Inspection·February 10, 2023

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview and observation on 02/10/2023 at 3:15 p.m. the MDS B stated it only took one occasion in the last 14 days from the look back date to count oxygen use on the MDS. She further reported when the MDS was completed a care management specialist (MDS A or MDS B) would look at the skilled MAR and the nurses notes for dates of usage, however they did not review the vitals section of the EMR. The MDS B reviewed Resident #40's skilled MAR and nurses notes stated oxygen use should have been coded due to documentation on 01/25/2023, however the resident's skilled MAR did not show the method resident was receiving oxygen via nasal cannula or room air. The MDS B stated it was the responsibility of the care management specialists (MDS A or MDS B) to complete the MDS. During an interview and observation on 02/10/2023 at 3:36 p.m. the MDS A stated when completing a MDS she would only need one documentation to count oxygen use on the MDS. She further stated she reviewed the skilled MAR, and the nurses notes for oxygen having been placed on the resident. The MDS A reviewed Resident #40's EMR and found a nurse had documented oxygen use 01/25/2023. The MDS A further stated she should have coded for oxygen use on the quarterly MDS. The MDS A stated she did not review vitals for oxygen use when she completed the MDS. During an interview on 02/10/2023 at 3:49 p.m. the DON stated the care management specialists (MDS A & MDS B) were responsible for the completion of the MDS. The DON further stated her signing of the MDS only confirmed the completion of the MDS not the accuracy. During an interview on 02/10/2023 at 4:30 p.m. the DON stated the facility followed the RAI Manual and did not have a policy regarding the MDS. Review of the RAI Manual for CMS's RAI Version 3.0 Manual CH 3: MDS Items [O] date October 2019 Section O Special Treatments, Procedures and Programs Intent: The intent of the items in this section is to identify any special treatments, procedures, and programs that the resident received during the specified time periods .Planning for Care: Reevaluation of special treatments and procedures the resident received or performed or programs that the resident was involved in during the 14-day look-back period is important to ensure the continued appropriateness of the treatments, procedures, or programs .O0100C, Oxygen therapy Code continuous or intermittent oxygen administered via mask, cannula, etc., delivered to a resident to relieve hypoxia in this item .this item may be coded if the resident places or removes his/her own oxygen mask, cannula. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455999 If continuation sheet Page 2 of 11 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 455999 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Port Lavaca Nursing and Rehabilitation Center 524 Village Rd Port Lavaca, TX 77979 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to develop and implement a comprehensive person-centered care plan for 3 of 18 residents (Residents #63, #42, and #11) reviewed for comprehensive person-centered care plans in that: 1. Resident #63's oxygen therapy was not addressed in the resident's comprehensive person-centered care plan. 2. Resident #42's comprehensive person-centered care plan did not reflect the resident had a pressure sore to the sacrum. 3. Resident #11's comprehensive person-centered care plan indicated the resident still had an indwelling urinary catheter when the resident no longer had one. These deficient practices could affect residents who receive individualized care base on their comprehensive person-centered care plans and could result in the improper delivery of care. The findings were: 1. Review of Resident #63's electronic face sheet dated 02/07/2023 revealed he was admitted to the facility on [DATE] with diagnoses of heart failure (the heart is not strong enough to pump blood properly), chronic kidney disease (gradual loss of kidney function), anemia (lack of enough healthy red blood cells to carry adequate oxygen to the body's tissues) and chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs). Review of Resident #63's Quarterly MDS assessment with an ARD of 12/26/2022 revealed he received oxygen therapy while in the facility. Further review revealed he scored a 15/15 on his BIMS which indicated he was cognitively intact. Review of Resident #63's comprehensive person-centered care plan dated 12/27/2022 revealed Focus .has history of CHF and COPD. Resident #63's comprehensive person-centered care plan did not address his use of oxygen. Review of Resident #63's Active Orders as of: 02/07/2023 revealed Oxygen at 3 L/min via nasal canula every shift for hypoxia (below-normal level of oxygen in the blood) with a start date of 12/22/2023. Review of Resident #63's SAR from 02/01/2023 - 02/28/2023 revealed he was initialed off each shift to have Oxygen at 3 L/min via nasal cannula. Observation on 02/07/2023 at 9:30 a.m. revealed Resident #63 had oxygen infusing via nasal cannula at 3 L/min. Observation on 02/08/2023 at 12:00 p.m. revealed Resident #63 had oxygen infusing via nasal cannula at 3 L/min. