Inspection·March 8, 2024

F 0656 Level of Harm - Minimal harm or potential for actual harm resident, consistent with the residents rights that includes measurable objectives and time frames to meet a residence medical, nursing, mental, and psychosocial needs that are identified in the comprehensive assessment . when developing the comprehensive care plan, facility staff will, at a minimum, use the minimum data set to assess the residents clinical condition, cognitive and functional status, and use of services Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455999 If continuation sheet Page 2 of 10 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 03/08/2024 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 1 of 6 resident (Resident #50) reviewed for incontinent care, in that: While providing incontinent care for Resident #50, CNA B did not clean between Resident #50's buttocks'' cheeks. This deficient practice could place residents at-risk for infection and skin break down due to improper care practices. The findings were: Record review of Resident #50's face sheet, dated 03/08/2024, revealed an admission date of 11/17/2023, with diagnoses which included: Dementia(decline in cognitive abilities), Major depressive disorder(mental disorder characterized by at least two weeks of pervasive low mood, low self-esteem, and loss of interest or pleasure), Anxiety (A group of mental illnesses that cause constant fear and worry), Hypertension (High blood pressure) and, Obstructive and reflux uropathy(Hindrance of normal urine flow). Record review of Resident #50's Quarterly MDS assessment, dated 02/20/2024, revealed Resident #50 has a BIMS score of 5, which indicated severe cognitive impairment. Resident #50 was indicated to always be incontinent of bowel and had an indwelling catheter. Record review of Resident #50's Optional State assessment dated [DATE] revealed Resident #50 required extensive assistance to total care with his activity of daily living. Review of Resident #50's care plan, dated 11/20/2023, revealed a problem of Has bowel incontinence R/T (related to) to inability to always recognize need for toileting D/T (due to) cognitive decline., with intervention of Provide pericare after each incontinent episode Observation on 03/07/24 01:07 p.m. revealed, while providing incontinent care for Resident #50, CNA B cleaned the surface of the buttocks but did not clean the anal area or the intergluteal cleft (between buttocks). During an interview on 03/07/2024 at 1:20 p.m. CNA B revealed she thought she had cleaned between Resident #50's buttocks' cheeks but confirmed she did not. She confirmed she should have cleaned the anal area. She confirmed receiving training for infection control and incontinent care within the last year. During an interview with the DON on 03/08/2024 at 09:20 a.m., the DON confirmed that during incontinent care the anal area of the buttocks needed to be cleaned. The facility was doing annual infection control, incontinent care training and annual skills checks. Review of annual skills check for CNA B revealed CNA B passed competency for Perineal (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455999 If continuation sheet Page 3 of 10 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 03/08/2024 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 0690 care/incontinent care on 12/05/2023. Level of Harm - Minimal harm or potential for actual harm Review of facility policy, titled Perineal care, dated 10/24/2022, revealed Cleanse buttocks and anus, front to back [ .] scrotum to anus in males. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455999 If continuation sheet Page 4 of 10 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 03/08/2024 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews the facility failed to ensure that nurse aides were able to demonstrate competency in skills and techniques to provide nursing and related services for 1 of 6 residents (Resident #50 ) by 1 of 4 certified staff (CNA B) reviewed for competent staff, in that: While providing incontinent care for Resident #50, CNA B did not clean between Resident #50'sc intergluteal cleft (between buttocks).and did not use the proper technique to sanitize her hands between change of gloves. These failures could place residents at risk for not receiving nursing services by adequately trained and certified aides and could result in a decline in health and infection. The findings included: Record review of Resident #3's face sheet, dated 01/16/2024, revealed an admission date of 05/04/2021, and a readmission date of 12/03/2023, with diagnoses which included: Hemiplegia (Paralysis of one side of the body),Dementia (decline in cognitive abilities), Anxiety (A group of mental illnesses that cause constant fear and worry), Macular degeneration (medical condition which may result in blurred or no vision in the center of the visual field), Type 2 diabetes mellitus (high level of sugar in the blood), Hyperlipidemia (Elevated level of any or all lipids(fat) in the blood), chronic kidney disease(gradual loss of kidney function). Record review of Resident #50's face sheet, dated 03/08/2024, revealed an admission date of 11/17/2023, with diagnoses which included: Dementia(decline in cognitive abilities), Major depressive disorder(mental disorder characterized by at least two weeks of pervasive low mood, low self-esteem, and loss of interest or pleasure), Anxiety (A group of mental illnesses that cause constant fear and