Inspection·April 3, 2024

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to immediately inform the resident,consult with the resident's physician and notify, consistent with his or her authority, the resident representative when there a significant change in the resident's physical, mental, or psychosocial status for 2 of 4 residents (Residents #1 and #2) reviewed for notification of change of condition, in that: The facility failed to ensure the MD was notified of a missed dialysis appointment when Resident #1 and Resident #2 missed scheduled dialysis appointments on 3/30/24 due to transportation being late. This failure could place residents at risk for not having their change of condition addressed appropriately by their attending physician which could cause serious harm. Findings include: 1. Record review of Resident #1's electronic medical record, dated 4/2/2024, reflected a [AGE] year old male with an original admission date of 04/30/2022 with readmission on [DATE] with diagnoses including: end stage renal disease(kidney failure)with dependence of renal dialysis, difficulty in walking, hypertensive heart, and Diabetes Mellitus type 2. Record review of Resident #1's MDS Assessment, dated 2/2/2024, reflected he had rejected dialysis care at times within the assessment period and received had dialysis treatments while a resident. Further review revealed the resident's cognitive status was documented in section C for BIMS score of 13 indicating cognitive stability. Record review of Resident #1's Care Plan reflected initiated date of 5/3/2022 and revision on 2/26/24 with focus of renal failure r/t end stage disease, resident is dependent on hemo-dialysis. Interventions included: encourage resident to go to dialysis if he refuses. Record review of Resident #1's order Summary dated 3/6/2024 reflected the following entry: Dialysis days are Tuesday, Thursday, and Saturdays at 5:00 am. Record review of Resident #1's Progress notes from 3/29/2024 to 4/2/2024 at 11:49 am revealed no entries to reflect MD notification of Resident #1 not going to dialysis on scheduled day. no documentation reflecting Resident #1 missed dialysis appointment due to transportation being late. Record review of facility's 24-hour nursing report revealed no documentation of Resident #1 missing dialysis on 3/30/2024. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 5 Event ID: 455999 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 04/03/2024 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)