Inspection·October 27, 2023

F 0558 Level of Harm - Minimal harm or potential for actual harm Record review of Resident #56's physician orders dated 10/26/2023 revealed there were no orders for any special call light. Observation on 10/24/2023 at 3:16 p.m. of Resident #56 lying in bed revealed the resident's call light was on the floor at the head of the bed. The call light was not within reach for Resident #56 to use. Residents Affected - Some Observation on 10/25/2023 at 3:16 p.m. of Resident #56 lying in bed revealed the call light remained in the same position as the day before, on the floor at the head of the bed. The call light was not within reach for Resident #56. Observation on 10/26/2023 at 2:17 p.m. of Resident #56 lying in bed and the call light was under her pillow and not within reach for the resident. Interview on 10/26/2023 at 2:27 p.m. LVN C confirmed call light was not within reach for Resident #56 and stated, she probably need on that is a bulb instead of the push button one. LVN C removed the call light from under Resident #56's pillow and attached the call light to her bed within reach. Record review of Resident #74's face sheet dated 10/26/2023 revealed the resident was admitted to the facility on [DATE] with diagnoses which included: Alzheimer's disease (is a brain disorder that slowly destroys memory and thinking skills, and, eventually, the ability to carry out the simplest tasks), left side hemiplegia and hemiparesis following a stroke (hemiplegia is defined as paralysis of partial or total body function on one side of the body, whereas hemiparesis is characterized by one?sided weakness, but without complete paralysis), depression recurrent (A mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), high blood pressure (a common condition in which the long-term force of the blood against your artery walls is high enough that it may eventually cause health problems, such as heart disease, hypothyroidism (A condition in which the thyroid gland doesn't produce enough thyroid hormone), chronic kidney disease stage 3 (your kidneys have mild to moderate damage, and they are less able to filter waste and fluid out of your blood) and delusional disorders (A delusion is an unshakable belief in something that's untrue). Record review of Resident #74's annual comprehensive assessment (MDS) dated [DATE] revealed the resident was assessed by the staff and indicated the resident had long and short- term memory problems and does not have the ability to recall current season, room, staff faces and/or names and that she is in a nursing home. With her ADLs she requires extensive to total dependence on 1 staff member for assistance. Record review of Resident #74's quarterly MDS dated [DATE] revealed the resident was assessed by the staff and indicated the resident had long and short- term memory problems and does not have the ability to recall current season, room, staff faces and/or names and that she is in a nursing home. With her ADLs she requires extensive to total dependence on 1 staff member for assistance. Record review of Resident #74's comprehensive care plan dated 10/01/2023 and revision 06/02/2023 and 06/03/2023 revealed focus areas of ADL self-performance deficit due to history stroke and dementia and one of the interventions Call light in easy reach. Encourage/remind resident to call staff for assistance. The other focus area is high risk for falls related to poor safety awareness secondary to dementia, stroke and history of falls. One of the interventions stated Be sure the resident's call light is within reach and encourage the resident to use it for assistance if needed. The resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676481 If continuation sheet Page 2 of 15 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 10/27/2023 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)

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some needs prompt response to all requests for assistance. Further review of the care plan revealed no documentation for the recliner. Observation on 10/24/2023 at 3:13 p.m. revealed Resident #74 was reclined in a recliner with her feet up and not able to get up. The resident was confused and was trying to get up but, unable to. The recliner was at the foot of the bed. The call light was over by the head of the bed and not within reach for Resident #74. Observation on 10/25/2023 at 1:54 p.m. revealed Resident #74 was lying on the recliner in a reclining position asleep. The call light was observed attached to the head of the bed. The recliner was at the foot of the bed. The call light was not within reach of the resident. Observation on 10/26/2023 at 2:15 p.m. revealed Resident #74 lying in her bed asleep. The call light was draped across her bedside dresser and the call light device was on the floor by the dresser. Resident #74 was not able to reach the call light. Interview on 10/26/2023 at 2:25 p.m. with LVN C confirmed the call light was across the bedside dresser and on the floor and was not within reach for Resident #74. When asked about the recliner