Bayou Pines Care Center

F 0583 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

to see her screen unless they were on the floor. She said the harm in leaving the screen up would be someone viewing another's personal information and residents should not be able to see the information either. She stated that sometimes she noticed nurses at the nurse's station would leave their computer screen unlocked, but they didn't realize that there was a screen they could click that would hide the information if they needed to walk away. The policy was to keep personal information hidden while you were not at your laptop or computer at the nurse's station.

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Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/16/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Bayou Pines Care Center

4905 Fleming Street LA Marque, TX 77568

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

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

F 0755 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

seizure activity is witnessed. In the event of a seizure, the physician will be informed and will follow physician recommendations. Documentation of calling MD and recommendations will be entered into medical records. Any new employee will be educated prior to start of shift. Staff will not be allowed to provide direct care until the training is completed. 6. On 9/15/2025 safe surveys were completed with residents by DON (RN), ADON (LVN), Social Services Director (LVN), and Administrator regarding receiving medications as ordered. No resident identified an issue with receiving or delivery. 7. As of 9/15/2025 Director of Nursing or Assistant DON will monitor unadministered medication prior to clinical meeting to determine why it was not administered (i.e. hospital, hospice, dc'd medication, extra). If it is determined it is extra, investigation will be initiated and pharmacy notified. A detailed list of any extra medication will be kept by the DON starting 9/15/25. This is a new practice that is not written in the Medication Administration Policy but will be an ongoing practice of the facility. 8. On 9/15/25, Medical Director declined to add new orders for Resident #1 to regularly monitor Carbamazepine level. 9. On 9/15/25 Ad Hoc QAPI was conducted with the Medical Director to review the plan of action and will be reviewed monitoring results will be reviewed monthly X 3 months in monthly QAPI. The Surveyor monitored

the POR on 9/16/25 as followed: Review of an in-service titled Extra Medication conducted 8/22/25 documented that the COO educated the DON and ADON on investigating extra medication and conducting thorough investigations regarding all medication concerns. DON explained in an interview on 9/16/25 at 11:30 pm that she was to investigate where extra medications came from by investigating if the resident was on hospice, in the hospital, or discharged . She created a spreadsheet that she would update daily that included the date, resident name, medication, and reason missed. This would help her track and trend all medication concerns. Review of the in-service dated 9/15/25 educated all nursing staff and medication aids

on what to do if they discovered additional medication packets on the medication cart. During interviews on 9/16/25 between 11:00 am- 2:00pm, Nurses (9 LVN's, 3 RN's, 2 medications aides) stated that they were to document the reason medication was not administered, write the reason why medication was not administered on all extra medication packets, and store those packets in the locked cabinet inside of medication room. On 9/15/25, an in-service dated 8/22/25 reflected that all nursing staff were educated seizure protocols and what do if a resident was having a seizure. During interviews on 9/16/25 from 11:00 am - 2:00 pm, nurses from the 7 am-7 pm and 7 pm-7 am shift were asked to review what was covered

during their in-services. Nurses stated that if a resident was experiencing a seizure, they were to make sure

the resident was safe, PRN medication was checked, and the NP or doctor was contacted on what recommendations to implement. Each seizure should be documented appropriately and additional notification should include the DON and family. Review of the Safety Rounds Checklist completed 9/12/25 with all cognizant residents concluded that residents felt safe at the facility and had no issues with receiving medications. An interview attempt was made on 9/16/25 with Medical Director but he could not be reached.

Record review of POR and in-service dated 09/15/25 documented a signature of agreement from Medical Director. RN B was terminated on 8/29/25. Review of the Employee Counseling Disciplinary Report documented that the reason for termination was substandard care and falsifying documentation. The ADM and DON were notified on 9/16/25 2:18 pm that the IJ had been removed. While the IJ was removed, the facility remained at a level of no actual harm at a scope of isolated that is not immediate jeopardy due to

the facility's need to evaluate the effectiveness of the corrective systems.

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