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455999 If continuation sheet Page 3 of 11 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 455999 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Port Lavaca Nursing and Rehabilitation Center 524 Village Rd Port Lavaca, TX 77979 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 Interview on 02/08/2023 at 1:00 p.m. with Resident #63 revealed he used oxygen continuously. Level of Harm - Minimal harm or potential for actual harm Interview on 02/10/2023 at 3:56 p.m. with the DON revealed that the facility had 20 days to do the comprehensive plan of care and did not know how Resident #63's oxygen therapy was missed. She stated it was important to have what the resident needed for care in the plan or it could result in him having difficulty breathing or the wrong rate given. Residents Affected - Some Interview on 2/10/2023 at 4:23 p.m. with MDS A revealed that Resident #63's comprehensive person-centered care plan should have reflected he was on oxygen therapy while in the facility and she could not explain how it was missed. 2. Review of Resident #42's electronic face sheet dated 02/09/2023 revealed he was admitted to the facility on [DATE] with diagnoses of sepsis (infection of the blood stream), pneumonia (an infection that inflames the air sacs in one or both lungs) gastrointestinal hemorrhage (symptom of disorder in the digestive tract) and cellulitis of other sites (a common, potentially serious bacterial skin infection). Review of Resident #42's admission MDS assessment dated [DATE] revealed he had a Stage II pressure sore (Partial thickness loss of dermis presenting as a shallow open ulcer with a red, pink wound bed, without slough). He scored 14/15 on his BIMS which indicated he was cognitively intact. Review of Resident #42's comprehensive person-centered care plan dated 02/02/2023 revealed Focus .SKIN INTEGRITY . is at risk for impaired skin integrity. Review of Resident #42's NURSING - Initial Baseline/Advanced Care Plan - V 2 dated 01/31/2023 revealed Resident #42 did not have a pressure ulcer. Review of Resident #42's NURSING - Weekly Pressure Ulcer Evaluation - V 2 dated 02/01/2023 revealed Resident #42 had a pressure ulcer to his sacrum 1.5 centimeters long, .5 centimeters wide and 02 centimeters deep and it was noted to not be a new wound. Review of Resident #42's Active Orders as of: 02/09/2023 revealed Stage 2 sacrum-clean with wound cleaner, pat dry, apply triad paste and leave open to air until resolved one time a day with a start date of 02/02/2023. Review of Resident #42's TAR dated 02/01/2023 - 02/28/2023 revealed Stage 2 sacrum-clean with wound cleaner, pat dry, apply triad paste, leave open to air until resolved one time a day. Resident #42's treatments were initialed off daily and started on 02/02/2023. Observations of Resident #42 on 02/09/2023 at 1:50 p.m. getting ready for a wound care treatment to his stage II pressure sore on his sacrum revealed he needed pain medication prior to his treatment. Interview with Resident #42 on 02/09/2023 at 2:00 p.m. revealed he had skin breakdown on his bottom, and he had it when he was admitted . Interview on 02/10/2023 at 3:56 p.m. with the DON revealed that the facility had 20 days to do the comprehensive plan of care and did not know why Resident #42's stage II pressure sore to his sacrum was not in his baseline care plan because he had it when he was admitted . She stated it was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455999 If continuation sheet Page 4 of 11 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 455999 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Port Lavaca Nursing and Rehabilitation Center 524 Village Rd Port Lavaca, TX 77979 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm important to know what type of care the resident required when they were admitted providing what is needed. Interview on 2/10/2023 at 4:23 p.m. with MDS A revealed that Resident #42's care plan needed to reflect any skin breakdown because the resident required a treatment and specialized care. Residents Affected - Some 3. Review of Resident #11's electronic face sheet dated 02/10/2023 revealed she was admitted to the facility on [DATE] with diagnoses of urinary tract infection (infection in any part of the urinary system), unspecified dementia (a group of symptoms affecting memory, thinking and social abilities) and cognitive communication deficit (difficulty with thinking and how someone uses language). Review of Resident #11's Significant Change MDS assessment dated [DATE] revealed