and if Resident #74 could get out of the recliner LVN C stated, Resident #74 cannot get out of the recliner by herself but, her daughter wants her to sit in the recliner. Interview on 10/27/2023 at 9:35 a.m. with CNA D revealed she had been working at the facility for almost 4 years. When asked about Resident #74's recliner. CNA D stated the resident has always had the recliner and said when she first came Resident #74 was walking on her [NAME] toes. Resident #74 cannot get out of the recliner by herself. If she did she would fall. The call light on the bed is where Resident #74 cannot reach it. CNA D stated The recliner was at the daughter's request. Her daughter always placed her in the recliner after lunch. Interview on 10/26/2023 at 9:46 a.m. with CNA D revealed Resident #74 was total care and staff have to feed her. Record review of Resident #77's face sheet revealed the resident was admitted to the facility on [DATE] with diagnoses which included dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), Type 2 diabetes (a chronic (long-lasting) health condition that affects how your body turns food into energy), osteoarthritis (when the protective cartilage that cushions the ends of the bones wears down over time), anxiety (a normal reaction to stress an intense, excessive, and persistent worry and fear about everyday situations), high blood pressure, depression (A mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life) and hypothyroidism (A condition in which the thyroid gland doesn't produce enough thyroid hormone). Record review of Resident #77's Quarterly MDS dated [DATE] revealed the resident had a BIMS (Brief Interview for Mental Status) was 99 indicating the resident was unable to complete the interview. Facility staff completed the cognitive assessment of Resident #77 revealed the resident had long and short-term memory problems not able to recall current season, location of room, staff faces and names, and she was in a nursing facility. Resident #77's ADLs, she requires extensive assistance with 2 + staff to help her with bed mobility, transfer, dressing toileting and hygiene. Record review of Resident #77's comprehensive care plan dated 08/25/2023 and revision the same date (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676481 If continuation sheet Page 3 of 15 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 10/27/2023 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)

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some revealed a focus are indicating Resident #77 was at risk for falls due to deconditioning, gait/balance and unaware of safety needs. One of the interventions was to make sure the resident's call light was within reach and encourage the resident to use the call light for assistance as needed. Observation on 10/24/2023 at 3:30 p.m. of Resident #77 revealed the resident was in bed asleep with her body facing the foot of the bed. The call light was attached to the head of the bed and was not within reach. Observation on 10/25/2023 at 2:00 p.m. of Resident #77 revealed the resident was setting up in her wheelchair on the right side of her bed and was straightening the cover on her bed. When this surveyor asked Resident #77 why she was sleeping with her body facing the foot of the bed. Resident #77 stated, I do that so I can look out the window and see when my family comes to visit me and her family can see her. Further observation reveled the call light was on the floor at the head of the bed. When this surveyor asked Resident #77 where her call light was, she reached down and picked it up and threw the call light on top of the bed and said there it is. Observation on 10/26/2023 at 2:20 p.m. revealed the call light on the floor by the head of the bed. Resident #77 was lying facing the foot of the bed. The call light was not within the resident's reach. Interview on 10/26/2023 at 2:30 p.m. with LVN C confirmed the call cord was lying on the floor. LVN C picked the call light up and placed it at the head of the bed and was not within reach of Resident #77. LVN C confirmed the call light was not long enough to reach the foot of the bed. When this surveyor asked LVN C what can happen if the resident can not reach the call light she stated the resident could fall and then when asked who's responsibility it was to ensure the call light was within the resident's reach she stated It is everyone who should be looking where the call light is placed otherwise a resident could fall trying to get up. Interview on 10/26/2023 at 9:50 a.m. with CNA D revealed Resident #77 she did not know why Resident #77 liked to lay at the foot of the bed. LVN D stated when she has gone into Resident #77's room she will turn the resident around with her head at the head of the bed. Then the resident will go back into the same position. Interview on 12/26/2023 at 12:00 p.m., with the DON revealed if the call lights are not within reach, the resident was not able to let anyone know what their needs are and can fall if they get up unassisted. When asked who was responsible for the call lights the DON stated it is everyone's responsibility to ensure the call light was within the resident's reach. Record review of the Facility Policy Interpretation and Implementation for the Resident Call System dated 09/2022 stated Residents are provided with a means to call staff for assistance through a communication system that directly calls a staff member or a centralized work station. 