Health inspection·November 14, 2023

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received necessary services to maintain personal hygiene for two (Resident #1 and Resident #2) out of five residents reviewed for showers, in that: Residents Affected - Some The facility failed to provide showers to Resident #1 and Resident #2 in compliance with their shower schedules. This failure placed residents at risk of a decline in hygiene, at risk of skin breakdown, level of satisfaction with life, and feelings of self-worth. Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including end-stage renal disease, type II diabetes, chronic obstructive pulmonary disease (a type of progressive lung disease), and depression. Review of Resident #1's admission MDS assessment, dated 11/13/23, reflected a BIMS of 13, indicating no cognitive impairment. Section G (Functional Status) reflected she required extensive assistance with all ADLs. Review of Resident #1's admission care plan, dated 11/08/23, reflected she had a physical functioning deficit with transfers and required assistance of two people. Review of Resident #1's bathing task in her EMR, from 11/05/23 - 11/14/23, reflected no documentation that a shower/bath had been given. Review of the facility's shower sheets for the month of November 2023, reflected one documented shower sheet for Resident #1 dated 11/09/23. During and observation and interview on 11/14/23 at 9:02 AM revealed Resident #1 was in her room sitting on her bed with her head down. She stated she was upset because she felt dirty. She stated when she was given a shower it was always rushed but she rarely got one. She stated she could not remember the last time she received one and it made her feel bad. Review of Resident #2's undated face sheet reflected an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including unspecified dementia, muscle wasting and atrophy (wasting away), bed confinement, need for assistance with personal care, and age-related physical (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 2 Event ID: 675075 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 675075 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Diversicare of Luling 208 Maple St Luling, TX 78648 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)