Few

Record review of Resident #138's therapy provider progress note dated 7/25/24 revealed supportive interventions related to patient's concerns about anxiety, explored triggers and coping strategies including distraction, deep breathing, and exercise, and discussed adjustment to placement, positive relationships issues, participation in activities, and reinforced cognitive and behavioral techniques.

Record review of Resident #138's therapy provider progress note dated 7/29/24 revealed supportive interventions related to care and facility issues, discussion of changes in medication and positive response to it, reviewed handling of different experiences and coping strategies, and reinforced adaptive cognitive and behavioral techniques.

Record review of PASRR denial letter dated 7/2/24 revealed Resident #138 was not eligible for specialized services because of not having a qualified diagnosis of mental illness, intellectual disability, or developmental disability.

In an interview with MDS A on 7/31/24 at 3:00 pm revealed Resident #138's care plan had not been updated for PTSD and cognitive behavioral therapy. She said she referred Resident #138 for PASRR Specialized Services due to the diagnosis of PTSD, but the facility received a PASRR denial letter on 7/2/24. She said all

the staff had input into the care plans, and she documented the final care plan, and if the care plan was not accurate, it could affect the care of the resident.

In an interview with the DON on 7/31/24 at 3:50 pm revealed the care plans needed to be accurate for the resident and if the care plan was not accurate, the resident would not get proper care.

Record review of the facility policy Goals and Objectives, Care Plans, revised April 2011, revealed, in part: . care plans shall incorporate goals and objectives that lead to resident's highest obtainable level of independence .goals and objectives are on the care plan, so all disciplines have access .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 10 676223 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 676223 B. Wing 07/31/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Bayou Pines Care Center 4905 Fleming Street LA Marque, TX 77568

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0742 Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress Level of Harm - Minimal harm or disorder. potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 48315 Residents Affected - Few Based on observation and record review, the facility failed to ensure a resident who displayed or diagnosis with a mental disorder or psychosocial adjustment difficulty received appropriate treatment and services to correct the assessed problem or to attain the highest practicable mental and psychosocial well-being for 1 of 5 residents (Resident #42) reviewed for psychosocial concerns, in that:

The facility failed to ensure Resident #42 received individualized behavioral health services addressed through a person-centered care plan.

The facility failed to ensure that Resident #42 diagnosis of Anxiety was addressed and followed up on per care plan.

The facility failed to update Resident #42s care plan to reflect psychological services declined by the responsible party.

These failures could put residents at risk for not receiving behavioral health services and a decline in quality of life.

The findings were:

Record review of Resident #42's admission face sheet dated1/26/2017 indicated she was a [AGE] year-old female. Resident #42 was admitted with a diagnosis of Anxiety.

record review Resident #42 Minimum Data Sheet (MDS) assessment dated [DATE REDACTED] revealed Resident #42 had a BIMS 99 score along with diagnosis of severe impaired cognition, exhibited screaming out and aggressive behaviors towards other residents.

Record review of Resident #42 comprehensive care plan last revised on dated 9/02/2018 for psychological consult as ordered by physician.

Record review of Resident #42 revealed no physician order for psychological services was initiated by the physician or call into physician for order on behalf of resident #42

Record review of Resident #42 revealed no progress note regarding any notifications or coordination of psychiatric services.

Record review of Resident #42 physician progress notes revealed no documentation of any referral to psychiatric services. There was no documentation of any physician or nurse practitioner notification for psychiatric related services.

Interview the Director of Nursing stated she could not explain why the order was not carried out or followed up on.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 10 676223 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 676223 B. Wing 07/31/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Bayou Pines Care Center 4905 Fleming Street LA Marque, TX 77568

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0742 Interview MDS A stated she was aware of the care plan addressing Resident #42 goals and interventions was to be seen by psychological consult but did not know why she was not seen or followed up on. Level of Harm - Minimal harm or potential for actual harm Record review of facility policy titled, Goals and Objectives, Care Plans, dated, April 2011, reflected in part, . Goals and objectives are reviewed and/or revised .at least quarterly . Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 10 676223 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 676223 B. Wing 07/31/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Bayou Pines Care Center 4905 Fleming Street LA Marque, TX 77568

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food

in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 26867

Residents Affected - Few Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety.

The facility failed to ensure all expired food products and dented cans were not stored in the kitchen's dry goods shelves and removed from the kitchen.

This failure placed residents at risk of foodborne illness.

Findings included:

Kitchen observation on [DATE REDACTED] at 11:00 AM revealed 7 one-quart cartons of Med Plus with a manufactural date of use by [DATE REDACTED]. Further observation revealed one dented 16oz can of tomato soup. The Dietary Manager removed the expired Med Plus products and the dented soup can off the dry goods shelf.

During an interview with the Dietary Manager on [DATE REDACTED] at 11:15AM, she said the Med plus was supplied as

a substitute for food items, but the Med plus was not used. She said the kitchen would not use any food products from dented cans due to food poising. She did not answer any questions on using expired food products.

In an interview with the facility Administrator on [DATE REDACTED] at 11:00Am, he said dented cans and expired food products should not be in the kitchen.

Record review of provided facility's policy on [DATE REDACTED] dated 2005, titled Food Service Problem did not address expired food products and dented food cans in the kitchen.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 10 676223