Inspection·August 19, 2022

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, 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 reviewed for kitchen sanitation in that: 1. Food items were not labeled and/or dated and did not contain discard dates. 2. Food items were opened and not refrigerated as recommended by the manufacturer. 3. Unpasteurized eggs were being used to make over easy eggs for a resident. Findings included: 1. Observation and interview on 8/16/2022 at 11:57 a.m. of the freezer behind the food prep table revealed: a. 9 white circular shaped items in a clear cellophane bag with no label or date, identified as crusts by the Cook. b. 15-cylinder shaped items approximately 15 inches in length and 1 inch in diameter in a clear cellophane bag not labeled or dated, identified as churros by the cook. c. A 29.7-pound box labeled biscuits opened and identified by the cook as needing to be returned to the manufacturer as not usable, damaged. [NAME] A said kitchen staff reported they believed they had gotten too warm prior to being delivered and the individual shapes were no longer uniform shape and size, as they had merged together and were now frozen together. The [NAME] said she forgot to throw them out. In an interview on 8/16/2022 11:57 a.m., [NAME] A said the items in the freezer should be labeled and dated and explained she did not know why they were not. In an Interview on 8/16/2022 the DM explained all items in the freezer should be labeled and dated according to the facility's policy. The DM further stated items should be labeled and dated in the freezer to prevent freezer burn and to prevent illness. In an interview on 8/19/2022 at 9:25 am, the Administrator said the items in the freezer should be closed properly, labeled, and dated so that people know when they can be used and when they are not in compliance to ensure they taste like they are supposed to and prevent adverse effects. (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 3 Event ID: 676481 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 676481 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/19/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lavaca Bay Nursing and Rehabilitation Center 118 Trinity Shores Drive 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)