she scored a 0/0 on her BIMS which indicated she was severely cognitively impaired. Further review revealed she has an indwelling urinary catheter. Review of Resident #11's comprehensive person-centered care plan dated 01/03/2023 revealed has indwelling catheter r/t having urinary retention. Review of Resident #11's Active Orders As of: 01/012023 revealed Foley catheter: Change 16F with 30ml bulb as needed for patency, dislodgement and leaking. Review of Resident #11's SAR dated 01/01/2023 - 1/31/2023 revealed Discontinue Foley catheter due to void with-in 8 hours from removal .start date 01/11/2023. Observation on 02/07/2023 of Resident #11 revealed she was lying on her bed sleeping and no indwelling urinary catheter tubing or drainage bag was present. Observation on 02/09/2023 at 2:30 p.m. of Resident #11 on a shower chair revealed she had no indwelling urinary catheter. Interview on 02/10/2023 at 3:56 p.m. with the DON revealed Resident #11's comprehensive person-centered care plan should have been revised after her indwelling urinary catheter was removed. She stated it was important to have what the resident needed for care in the plan or it could result in missed care. Interview on 2/10/2023 at 4:23 p.m. with MDS A revealed that Resident #11's comprehensive person-centered care plan should not have the indwelling urinary catheter on it because she had it taken out on 01/11/2023 and she felt like knowing the resident's urinary status was an important part of her care. Review of the facility policy titled Care Plan Revisions Upon Status Change date implemented 10/24/22 revealed the comprehensive care plan will be reviewed, and revised as necessary, when a resident experiences a status change .the care plan will be modified with the new or modified interventions. Review of the facility policy titled Comprehensive Care Plans date implemented 10/24/22 revealed It is the policy of this facility to develop and implement a comprehensive person-centered plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455999 If continuation sheet Page 5 of 11 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 455999 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Port Lavaca Nursing and Rehabilitation Center 524 Village Rd Port Lavaca, TX 77979 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 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** Based on observation, interview, and record review, the facility failed to ensure that the resident environment remained as free of accident hazards as was possible and that each resident received adequate supervision to prevent accidents for 2 of 24 residents (Residents #3 and #52) reviewed for accidents/supervision, in that: 1. Resident #3 had a lighter in her bedside table. 2. Resident #52 was smoking outside of the designated smoking area. This failure could place residents at risk for smoking-related injuries. The findings were: 1. Record review of Resident #3's face sheet, dated 02/08/2023, revealed the resident was admitted to the facility on [DATE], with diagnoses that included: dementia (group of symptoms affecting memory, thinking and social abilities severely enough to interfere with your daily life), muscle wasting and atrophy (loss of muscle tissue), lack of coordination and borderline intellectual functioning (general mental ability that includes reasoning, planning and problem solving). Record review of Resident #3's Quarterly MDS, dated [DATE], revealed the resident had a BIMS score of 09, which indicated moderate cognitive impairment. Further review revealed the resident's level of assistance with ADLs of walking on and off the unit at a supervised level and personal care and dressing at extensive assistance. Record review of Resident #3's Care Plan, revised on 08/25/2022, revealed a focus area [Resident #3] is a smoker. [Resident #3] does not require safety devices. [Resident #3] has behavioral problem r/t emotional outbursts and cursing at staff when smoke breaks are not started at exact time of scheduled smoke time. Interventions included, Staff will provide a designated smoking area [Resident #3]. Staff will store [Resident#3's] smoking supplies. Further review of Resident #3's Care Plan, revised on 01/26/2023, revealed a focus area [Resident #3] is at risk for improper coping r/t Dx Depression. Target Behavior: crying, loss of appetite, not coming out for smoke breaks. Triggers: feeling like she is in trouble, delusions, disease process. Interventions include, Encourage [Resident #3] to participate in activities, talk to social services. [Resident #3] enjoys going outside to smoke. Staff will allow [Resident #3] to have her supervised smoke breaks. Encourage family involvement. Review of a Smoking/Tobacco Acknowledgement document dated 11/17/2020 and signed by Resident #3 revealed All tobacco products will be kept by the facility staff. The facility will designate a specific outdoor location and time for smoking. Smoking will be permitted only in the designated area. All residents will be allowed to smoke, with supervision, in the designated areas and times. Review of Resident #3's Smoking Safety Screen dated 10/11/2022 and completed by the SW, revealed D. 2. Resident/RP understands that all tobacco will be kept by facility staff. 