1. Each resident with a means to call staff directly for assistance from his/her bed from toileting/bathing facilities and from the floor 4. If the resident has a disability that prevents him/her from making use of the call system, an alternative means by communication that is usable for the resident is provided and documented in the care plan. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676481 If continuation sheet Page 4 of 15 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 10/27/2023 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)

F 0604 Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. 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 had the right to be treated with respect and dignity, including the right to be free from any physical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms for 1 of 1 (Resident #74) resident observed for physical restraints in that: Residents Affected - Few The facility failed to assess, care plan and obtain a consent for Resident #74 to be in a recliner which prevents rising on her own. This failure could place residents at risk for a decreased quality of life, a decline in physical functioning and injury. The findings included: Record review of Resident #74's face sheet dated 10/26/2023 revealed the resident was admitted to the facility on [DATE] with diagnoses which included: Alzheimer's disease (is a brain disorder that slowly destroys memory and thinking skills, and, eventually, the ability to carry out the simplest tasks), left side hemiplegia and hemiparesis following a stroke (hemiplegia is defined as paralysis of partial or total body function on one side of the body, whereas hemiparesis is characterized by one sided weakness, but without complete paralysis), depression recurrent (A mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), high blood pressure (a common condition in which the long-term force of the blood against your artery walls is high enough that it may eventually cause health problems, such as heart disease, hypothyroidism (A condition in which the thyroid gland doesn't produce enough thyroid hormone), chronic kidney disease stage 3 (your kidneys have mild to moderate damage, and they are less able to filter waste and fluid out of your blood) and delusional disorders (A delusion is an unshakable belief in something that's untrue). Record review of Resident #74's physician's orders dated 10/26/2023 revealed there was no order for the recliner (restraint). Record review of Resident #74's annual comprehensive assessment (MDS) dated [DATE] revealed the resident was assessed by the staff and indicated the resident had long and short- term memory problems and does not have the ability to recall current season, room, staff faces and/or names and that she is in a nursing home. With her ADLs she requires extensive to total dependence on 1 staff member for assistance. Review of Section P Restraints and Alarms, number G chair prevents rising was coded 0 indicating it was not used Record review of Resident #74's quarterly MDS dated [DATE] revealed the resident was assessed by the staff and indicated the resident had long and short- term memory problems and does not have the ability to recall current season, room, staff faces and/or names and that she is in a nursing home. With her ADLs she requires extensive to total dependence on 1 staff member for assistance. Review of Section P Restraints and Alarms, number G chair prevents rising was coded 0 indicating it was not used. Record review of Resident #74's comprehensive care plan dated 10/01/2023 and revision 06/02/2023 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676481 If continuation sheet Page 5 of 15 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 10/27/2023 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)

F 0604 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few and 06/03/2023 revealed focus area is high risk for falls related to poor safety awareness secondary to dementia, stroke and history of falls. One of the interventions stated Be sure the resident's call light is within reach and encourage the resident to use it for assistance if needed. The resident needs prompt response to all requests for assistance. Further review of the care plan revealed no documentation for the recliner. Observation on 10/24/2023 at 3:13 p.m. revealed Resident #74 was reclined in a recliner with her feet up in a reclining position and not able to get up. The resident was confused and was trying to get up but, unable to. The recliner was at the foot of the bed. Observation on 10/25/2023 at 1:54 p.m. revealed Resident #74 was lying on the recliner in a reclining position asleep. The recliner