Bay Ridge Healthcare Center

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

said when incidents were reported to her, she would inform the Administrator. She said the Administrator would investigate and report it to the state. She said unwitnessed falls should be investigated and reported if there were injuries and if the resident was unable to say what caused the fall. Further interview on 10/28/2025 at 10:30 am with the Administrator she said the incident was not investigated and reported. She said she took full responsibility for not investigating and reporting the incident in the 2 hours or 24 hours' time frame for reporting and investigating abuse and neglect. She said the day they told her about the incident she had intended to investigate and report it but did not get a chance. She said she had missed it.

In an interview on 10/28/2025 at 3:50pm LVN B said she was the nurse working at the time the incident occurred. She said it was around dinnertime and Resident #2 was in bed, the bed was in the lowest position, and she heard her yelling and when she got to the room the resident was at the door on the floor

on her left side and bleeding. She said Resident #2 had a skin tear with blood and hematoma to the forehead. She said she immediately checked her vitals, called the MD, DON, 911, cleaned the area to the forehead and Resident #2 was sent out 911 to the nearest hospital. She said Resident #2 returned from the hospital the same day with no stitches, bleeding, or fracture. In an interview on 10/28/2025 at 5:14pm, the Administrator said usually when there was an incident regarding abuse, neglect or exploitation they would report to the administrator. She said if it were nursing issues then the staff would report to the DON or Charge nurse, and they would inform her. She said she was informed about Resident #2's fall and had got written up because it was not investigated and reported within the reporting time frame. She said she will ensure that all incidents regarding abuse, neglect and exploitation would be investigated and reported in

the timely reporting manner. Record review of the facility's Abuse Prohibition Policy, dated 06/02/2025, revealed.INTENT:This protocol was intended to assist in the prevention of abuse, neglect and misappropriation of property.Each resident has the right to be free from abuse, mistreatment, neglect, corporal punishment, involuntary seclusion and financial abuse.POLICY:2. The facility will conduct an investigation of alleged or suspected abuse, neglect, or misappropriation of property, and will provide notification of information to the proper authorities according to state and federal regulations.3.The facility will designate a qualified staff member to oversee the abuse prohibition program.4. The facility will post the Abuse Prohibition poster in the facility easily visible to residents, families, significant others and staff. Abuse Prohibition Program:The facility's abuse prevention program includes the following components:?Screening?Training?Prevention?Identification?Investigation?Protection?Reporting/ Response

Investigation

1.The facility will thoroughly investigate all alleged violations and take appropriate actions.2.The Abuse Coordinator will report such allegations to the state agency in accordance with state law. The Abuse Coordinator will report all allegations of abuse, neglect with serious bodily injury, mistreatment with serious bodily injury, exploitation with serious bodily injury, and injuries of unknown source with serious bodily injury within two hours of the allegation. The Abuse Coordinator will report all other allegations of neglect, mistreatment, exploitation, injuries of unknown source and misappropriation within 24 hours of the allegation. 3. The facility will report the results of the investigation to the enforcement agency in accordance with state law, including the state survey and certification agency.5.Investigations will be prompt, comprehensive and responsive not involves serious bodily injury.

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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

11/25/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Bay Ridge Healthcare Center

208 South Utah 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 - Few

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

be a learning experience for the nurses to always document and ensure that no blanks were on the MARs.

In an interview on 10/28/2025 at 5:30pm, the Administrator said the resident record should be complete and accurate. She said they were going to do a complete audit of resident's medical records. She said the nursing staff would would be in-serviced on documentation regarding physician's orders, medication administration and the adverse effect of not documenting could influence resident's care. She said her expectations of the staff were to ensure the physician's orders were followed and documented in the clinical records. She said the plan going forward was to ensure that staff were documenting accurately in resident clinical records. Record review of the facility policy titled, Medication Administration, dated 07/2025, revealed .21. If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall initial and circle the MAR space provided for that drug and dose.22. The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next one.23. As required or indicated for a medication, the individual administering the medication records in the resident's medical record:a. the date and time the medication was administered.b. the dosage.c. the route of administration.g. the signature and title of the person administering the drug.24. Topical medications used in treatments are recorded on the resident's treatment record (TAR).25. Staff follow established facility infection control procedures (e.g., handwashing, antiseptic technique, gloves, isolation precautions, Enhanced Barrier Precautions etc.) for the administration of medications, as applicable.

Event ID:

Facility ID:

If continuation sheet

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

11/25/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Bay Ridge Healthcare Center

208 South Utah 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 - Some

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

AM and PM (Report result over >300 to NP/MD). two times a day related to DM Type 2. Record review of Resident #2's TAR for October 2025 revealed the Accu-Chek was not documented as checked on 10/02/2025 at 5:00pm. Further record review of the TAR revealed there were blanks on the treatment administration records. Record review of Resident #2's nurse's progress notes, dated 10/02/2025, revealed no documentation as to why the Accu Check was not done. Observation on 10/24/2025 at 11:45 am revealed Resident #2 was lying in bed resting. Resident #2 was alert and oriented with confusion. She was clean, well-groomed with no offensive odor, and the call light was observed to be within reached. interview

on 10/28/2025 at 4:00 p.m., LVN C said she was not the one who provided treatment to Resident #1. She said there should be no blanks on the MARs/TARs. She said if there were blanks on the MARs/TARs it would be difficult to determine if the medication was given or not given. She said if the treatment or medication was not done there should be a check stating why it was not done but there should be no blanks on the MARs. In an interview on 10/28/2025 at 5:00 p.m., RN A said there should be no blanks on

the MARs /TARs. She said whether the treatment was done, or not, it should be documented. She said she must pay more attention and always document when medications were given and or not given. She said blanks on the MARs could indicate the medication was given or not given. She said this should be a learning experience for the nurses to always document and ensure that no blanks were on the MARs. In an

interview on 10/28/2025 at 5:30pm, the Administrator said the resident record should be complete and accurate. She said they were going to do a complete audit of resident's medical records. She said the nursing staff would be in-serviced on documentation regarding physician's orders, medication administration and the adverse effect of not documenting could influence resident's care. She said her expectations of the staff were to ensure the physician's orders were followed and documented in the clinical records. She said the plan going forward was to ensure that staff were documenting accurately in resident clinical records. Record review of the facility's policies and procedures dated July 2017 titled Charting and Documentation read in part.Policy StatementAll services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between

the interdisciplinary team regarding the resident's condition and response to care.Policy Interpretation and Implementation2. The following information is to be documented in the resident medical record:b.

Medications administered;c. Treatments or services performed;3. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate.4. Entries may only be recorded in the resident's clinical record by licensed personnel (e.g., RN, LPN/LVN, physicians, therapists, etc.) in accordance with state law and facility policy. Certified nursing assistants may only make entries in the residents' medical chart as permitted by facility policy.6. To ensure consistency in charting and documentation of the resident's clinical record, only facility approved abbreviations and symbols may be used when recording entries in the resident's clinical records.7. Documentation of procedures and treatments will include care-specific details, including:a. the date and time the procedure/treatment was provided;b. the name and title of the individual(s) who provided the care;e. whether the resident refused the procedure/treatment;f. notification of family, physician, or other staff, if indicated; andg. the signature and title of the individual documenting.

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If continuation sheet