2a. Resident/RP understand that all use of tobacco products will be supervised by facility staff. Observation on 02/07/2023 at 11:17 a.m. revealed Resident #3 lying in bed. The resident voiced (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455999 If continuation sheet Page 6 of 11 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 455999 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Port Lavaca Nursing and Rehabilitation Center 524 Village Rd Port Lavaca, TX 77979 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 concern that staff do not provide residents their 6:30 a.m. smoking break. Resident states they are told this happens when there is not enough staff. Resident #3 added but I found someone to give me a few (cigarettes) and I have a lighter to keep in case they don't show up. Resident #3 added that she was not the only one, just the only one being honest, and that she kept them hidden so no one else can find them. Observation on 02/09/2023 at 6:32 a.m. revealed Resident #3 and LW F walking out of resident's room and Resident #3 holding a lighter in her left hand. Resident #3 was asked if she would show LW F and surveyor what was in her hand and Resident #3 stated, busted and showed staff and surveyor the lighter. LW F was asked if she knew Resident #3 had the lighter and she stated she did not know when or how Resident #3 obtained the lighter. Observation on 02/09/2023 at 6:35 a.m. revealed Resident #3 in the designated smoking area being supervised by LW G and LW F. LW G provided Resident #3 with a cigarette and then Resident #3 lit the cigarette with the lighter she brought out from her room. No cigarette burns or holes were observed in Resident #3's clothes. LW F was asked how staff determine if residents are safe to light their own cigarettes or need smoking aprons. LW G stated the smoking box would have a note from nursing staff with special instructions for the resident. When asked about residents storing lighters and cigarettes in their rooms LW F stated, we encourage them not to keep anything in their room but sometimes family and friends brings them in and don't tell us. In an observation and interview with the Administrator on 02/09/23 at 06:38 a.m., in the designated smoking area, the Administrator was asked if residents are allowed to store smoking materials and cigarettes in their rooms. The Administrator stated that they attempt to control it as best possible however residents do have family and friends bring items in and never report it to the staff. Resident #3 stated, There aren't any more of these (holding up the cigarette she was smoking) in my room. The Administrator explained to Resident #3 that her lighter would have to be stored in the box at the nurse's station and LW G informed him it had been taken after Resident #3 lit her cigarette. In an interview with LW G on 02/09/2023 at 06:46 a.m., LW G was asked if she previously knew the Resident #3 had smoking items in her room. LW G stated she did not but revealed the laundry dept had only started supervising smoking breaks approximately one week ago because it was difficult for nursing staff to supervise that time due to change of shift. In an interview with the SW on 02/09/2023 at 02:24 p.m., the SW, revealed smoking safety screens are completed on admission and quarterly. The SW added that any specific needs or requirements related to resident smoking are then included on the care plan. The SW also stated We try to keep all smoking items in the lock box at the nurse's station but if they refuse to turn them in, we can't search their rooms. It makes it very difficult when family and friends bring items in and don't let us know. 2. Record review of Resident #52's face sheet, dated 02/10/2023, revealed the resident had an initial admission date of 02/20/2018 with a re-admission on [DATE], with diagnoses that included: chronic obstructive pulmonary disease (A group of lung diseases that block airflow and make it difficult to breathe), age-related nuclear bilateral cataracts (condition affecting the eye that causes clouding of the lens, gradual progression of vision problems, eventually may result in vision loss), muscle wasting and atrophy (loss of muscle tissue) and lack of coordination. Record review of Resident #52's Quarterly MDS, dated [DATE], revealed the resident had a BIMS score (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455999 If continuation sheet Page 7 of 11 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 455999 