was at the foot of the bed. Interview on 10/26/2023 at 2:25 p.m. with LVN C confirmed Resident #74 could not get out of the recliner LVN C stated, Resident #74 cannot get out of the recliner by herself but, her daughter wants her to sit in the recliner. Interview on 10/27/2023 at 9:35 a.m. with CNA D revealed she had been working at the facility for almost 4 years. When asked about Resident #74's recliner. CNA D stated the resident has always had the recliner and said when she first came Resident #74 was walking on her [NAME] toes. Resident #74 cannot get out of the recliner by herself. If she did she would fall. CNA D stated The recliner was at the daughter's request. Her daughter always placed her in the recliner after lunch. Interview on 10/26/2023 at 9:46 a.m. with CNA D revealed Resident #74 was total care and staff have to feed her. Interview on 12/26/2023 at 12:10 p.m. with the DON revealed she was not aware a recliner could be considered a restraint. The DON stated so, I guess if anyone comes in with a recliner, we should assess them to see if they can get out by themselves and if they can't we need to assess, get orders, get consent and care plan the recliner as a restraint. Record review of the facility Policy for the use of restraints revised on 04/2017 revealed in part the following: Restraints shall only be used for the safety and well-being of the resident(s) and only after other alternatives have been tried unsuccessfully 4. Practices that inappropriately utilize equipment to prevent resident mobility are considered restraints and are not permitted, including c. placing a resident in a chair that prevents the resident from rising 6. Prior to placing a resident in a restraint, there shall be a pre-restraining assessment and review to determine the use for the restraint 9. Residents shall only be used upon the written order of a physician and after obtaining consent from the resident and/or representative . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676481 If continuation sheet Page 6 of 15 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 10/27/2023 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)

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure assessments accurately reflected the resident's status for 1 of 1 Resident #74) resident who's quarterly MDS was reviewed for accuracy in that: Residents Affected - Few Resident #74's quarterly MDS assessment dated [DATE] incorrectly documented the resident had a restraint. This failure could place residents at risk for inadequate care due to inaccurate assessments. The findings included: Record review of Resident #74's face sheet dated 10/26/2023 revealed the resident was admitted to the facility on [DATE] with diagnoses which included: Alzheimer's disease (is a brain disorder that slowly destroys memory and thinking skills, and, eventually, the ability to carry out the simplest tasks), left side hemiplegia and hemiparesis following a stroke (hemiplegia is defined as paralysis of partial or total body function on one side of the body, whereas hemiparesis is characterized by one sided weakness, but without complete paralysis), depression recurrent (A mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), high blood pressure (a common condition in which the long-term force of the blood against your artery walls is high enough that it may eventually cause health problems, such as heart disease, hypothyroidism (A condition in which the thyroid gland doesn't produce enough thyroid hormone), chronic kidney disease stage 3 (your kidneys have mild to moderate damage, and they are less able to filter waste and fluid out of your blood) and delusional disorders (A delusion is an unshakable belief in something that's untrue). Record review of Resident #74's physician's orders dated 10/26/2023 revealed there was no order for the recliner (restraint). Record review of Resident #74's quarterly MDS dated [DATE] revealed the resident was assessed by the staff and indicated the resident had long and short- term memory problems and does not have the ability to recall current season, room, staff faces and/or names and that she is in a nursing home. With her ADLs she requires extensive to total dependence on 1 staff member for assistance. Review of Section P Restraints and Alarms, number G chair prevents rising has 0 indicating it was not used. Record review of Resident #74's comprehensive care plan dated 10/01/2023 and revision 06/02/2023 and 06/03/2023 revealed focus area is high risk for falls related to poor safety awareness secondary to dementia, stroke and history of falls. One of the interventions stated Be sure the resident's call light is within reach and encourage the resident to use it for assistance if needed. The resident needs prompt response to all requests for assistance. Further review of the care plan revealed no documentation for the recliner. Observation on 10/24/2023 at 3:13 p.m. revealed Resident #74 was reclined in a recliner with her feet up in a reclining position and not able to get up. The resident was confused and was trying to get up but, unable to. The recliner was at the foot of the bed. Observation on 10/25/2023 at 1:54 p.m. revealed Resident #74 was lying on the recliner in a reclining position asleep. The recliner was at the foot of the bed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676481 If continuation sheet Page 7 of 15 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 10/27/2023 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)