worry), Hypertension (High blood pressure) and, Obstructive and reflux uropathy(Hindrance of normal urine flow). Record review of Resident #50's Quarterly MDS assessment, dated 02/20/2024, revealed Resident #50 has a BIMS score of 5, which indicated severe cognitive impairment. Resident #50 was indicated to always be incontinent of bowel and had an indwelling catheter. Record review of Resident #50's Optional State assessment dated [DATE] revealed Resident #50 required extensive assistance to total care with his activity of daily living. Review of Resident #50's care plan, dated 11/20/2023, revealed a problem of Has bowel incontinence R/T (related to) to inability to always recognize need for toileting D/T (due to) cognitive decline., with intervention of Provide pericare after each incontinent episode Observation on 03/07/24 at 01:07 p.m. revealed, while providing incontinent care for Resident #50, CNA B cleaned the surface of the buttocks but did not clean the anal area or the intergluteal cleft (between buttocks). CNA B did not use the correct technique to use hand sanitizer between change of gloves and only sanitized the palms of her hands. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455999 If continuation sheet Page 5 of 10 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 03/08/2024 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 0726 Level of Harm - Minimal harm or potential for actual harm During an interview on 03/07/2024 at 1:20 p.m. CNA B revealed she thought she had cleaned between Resident #50's buttocks' cheeks but confirmed she did not. She confirmed she should have cleaned the anal area. CNA B revealed she did not remember not sanitizing both of her entire hands and only her palms but confirmed the correct technique was to rub her whole hands including between the fingers and her wrist. She confirmed receiving training for infection control and incontinent care within the last year. Residents Affected - Few During an interview with the DON on 03/08/2024 at 09:20 a.m., the DON confirmed that during incontinent care the anal area of the buttocks needed to be cleaned. the DON confirmed that the correct technique to use hand sanitizer was to sanitize the whole hand, including between the fingers. The facility was doing annual infection control, incontinent care training and annual skills checks. Review of annual skills check for CNA B revealed CNA B passed competency for Perineal care/incontinent care and infection control on 12/05/2023. Review of facility policy, titled Perineal care, dated 06/2020, revealed pull back the foreskin on uncircumcised male and clean under it. Review of facility policy, titled Hand hygiene, dated 10/24/2022, revealed rub hands together, covering all surfaces of hands and fingers until hands feel dry. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455999 If continuation sheet Page 6 of 10 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 03/08/2024 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 observations, interviews, 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. Residents Affected - Some 1. Dietary Aide D was not properly wearing a hair restraint. 2. A food item in the kitchen storage area was not properly dated and labeled. 3. A refrigerator shelve was broken 4. The floor in the dish machine room had broken floor tiles. 5. The vent inside the dish machine was dirty with grease. 6. The ceiling vent across from the dish machine had mold around the edges of the vent. 7. The wall above the dish machine tray line had mold on the wall surface. 8. The bilateral floor moulding leading into the kitchen storage area was missing. 9. The ceiling vent in the office of the Food Service Director was dirty. These deficient practices could place residents who received meals and snacks from the kitchen at risk for food borne illness from improper infection control, from a lack of food label date monitoring, from a lack of equipment maintenance, and improper sanitation in the kitchen area. The findings included: Observation on 03/05/2024 from 9:30 a.m. to 10:10 a.m. during the kitchen tour revealed the following: a. Dietary Aide D was working in the kitchen wearing a hair restraint that did not fully cover the back of her head with visible exposed hair. b. There were 4 one gallon containers of ice cream in the refrigerator that were not dated. c. There was a refrigerator shelve drawer which measured approximately 4x2 foot holding ice cream that was unsecured inside the refrigerator. d. There were 4 pieces of broken floor tile which each measured 4x4 inches that were broken. e. The vent inside the dish machine which measured 1.5x1 foot had grease residue on the vent. f. The ceiling vent which measured 1.5x1 foot across from the dish machine had mold on the ceiling surface around the vent. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455999 If continuation sheet Page 7 of 10 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 03/08/2024 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 g. The wall measuring 6x2 feet directly above the dish machine tray line had mold residue on the wall surface. h. The bilateral floor moulding which measured 4x8 inches on each side of the entrance to the kitchen storage area was missing. Residents Affected - Some i. The ceiling vent which measured 1x6 inches located in the office of the Food Service Director had dirt particles on the vent. During an interview with the Dietary Aide D, during the kitchen tour, on 03/05/24 at 9:35 a.m. Dietary Aide D stated that she understood the hair restraint had to totally cover her hair from falling onto the kitchen floor surface. During an interview with the [NAME] E on 03/05/24 at 9:00 a.m., [NAME] E stated that he did not know why the four 1 gallon containers of ice cream were not dated or how long they were in the refrigerator. [NAME] E stated he was unsure how long the refrigerator shelf holding the ice cream was broken. During an interview with the Food Service Director and the Administrator on 3/05/24 from 11:30-11:55 a.m., the Food Service Director stated that not wearing the hair restraint potentially would allow hair to fall onto the kitchen floor. She stated that the ice cream containers should have been dated to show the expiration date. The Food Service Director stated that the broken refrigerator shelve unit was to be repaired by the Maintenance Director. She stated that any dirt or mold on the ceiling vents and on the wall would impact the kitchen's sanitation. The Administrator stated that the floor tiles, floor moulding, vents, and the wall beside the dish machine would all be repaired by a planned remodel of the kitchen. Record review of the facility's policy # 04.001 titled, Employee Sanitation, dated 10/1/18, revealed, Hair nets or other effective hair restraints must be worn to keep hair from food and food-contact surfaces. Record review of the facility's policy # 03.003, titled Food Storage, dated 10/1/18, revealed, All containers must be labeled and dated. Record review of the facility's policy # 04.008 titled, Cabinets, Drawers, and Shelving dated 10/1/18, revealed, The facility will maintain cabinets, drawers, and shelving to minimize the risk of food hazards. Record review of the facility's policy # 04.013 titled Floors, Tables, and Chairs dated 10/1/18, revealed, The facility will maintain floors, tables, and chairs in a clean and sanitary condition to minimize the risk of food hazards. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2017, U.S. Department of H&HS, revealed 4-601.11 Equipment, Food-Contact Surfaces, Non-food-Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) Non-FOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455999 If continuation sheet Page 8 of 10 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 03/08/2024 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to maintain an Infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 1 of 6 residents (Resident #50) reviewed for infection control, in that: Residents Affected - Few CNA B did not use the proper technique to sanitize her hands while providing incontinent care for Resident #50. These deficient practices could place residents at-risk for infection due to improper care practices. The findings included: Record review of Resident #50's face sheet, dated 03/08/2024, revealed an admission date of 11/17/2023, with diagnoses which included: Dementia(decline in cognitive abilities), Major depressive disorder(mental disorder characterized by at least two weeks of pervasive low mood, low self-esteem, and loss of interest or pleasure), Anxiety (A group of mental illnesses that cause constant fear and worry), Hypertension (High blood pressure) and, Obstructive and reflux uropathy(Hindrance of normal urine flow). Record review of Resident #50's Quarterly MDS assessment, dated 02/20/2024, revealed Resident #50 had a BIMS score of 5, which indicated severe cognitive impairment. Resident #50 was indicated to always be incontinent of bowel and had an indwelling catheter. Record review of Resident #50's Optional State assessment dated [DATE] revealed Resident #50 required extensive assistance to total care with his activity of daily living. Review of Resident #50's care plan, dated 11/20/2023, revealed a problem of Has bowel incontinence R/T (related to) to inability to always recognize need for toileting D/T (due to) cognitive decline., with intervention of Provide pericare after each incontinent episode Observation on 03/07/24 01:07 p.m. revealed, while providing incontinent care for Resident #50, CNA B did not use the correct technique to use hand sanitizer between change of gloves and only sanitize the palms of both her hands. During an interview on 03/07/2024 at 1:20 p.m. CNA B revealed she did not remember not sanitizing both of her entire hands and only her palms but confirmed the correct technique was to sanitize both of her entire hands including between the fingers and her wrist. She confirmed receiving training for infection control and incontinent care within the last year. During an interview with the DON on 03/08/2024 at 09:20 a.m., the DON confirmed that the correct technique to use sanitizer was to sanitize the whole hand, including between the fingers. The facility was doing annual infection control and incontinent care training and annual skills checks. Review of annual skills check for CNA B revealed CNA B passed competency for Infection control on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455999 If continuation sheet Page 9 of 10 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 03/08/2024 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 0880 12/05/2023. Level of Harm - Minimal harm or potential for actual harm Review of facility policy, titled Hand hygiene, dated 10/24/2022, revealed rub hands together, covering all surfaces of hands and fingers until hands feel dry. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455999 If continuation sheet Page 10 of 10