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Port Lavaca Nursing and Rehabilitation Center 524 Village Rd Port Lavaca, TX 77979 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 of 15, which indicated no cognitive impairment. Further review revealed the resident primarily utilized a wheelchair for mobility and required supervision for all ADLs. Record review of Resident #52's Care Plan, revised on 07/07/2022, revealed a focus area [Resident #52] is a smoker. Does not require safety devices. Goal: [Resident #52] will practice safe smoking. [Resident #52] will smoke during smoking hours. Interventions included, Staff will provide a designated smoking area for [Resident #52]. Review of a Smoking/Tobacco Acknowledgement document dated 11/17/2020 and signed by Resident #52 revealed All tobacco products will be kept by the facility staff. The facility will designate a specific outdoor location and time for smoking. Smoking will be permitted only in the designated area. All residents will be allowed to smoke, with supervision, in the designated areas and times. Review of Resident #52's Smoking Safety Screen dated 12/02/2022 and completed by RN H, revealed D. 2. Resident/RP understands that all tobacco will be kept by facility staff. 2a. Resident/RP understand that all use of tobacco products will be supervised by facility staff. In an observation and interview on 02/10/2023 at 9:14 a.m. revealed Resident #52 smoking unsupervised at the end of 600 hall outside of the building in a non-designated smoking area for residents. Resident #52 leaned back in his wheelchair and extinguished cigarette before wheeling towards this surveyor. When asked if he was smoking in a designated area, and about the risk of smoking alone Resident #52 revealed his friend had just met him out there to bring him a cigarette. He then added, I'm not like others here. I can do for myself. No cigarette burns or holes were observed in Resident #52's clothes. Resident #52 was then asked if he had a lighter and he stated no, we don't have anything, you took care of that yesterday, and then revealed that his friend had lit the cigarette, holding up the half-extinguished cigarette he had been smoking, before leaving. Resident #52 was asked what he planned to do with the half cigarette left from earlier and Resident #52 stated he was taking it to the designated smoke break that had just started. In an observation on 02/10/2023 at 9:54 a.m. revealed the facility's AA was sitting in the courtyard/designated smoking area supervising Residents #3 and #52 and two other residents as they smoked. In an interview with the AA on 02/10/2023 at 10:11 a.m. the AA revealed each of the daily smoke breaks are supervised by different departments of the facility. She added the Activity department supervises the 9:30 a.m. smoke break each day. The AA was asked if Resident #52 arrived at this morning's smoke break with a half-smoked cigarette and she replied that he did and informed her a friend brought it to him outside. The AA added she does not think Resident #52 has cigarettes in his room because he usually borrows from other residents at smoke breaks. In an interview with the Administrator on 02/10/2023 at 11:27 a.m. the Administrator revealed there has been some confusion on which residents need supervision regarding care plans and smoking screens however all residents must smoke in the designated area. The administrator stated it has now been confirmed some residents have been non-compliant with the smoking policy by not turning in smoking paraphernalia to staff when families bring in items. He stated the residents sign an agreement upon admission and staff are continually educating residents on the importance of smoking items being kept in the smoking box. The administrator revealed a need to address with all residents, staff, as well as families once again. In an interview with the DON on 02/10/2023 at 3:58 p.m. the DON stated it is a difficult line (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455999 If continuation sheet Page 8 of 11 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 455999 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Port Lavaca Nursing and Rehabilitation Center 524 Village Rd Port Lavaca, TX 77979 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 because of resident rights. We ask them to turn items in, but we can't search their rooms. Level of Harm - Minimal harm or potential for actual harm Review of a list of residents who smoke, undated, provided by the facility on 02/07/2023, revealed (11) residents in the facility smoked cigarettes. Residents Affected - Few Record review of the facility's Resident admission Agreement, Resident Rights revised 7/14/2020, revealed, pages 29-30, Prohibited Items: no smoking or tobacco products, or matches, lighters, or other smoking paraphernalia. Alcohol & Tobacco: Smoking is permitted in designated areas. Record