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 10/26/2023 at 2:25 p.m. with LVN C confirmed Resident #74 could not get out of the recliner LVN C stated, Resident #74 cannot get out of the recliner by herself but, her daughter wants her to sit in the recliner. Interview on 10/27/2023 at 9:35 a.m. with CNA D revealed she had been working at the facility for almost 4 years. When asked about Resident #74's recliner. CNA D stated the resident has always had the recliner and said when she first came Resident #74 was walking on her [NAME] toes. Resident #74 cannot get out of the recliner by herself. If she did she would fall. CNA D stated The recliner was at the daughter's request. Her daughter always placed her in the recliner after lunch. Interview on 10/26/2023 at 9:46 a.m. with CNA D revealed Resident #74 was total care and staff have to feed her. Interview on 12/26/2023 at 12:10 p.m. with the DON revealed she was not aware a recliner could be considered a restraint. The DON stated so, I guess if anyone comes in with a recliner, we should assess them to see if they can get out by themselves and if they can't we need to assess, get orders, get consent and care plan the recliner as a restraint. Record review of the Facility Policy and Procedure dated 11/2019 states in part: 4. The resident assessment coordinator is responsible to ensure the MDS assessment has been completed for each resident. Each assessment is coordinated and certified as being complete by the resident assessment coordinator, who is registered nurse . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676481 If continuation sheet Page 8 of 15 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 10/27/2023 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)

F 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure individuals with mental disorders were evaluated and received care and services in the most integrated setting appropriate to their needs for 1 of 5 residents, (Resident #39) reviewed for Pre-admission Screening and Resident Review (PASRR) Level 1 screenings. Residents Affected - Few The facility failed to identify on Resident #39's PASRR Level l that the resident had a diagnosis of a mental disorder. This deficient practice could affect all residents who had a mental illness and place them at risk for not receiving needed care and services to meet their needs. Findings include: Record Review of Resident #39's admission record revealed Resident #39 has a diagnosis of Post-Traumatic Stress Disorder (PTSD) prior to admission to the facility on [DATE]. Record Review of the admission PASRR Level I for Resident #39, dated 09/28/2023, revealed no was the response documented for the question: Is there evidence or an indicator this is an individual that has a Mental Illness? Record Review of the facilities admission Criteria Policy Statement reveled all new admissions and readmissions are screen for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre-admission Screening and Resident Review (PASRR) process. Interview with LVN F on 10/27/2023 at 9:27 A.M. revealed Resident #39 was admitted from the hospital where a PASRR Level 1 was completed on the day of admission. Staff F stated that the facility reviews the PASRR Level 1 for accuracy at admission and, if needed, must correct the PASRR Level 1 within 48 hours of admission. Staff F was asked to identify qualifying mental health diagnosis that could be listed on a PASRR Level 1. Staff F stated depression and schizophrenia but could not recall others. Staff F stated the facility has a procedure they follow when reviewing PASRR Level 1 prior to or at admission. Staff F stated that Resident #39's PASRR was reviewed at admission, appeared to be correct so no corrections were made. A PASARR Level I Screening dated 9/28/23 indicated Resident #39 had no indication of mental illness. No Level II screening was found for Resident #39 in the clinical record. The admission record dated 10/15/23 indicated Resident #39, under Diagnosis Information section, indicated resident has a diagnosis of PTSD with onset date of 10/06/2022 and 09/28/2023. The facility's PASRR Policy, dated 2001 and updated March 2019, reflected, all new admissions and readmissions are screen for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre-admission Screening and Resident Review (PASRR) process. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676481 If continuation sheet Page 9 of 15 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 10/27/2023 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)

