Inspection·August 2, 2024

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the resident and resident's representative of the discharge and the reasons for the move in writing and in a language and manner they understand, failed to update the recipients of the notice as soon as practicable once the updated information became available, and failed to send a copy of the notice to a representative of the Office of the State Long-Term Ombudsman for 1 of 5 residents (Resident #1) reviewed for discharge, in that: The facility failed to notify Resident #1's RP in writing and did not notify the State Long Term Care Ombudsman by phone or in writing of Resident #1's discharge due to safety concerns. This deficient practice could place residents at risk of being discharged and not allowed to return to the facility, causing a disruption in their care and services and potential decline in health. Findings included: Closed record review of Resident #1's undated face sheet revealed the resident was a [AGE] year-old male admitted to the facility initially on 3/14/2024 with diagnoses that included Hypertension (High pressure in the arteries [vessels that carry blood from the heart to the rest of the body]. Symptoms varies from person to person and generally include unexplained fatigue and headache), Diabetes Mellitus 2 (Type 2 diabetes is a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel.), cognitive deficit (Cognition is the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses), GERD (Gastroesophageal reflux disease is a condition in which stomach acid repeatedly flows back up into the tube connecting the mouth and stomach, called the esophagus) mood disorder, hepatitis (is a liver disease that can have different causes and outcomes, from mild to life-threatening) and hearing loss. Resident #1 discharged to a hospital on 5/11/2024, returned to facility on 5/14/2024 and then discharged to a psychiatric facility on 5/14/2024 for medication review and behavioral placement. Further review of the face sheet revealed the resident's primary payor source was Managed Care Provider. Closed record review of Resident #1's quarterly MDS, dated [DATE], revealed the resident had a BIMS score of 14 indicating he was cognitively intact. Further review of this MDS reveals the resident had no symptoms of delirium, no behaviors documented. Closed record review of Resident #1's care plan, dated 3/22/2024, revealed a focus area that included Resident #1 required assistance on staff for ADL care. There was a focus area indicating behaviors of resisting care, refusal of care, hitting staff and cursing at staff. No behaviors towards other residents before the incident leading to his admission to the psychiatric facility on 5/15/2024. (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 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 08/02/2024 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)