review of the facility's policy titled, Resident Smoking, implemented 10/24/22, revealed, Policy: It is the policy of this facility to provide a safe and healthy environment for residents, visitors, and employees, including safety as related to smoking. Safety protections apply to smoking and non-smoking residents. Policy Explanation and Compliance Guidelines: 1. Smoking is prohibited in all areas except the designated smoking area. 8. Any resident who is deemed safe to smoke, with or without supervision, will be allowed to smoke in designated smoking areas (weather permitting), at designated times, and in accordance with his/her care plan. 13. Smoking materials of residents requiring supervision with smoking will be maintained by nursing staff. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455999 If continuation sheet Page 9 of 11 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 455999 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Port Lavaca Nursing and Rehabilitation Center 524 Village Rd Port Lavaca, TX 77979 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen, in that: Residents Affected - Some The facility failed to ensure all foods in the kitchen were labeled and dated. 1. in the food pantry there was a small plastic container of oatmeal not labeled or dated. 2. in the main refrigerator in the kitchen there was a medium size plastic container with approximately 15 eggs and a tray with two ham and cheese sandwiches that were not labeled or dated. These failures could place residents who received meals and/or snacks from the kitchen at risk for food borne illness. The findings were: 1. An observation and interview with the Food Service Supervisor on 02/07/2023 at 10:30 a.m., revealed a small, sealed plastic container of dry oatmeal on the shelf in the food pantry. The FSS confirmed the oatmeal was not labeled or dated and should have been following breakfast. The FSS revealed each morning after breakfast the cook scoops out enough oatmeal for the next morning and puts it into the small container to prep for breakfast the following morning. The FSS asked [NAME] C why the oatmeal had been put away in the food pantry and not labeled and dated. [NAME] C stated she had gotten busy and put it away and forgot to place a new label on the container. 2. An observation and interview with [NAME] C on 02/07/2023 at 10:38 a.m. revealed a plastic container inside the large reach in refrigerator with approximately 15 eggs that was not covered, labeled, or dated. [NAME] C stated it was her responsibility to have labeled and dated the eggs when she placed them in the container after breakfast. [NAME] C added that she had been told state was here and got nervous trying to clean up and forgot to date the items. Further observation of the refrigerator revealed (2) individually wrapped ham and cheese sandwiches and (2) individually wrapped slices of cheese. There were no labels indicating what each item was or when they were made. When asked when the sandwiches were made [NAME] C stated, I think this morning. In an interview with the FSS on 02/07/2023 at 10:50 a.m. the FSS asked two of the dietary aides if they had made the sandwiches and their response was no. The FSS started to throw away the food but then asked Dietary Aide D if she made the sandwiches. DA D revealed she had made the sandwiches that morning. When asked if she had been trained to label and date food items the dietary aide stated she had been trained but rushed this morning and forgot. Dietary Aide D was asked what the harm would be of not labeling and dating food items and DA D revealed expired foods could be served to residents and make them sick. In an interview with the FSS and [NAME] E on 02/07/2023 at 11:03 am, [NAME] E stated, I have been here almost 20 years and the cooks do a good job in here, they know to label and date and do it on a regular basis. But they get so scared when hear state is in the building. Record review of the facility's policy titled, Food Storage, revised 5/10/18, revealed Policy: all (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455999 If continuation sheet Page 10 of 11 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 455999 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Port Lavaca Nursing and Rehabilitation Center 524 Village Rd Port Lavaca, TX 77979 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm food will be stored according to the state and federal food codes. Guidelines: 1. Dry storage rooms: d. to ensure freshness, opened and bulk items are stored in tightly covered containers. All containers are labeled and dated. 2. Refrigerators: e. all refrigerated foods are dated, labeled and tightly sealed, including leftovers, using clean, nonabsorbent, covered containers that are approved for food storage. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455999 If continuation sheet Page 11 of 11