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. 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 provide services as outlined by the comprehensive care plan to meet professional standards of quality for 3 of 3 (Residents #20, #32 and #48) residents observed for insulin injections in that: Residents Affected - Some LVN E administered 9 Units of Aspart (brand name Novolog) insulin to Resident #20 without priming the flex pen before injection. LVN E administered 7 Units of Lispro insulin to Resident #32 without priming the flex pen before injection. LVN E administered 2 Units of Lispro insulin to Resident #48 without priming the flex pen before injection. This deficient practice could affect residents who received insulin by a flex pen in the facility by not receiving the intended therapeutic benefit of their medication. The Findings included: Record review of Resident #20's face sheet, dated 10/27/2023 revealed an admission date of 09/21/2020 with diagnoses which included cerebral vascular accident (CVA) (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), osteoarthritis (when the protective cartilage that cushions the ends of the bones wears down over time), type 2 diabetes mellitus (a chronic (long-lasting) health condition that affects how your body turns food into energy, major depression, recurrent (A mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), anxiety (a normal reaction to stress an intense, excessive, and persistent worry and fear about everyday situations) and high blood pressure (a common condition in which the long-term force of the blood against your artery walls is high enough that it may eventually cause health problems, such as heart disease). Record review of Resident #20's physician orders report dated 10/27/2023 revealed an order for insulin Novolog Flex Pen U-100 insulin (insulin aspart U-100), insulin pen, 100 units per milliliter, amount to administer per sliding scale if blood sugar is 201 to 250, give 9 units before meals and at bedtime with order date 10/23/2023 and no end date. Record review of Resident #20's medication administration record dated 10/27/2023 revealed on 10/26/2023 at 11:30 am LVN E gave Resident #20, aspart 9 units for blood sugar of 242 per sliding scale. Record review of Resident #20's care plan dated 10/19/2020 with a revision on 08/25/2022 revealed a focus area indicating Resident #20 was a diabetic and one of the interventions was to administer NOVOLOG (aspart) as ordered by the physician. Record review of Resident #20's annual MDS dated [DATE] revealed the resident had a BIMS score of 06 and was dependent upon staff for mobility and transferring. Section N Medications N0350 A. Insulin Injections, 7 days out of 7 days, indicating the resident gets daily insulin injections. Observation on 10/26/2023 at 12:00 p.m., during the medication pass revealed LVN E obtained an (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676481 If continuation sheet Page 10 of 15 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 10/27/2023 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)

F 0658 accu- check (blood glucose measuring system) reading on Resident #20 with results of 242. Level of Harm - Minimal harm or potential for actual harm LVN E administered 9 units of aspart insulin per flex pen but did not prime the pen before injecting the insulin. Residents Affected - Some Record review of Resident # 32's face sheet dated 10/27/2023 revealed the resident was admitted to the facility on [DATE] with diagnoses which included dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities). and type 2 diabetes (a chronic (long-lasting) health condition that affects how your body turns food into energy). Record review of Resident 32's physician's orders dated 10/27/23 revealed an order for Lispro insulin pen 100 Units/ml, give per sliding scale. If blood sugar is 200 to 300 give 7 Units. Before meals and at bedtime. Started on 10/23/2023. Record review of Resident #32's medication administration record dated 10/27/2023 revealed on 10/26/2023 at 11:30 am LVN E gave Resident #32, lispro 7 units for blood sugar of 261 per sliding scale. Record review of Resident #32's care plan dated 05/31/2020 with a revision on 08/16/2022 revealed a focus area indicating Resident #32 was a diabetic and one of the interventions was to administer lispro (admelog solostar) as ordered by the physician. Record review of Resident #32's annual MDS dated [DATE] revealed the resident had a BIMS score of 99 and was assessed by staff indicating the resident had long term and short- term memory problems and was dependent upon staff for ADLs. Section N Medications N0350 A. Insulin Injections, 7 days out of 7 days, indicating the resident gets daily insulin injections. Observation on 10/26/2023 at 11:20 a.m. during the medication pass revealed LVN E obtained an accucheck (blood glucose measuring system) reading on Resident #32 with results of 261. LVN E administered 7 units of lispro insulin per flex pen but did not prime the pen before injecting the insulin. Record review of Resident # 48's face sheet dated 10/27/2023 revealed the resident was admitted