Inspection·November 25, 2025

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few notified of the bruises on Resident #1's knee and on his face that morning. She said the CNA should have seen the bruise on Resident #1's knee when he was given a shower. She also said when the nurse did the skin check that morning, she should have seen the bruise on his knee and on his face. She said the nurse should have documented the bruises on the skin assessment. When asked how an inaccurate skin assessment could affect Resident #1, she said she did not know how to answer the question. She said she was responsible for monitoring to ensure the nurses were completing the skin assessments correctly. She said the treatment nurse monitored the skin assessments. She said the treatment nursed monitored by running a report to check that skin assessments are done correctly. She said skin assessments were supposed to be done weekly. She also said CNAs should report any skin issues to the nurse. She said she did not know why the bruises were not reported. During an interview with CNA B on 11/25/2025 at 4:34p.m., she said she was supposed to check for any skin issues when she gave a resident a bath. She said she worked with Resident #1 all the time. She said she did not notice the bruise when she worked three days prior. She said the nurse saw the bruise on Resident #1's face that morning after shift change. She said the previous CNA did not report any skin issues to her during shift report. She said the CNAs were responsible for reporting skin issues to the nurse. She said if skin issues were not reported the resident may not get the proper care. She said that she did not know how Resident #1 got the bruise on his knee or the one on his face. During an interview with LVN A on 11/25/2025 at 4:54p.m., revealed that she did not know about the bruise on Resident #1's knee. She said the nurses were supposed to do skin assessments once a week on all residents. She said if she saw a skin issue, she would check the residents medical record and see if it was documented. She said it the skin issue was not documented she would start an incident report and notify the administrator. She also said it the skin issue was serious she would take care of it before doing anything else. She said if a bruise or skin issue was not reported it would be considered neglect. She said she thought the treatment nurse monitored the skin assessments. She said she did not know how she monitored the skin assessments. She said she did not know that he had a bruise on his knee. She said when she went into his room that morning, she said he was on his knees. She said that was when she noticed the bruise on his left cheek. During an interview with the DON on 11/25/2025 at 5:15p.m., revealed the charge nurses were to do a skin assessment on each resident weekly. She said the skin assessments were broken down, and each shift was responsible for doing certain residents. She said skin assessment are done every 7 days for all residents. She said the skin assessments were documented in the computer. She said the nurse was to complete a skin assessment for any skin issues. She said it would depend on the resident and what was going on with the resident on how not reporting a skin issue could affect a resident. She said the IDT team monitored the skin assessments. She said the IDT team pulled up the skin assessments and the skin assessment would be put on the 24-hour report. She said the bruise on Resident #1's eye was from that morning. She also said that Resident #1's eye was puffy and that since the morning the puffiness had gone down. She said she did not know why the bruise on his knee was not on the skin assessment. She said she would assume the nurses were rushing. During an interview with the ADM on 11/25/2025 at 5:31p.m., revealed that the nurses and CNAs were responsible for checking the residents for skin issues. He said the staff should check the resident's skin every week. He also said staff should be checking for skin issues when getting a resident dressed or giving them a shower. He said if staff were not checking the resident's skin and a resident had a skin issue or bruise the facility would not be able to provide treatment that the resident might need. He said staff should report any skin issues when they first see it. He said the DON was responsible for monitoring to ensure skin issues are being reported. He said that the DON would bring up the (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 11/25/2025 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete skin issues on any resident in the morning start up meeting. He said he was told the bruise on Resident #1's face was from that morning. He said he did not know why the bruise on Resident #1's knee was not noticed or put on the skin assessment. Record review of Skin Assessment Policy dated 4/24/2025 revealed It is our policy to perform a full body skin assessment as part of our systematic approach to pressure injury prevention and management. This policy includes the following procedural guidelines in performing the full body skin assessment. A full body, or head to toe, skin assessment will be conducted by a licensed or registered nurse upon admission/re-admission and weekly thereafter. Procedure: Wash hands. Explain the procedure to the resident. Provide privacy and adequate lighting. Put on gloves. Begin head to toe, thoroughly examining the resident's skin for conditions. Pay close attention to pressure points, bony prominences, and underneath medical devices. Remove any special garments or devices, if not contraindicated or ordered to remain in place. Remove any dressings, using clean technique, unless contraindicated or ordered to remain in place, and note findings. Note any skin conditions such as redness, bruising, rash. Event ID: Facility ID: 676481 If continuation sheet Page 3 of 3