Health inspection·November 22, 2024

F 0732 Post nurse staffing information every day. Level of Harm - Potential for minimal harm Based on observation, interview, and record review the facility failed to post daily information that included the facility name, current date total number and actual hours worked by registered nurses, licensed practical or licensed vocational nurses, certified nurse aides directly responsible for resident care per shift and the resident census for 4 days (11/19/2024,11/20/2024,11/21/2024, and 11/22/2024) of 13 days reviewed. Residents Affected - Many The facility did not post the required current nurse staffing information for 11/19/2024,11/20/2024,11/21/2024, and 11/22/2024. This failure could place residents, their families, and facility visitors at risk of not having access to information regarding the total number of hours staff worked and the facility census. Findings included: During an observation on 11/19/2024 at 10:00 am, a document labeled Daily Nurse Staffing Report dated 11/6/2024, was posted in a plastic sheet protector and taped inside a glass cabinet on 100 hall. During an observation on 11/20/2024 at 11:30 am, a document labeled Daily Nurse Staffing Report dated 11/6/2024, was posted in a plastic sheet protector and taped inside a glass cabinet on 100 hall. During an observation on 11/21/2024 at 9:30 am, a document labeled Daily Nurse Staffing Report dated 11/6/2024, was posted in a plastic sheet protector and taped inside a glass cabinet on 100 hall. During an observation on 11/22/2024 at 8:30 am, a document labeled Daily Nurse Staffing Report dated 11/6/2024, was posted in a plastic sheet protector and taped inside a glass cabinet on 100 hall. Record review on 11/19/2024 of Daily Nurse Staffing Report was dated 11/6/2024 and did not reflect dates from 11/6/2024-11/19/2024. During an interview on 11/22/24 at 1:30 p.m. the facility Administrator stated the daily nurse staffing data was located was in a plastic sheet protector and taped inside a glass cabinet on 100 hall. The Administrator further revealed the staffing coordinator was new to her position as of 3 weeks and had not learned all the requirements of staffing. He stated it was a requirement to have staffing posted and he would make sure the staffing coordinator would post the staffing moving forward. The Administrator stated there was not a policy on posting staffing, it is a state requirement. Page 1 of 3 676481 676481 11/22/2024 Lavaca Bay Nursing and Rehabilitation Center 118 Trinity Shores Drive Port Lavaca, TX 77979

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 676481 Page 2 of 3 676481 11/22/2024 Lavaca Bay Nursing and Rehabilitation Center 118 Trinity Shores Drive Port Lavaca, TX 77979

F 0842 not document in Resident #1's POC. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 676481 Page 3 of 3