to the facility on [DATE] with diagnoses which included chronic kidney disease stage 3 (your kidneys are damaged and can't filter blood the way they should), type 2 diabetes (a chronic (long-lasting) health condition that affects how your body turns food into energy), congestive heart failure (a serious condition in which the heart doesn't pump blood as efficiently as it should) and high blood pressure (a common condition in which the long-term force of the blood against your artery walls is high enough that it may eventually cause health problems, such as heart disease). Record review of Resident 48's physician's orders dated 10/27/23 revealed an order for Lispro insulin pen 100 Units/ml, give per sliding scale. If blood sugar is 151 to 200 give 2 Units. Before meals and at bedtime. Started on 10/23/2023. Record review of Resident #48's medication administration record dated 10/27/2023 revealed on 10/26/2023 at 12:00 noon LVN E gave Resident #48, lispro 2 units for blood sugar of 153 per sliding scale. Record review of Resident #48's care plan dated 11/06/2020 with a revision on 10/04/2022 revealed a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676481 If continuation sheet Page 11 of 15 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 10/27/2023 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)

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some focus area indicating Resident #48 was a diabetic and one of the interventions was to administer lispro as ordered by the physician. Record review of Resident #48's annual MDS dated [DATE] revealed the resident had a BIMS score of 14 indicating his cognition was intact and was independent to supervision with staff for ADLs. Section N Medications N0350 A. Insulin Injections, 7 days out of 7 days, indicating the resident gets daily insulin injections. Interview on 10/26/2023 at 12:10 p.m. stated she did not prime the pens prior to administering insulin to Residents #20, 32 and 48 because they were not new pens. LVN E stated, she was not aware the insulin pen had to be primed before each injection. LVN E stated if the insulin pen had been new you prime the pen. LVN E stated when asked what could happen, she stated the resident may not be getting the amount of insulin needed. Interview on 10/27/2023 at 12:20 p.m. with the DON revealed she had already talked and retrained LVN E on the insulin injection with a pen. She stated she told LVN E she was sure she was not the only one who was not aware to prime the pen before giving the insulin. The DON stated she had already completed a Clinical Skills Checklist with LVN E. When asked what could happen to a resident if they do not get all their insulin, she stated the resident could end up having a reaction. Record review of LVN E's training revealed she was hired on 06/15/2020 and had RN/LVN Skills Check list on 10/18/2023 and the Clinical Skills Checklist for Insulin Injection per Insulin Pen training on 10/26/2023. Record review of the facility policy and procedure for Administering medications dated 04/2019 revealed the policy does not indicate anything concerning priming an insulin pen. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676481 If continuation sheet Page 12 of 15 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 10/27/2023 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)

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. Residents Affected - Some The facility failed to ensure DA was wearing a beard restraint who had facial hair. These failures could place resident who received meals and/or snacks from the kitchen at risk for food borne illness. The findings were: Observation and interview on 10/26/2023 at 11:09 a.m. revealed the DA opening cans of diced peaches not wearing a beard restraint with approximately half inch hairs to his chin and hair to the sides of his upper lip. The DA stated he should have been wearing a beard guard. DA then walked over to the Interim DM then returned and stated the Interim DM told him there were none for him to wear. The DA then washed his hands and went back to preparing the diced peaches without wearing a facial hair net. The DA was observed putting diced peaches in souffle dishes. The DA stated during his food handlers training he did remember having been trained the use of hair nets, however he had forgotten about beard guards/restraints. During an interview on 10/26/2023 at 11:33 a.m. the interim DM stated there had not been a male staff member in the kitchen for a long time and they did not have any beard guards/restraints. The interim DM further stated the food handlers course covered a lot of things, but she was sure hair restraints was part of the course. During an interview on 10/26/2023 at 2:34 p.m. the interim DM stated the purpose of hair restraints was to keep the hair from getting in the food. Interim DM further stated hair getting into food could make them sick and it could contaminate the food. Record review of dietary staff's food handlers' certificates revealed the staff in mention had taken the food handler's course. The