Inspection·November 22, 2024

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record reviews, the facility failed to maintain medical records, in accordance with accepted professional standards and practices that are complete; and accurately documented for 1 of 6 residents (Resident #1 ) reviewed for medical records. Resident #1's 2024 POC (an electronic record system) documentation for showers was not accurately documented by CNA's in October and November of 2024. This failure could result in residents not having accurate overall view of their care and services. The findings were: Record review of Resident #1's face sheet, dated reflected a female age [AGE]. The resident was admitted on [DATE]with diagnoses which included unspecified dementia (a term used to describe a group of symptoms affecting memory, thinking and social abilities.), Alzheimer's disease (most common of dementia affecting memory), Crohn's disease(inflammation of the digestive tract), Anxiety and depression(feelings on hopelessness and anxiousness). Record review of Resident #1's quarterly MDS, dated [DATE] reflected the resident's BIMS score was 5 (severe impairment) . The residents shower and bathing was listed as assistance of 1 staff member. Record review of Resident #1's Care Plan , dated 1/9/2024, reflected a care area of ADL's support and interventions included: bathing extensive assistance and dressing. Record review of Resident #1's Nurses Notes for the months of October and November 2024 reflected there were no days the resident refused a shower or bathing. Record review of Resident #'s October and November POC reflected the shower days were Tuesday, Thursday, and Saturday. Further, the POC was documented as the resident not receiving showers on 10/22/2024,10/24/2024,10/26/2024, 11/5/2024,11/9/2024,11/12/2024,11/14/2024. During an observation and interview on 11/19/2024 at 10:22 am Resident #1 was able to respond to questions asked by surveyor. The resident was in her room sitting on side of the bed, well groomed, no odors of urine or feces. The resident was able to say she received showers with the assistance of staff but could not recall the dates. She stated she required one person to help her. She further stated some days she did not want to shower and would get a shower another day. During an interview on 11/21/2024 at 2:30 pm CNA A stated she had worked with Resident #1 on many of the shower days listed and she had given her a shower. She stated she may have forgotten to document the shower was done. She further revealed when a resident has a shower or a bedbath CNA's are to document in the POC if they had one or refused. During an interview on 11/22/24 at 1:30 pm the facility Administrator stated the nursing staff should document in the residents POC when they receive a shower and also if they refuse a shower so that nursing personnel can provide interventions. He further revealed he did not know why the CNA's did (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676481 If continuation sheet Page 2 of 3 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 11/22/2024 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)

F 0842 not document in Resident #1's POC. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676481 If continuation sheet Page 3 of 3