interim DM's food handlers certificate revealed she had completed the food handlers' course 08/22/2022 with expiration for 5 years from the date. The DA's food handler's certificate revealed a completion date of 04/05/2023. Record review of the facility's policy titled Food Preparation and Service, revision date November 2022, Policy Statement: Food and nutrition services employees prepare, distribute and serve food in a manner that complies with safe food handling practices., Section: Food Distribution and Services, 8. Food and nutrition services staff wear hair restraints (hair nets, hat, beard restraint, etc.) so that hair does not contact food. Review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed, 2-402 Hair Restraints, 2-402.11, Effectiveness., (A) Except as provided in paragraph (B) of this section, FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676481 If continuation sheet Page 13 of 15 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 10/27/2023 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)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, 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 #27) reviewed for infection control, in that: Residents Affected - Few While providing incontinent care for Resident #27, the soiled brief came in contact with Resident #27's clean genitals and CNA A did not wash her hands after cleaning the resident and before touching the clean brief. These failures could place residents at-risk for infection due to improper care practices. The findings include: Record review of Resident #27's face sheet, dated 10/26/2023, revealed an admission date of 10/26/2021, with diagnoses which included: Cerebral infarction(Stroke), Chronic kidney disease(gradual loss of kidney function), Diabetes mellitus(high level of sugar in the blood), Hypertension(High blood pressure). Record review of Resident #27's MDS quarterly assessment, dated 08/11/2023, revealed the resident had a BIMS score of 5, indicating severe cognitive impairment. Resident #27 required limited to extensive assistance, had an indwelling catheter and was occasionally incontinent of bowel and bladder. Record review of Resident #27's care plan, dated 02/06/2023, revealed a care plan with a problem of I, [ .], have Indwelling catheter in place related to obstructive uropathy and a goal of [ .] will remain free from catheter-related trauma or complications through review date Observation on 10/26/23 11:25 a.m., revealed while providing catheter care and incontinent care for Resident # 27 CNA A, after cleaning the resident's scrotum, rolled the soiled brief between the resident's legs. The soiled brief came in contact with Resident #27's cleaned scrotum when CNA A and CNA B turned the resident on his side. CNA A placed the clean brief by Resident #27's side prior to clean the resident's buttock. After cleaning the resident's buttock, CNA A did not change her gloves and wash her hands prior to touching the clean brief. During an Interview with CNA A on 10/26/2023 at 11:30 a.m., CNA A confirmed placing the soiled brief between the resident leg and confirmed they came in contact with the resident scrotum. she forgot to change her glove and wash her hands prior to handling the clean brief. She confirmed receiving infection control training within the year. She confirmed there was a risk of infection for the resident. During an interview with the DON on 10/26/2023 at 3:07 p.m., the DON confirmed the staff should not place the soiled brief during the resident leg because there was a risk they would get in contact with the cleaned genitals. She confirmed the staff should have changed gloves and wash their hands prior to touching the clean brief to prevent cross contamination and infection. She confirmed the staff received infection control training within the year. The DON confirmed they did annual check of the staff skills. They also did spot check of skills and infection control knowledge in case of noted issues. The staff nurse, who is in charge of training, was in charge of the skills check. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676481 If continuation sheet Page 14 of 15 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 10/27/2023 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)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of CNA orientation skills checklist, dated 03/04/2023, revealed CNA A passed competency in infection control and perineal care. Review of the facility's policy, titled Perineal care , dated February 2018, revealed The purpose of this procedure are to provide cleanliness and comfort to the resident, too prevent infections and skin irritation, and to observe the resident skin. Review of facility's Incontinent care proficiency checklist, dated 10/26/2023, revealed Dispose of soiled clothes in a plastic bag [ .] turn resident to side away from you [ .]Use hand gel between glove changes. [ .] wash hands after cleaning the resident and before touching clean linens. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676481 If continuation sheet Page 15 of 15