Lavaca Bay Nursing and Rehabilitation Center

Inspectors wroteBased on interview and record review the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 5 days a week, for 1 of 1 facility reviewed for nurse staffing. The facility failed to have RN coverage for 5 days on 11/08/2025, 11/22/2025, 11/27/2025, 11/30/2025, and 01/31/2026. This failure could place residents at risk of harm by denying residents the advanced critical thinking skills a registered nurse could provide.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident assessment accurately reflected the resident's status for 3 of 12 residents (Residents #12, #13, and #65) who were reviewed for resident assessments. 1. The facility failed to document Resident #13's use of anxiolytic and hypoglycemic medications on the quarterly MDS (Minimum Data Set) assessment. 2. The facility failed to document Resident #65's diagnosis of schizoaffective disorder as an active diagnosis on the resident's MDS. 3. The facility failed to document Resident #12's diagnosis of schizoaffective disorder as an active diagnosis on the resident's MDS These failures could place residents at risk of improper or incorrect care or of not receiving services necessary for their physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to treat each resident with respect and dignity and care in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life for 1 of 8 residents (Resident #14) reviewed for resident rights. CNA F referred to Resident #14 as honey and sweetie during catheter/incontinent care. This failure could place residents at risk of loss of dignity and self-worth.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the resident's environment remains as free of accident hazards as is possible, for 1 of 5 residents (Resident #82), reviewed for accidents. The facility failed to ensure Resident #82 did not have scissors and nail clippers in her room. This failure could place the resident at risk of injury and contribute to avoidable accidents and a decline in health.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all drugs and biologicals used in the facility were stored and labeled in accordance with currently accepted professional principles for one of four medication carts (400/right side 600 nurse medication cart) observed for drug storage and labeling. 1. The facility failed to ensure all insulin pens located inside the 400/right side 600 nurse medication cart were properly labeled with opened dates.2. The facility failed to ensure Resident #37 did not have a bottle of allergy medications at the bedside. These failures could place residents at risk of receiving inadequate treatments and medication misuse.

Inspectors wroteBased on interview and record review the facility failed to ensure assessments accurately reflected the resident's status for 1 of 6 residents (Resident #1) reviewed for accuracy of assessments. The facility failed to ensure Resident #1's skin assessments dated 11/13/2025 and 11/25/2025 accurately reflected a bruise on his knee or the bruise on his cheek. The facility failed to accurately document skin issues on Resident #1 according to his care plan. This failure could place residents at risk of inadequate care due to an inaccurate skin assessment.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement its written policies and procedures that prohibit and prevent abuse, neglect, and misappropriation for 2 of 24 residents (Resident #31 and #64) reviewed for misappropriation. The facility did not conduct training after an allegation of misappropriation of $20 involving Resident #31 on 11/22/24. The facility did not conduct training after an allegation of misappropriation involving the missing of two NARCO pills for Resident # 64 on 11/27/24. This failure could place residents at risk for misappropriation, a diminished quality of life, and psychosocial harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 2 of 18 residents (Resident #23 and #74) reviewed for incontinence care. 1. CNA Y wiped in the wrong direction and did not complete care when providing incontinent care to Resident #23. 2. When CNA-L and CNA-M were providing incontinent and indwelling urinary catheter care to Resident #74 on 12/18/24, CNA-L did not clean the resident's genital area. These failures could place residents who required incontinence care at risk for cross contamination and the development of new or worsening urinary tract infections.

Inspectors wroteBased on interviews and record review, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for 5 days of 30 days for November 2024 (11/10/24, 11/16/24, 11/18/24, 11/23/24, and 11/30/24) upon review for nursing services. The facility had less than 8 hours a day of RN coverage for 11/10/24, 11/16/24, 11/18/24, 11/23/24, and 11/30/24 for a total of 5 days from November 1, 2024 through November 30, 2024. This failure could result in residents not receiving the required services to meet their needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain clinical records on each resident that were complete and accurately documented in accordance with accepted professional standards and practices for five (5) (Resident #23, #25, #73, #74, and #78) of 18 residents reviewed for accuracy and completeness of clinical records. 1. The facility failed to obtain a consent for Resident #23 to reside in the secure unit. 2. Resident #25 was in the secure unit, but there was no physician order for putting the resident in the secure unit. 3. The facility failed to obtain a consent and a physician's order for Resident #73 to reside in the secure unit. 4. Resident #74 was in the secure unit, but there was no physician order for putting the resident in the secure unit. 5. [...]

Inspectors wroteBased on interviews and record review, the facility failed to provide required training on restraints for 5 of 25 (Activity Director, CNA Q, PTA O, CNA N, and the Speech Therapist) staff sampled for licensure and training. The facility failed to ensure that the Activity Director, CNA Q, PTA O, CNA N, and the Speech Therapist had completed their mandatory restraints training. This failure could place residents at risk of being cared for by untrained staff.

Inspectors wroteBased on interviews and record review, the facility failed to provide required Quality Assurance Performance Improvement (QAPI) training that outlines and informs staff of the elements and goals of the facility's QAPI program, for 10 of 25 (Housekeeper P, MA R, CNA S, Food Service Director, RN T, LVN U, Speech Therapist, Social Worker, Occupational Therapist, and LVN E) staff sampled for licensure and training. The facility failed to ensure that Housekeeper P, MA R, CNA S, Food Service Director, RN T, LVN U, Speech Therapist, Social Worker, Occupational Therapist, and LVN E had completed their mandatory QAPI training. This failure could place residents at risk of being care for by untrained staff.

Inspectors wroteBased on interviews and record review, the facility failed to provide required training on behavioral health for 2 of 25 employees sampled for licensure and training. The facility failed to ensure that 2 of 25 staff reviewed for behavioral health training (RN V and the Physical Therapist) had completed this mandatory training. This failure could place residents at risk of not attaining or maintaining their highest practicable physical, mental, and psychosocial well-being due to lack of staff training.

Inspectors wroteBased on observation, interview and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 1 of 6 resident units (300 unit) reviewed for dignity. Laundry Aide X walked into several resident rooms in the 300 unit without knocking. This failure could place residents at risk for diminished quality of life, loss of dignity and self-worth.

Inspectors wroteBased on interview and record review, the facility failed to promote the residents' right to receive mail, for all facility residents: Facility staff did not distribute mail received on Saturdays to the residents. This deficient practice could result in residents not receiving mail in a timely manner and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that licensed staff were able to demonstrate the specific competencies and skill sets necessary to care for resident's needs for 1 of 4 staff (CNA-K) reviewed for competencies. The facility failed to ensure CNA-L had competencies to care as evidence by CNA-L did not clean the resident's genital area when CNA-L was providing incontinent and indwelling urinary catheter care to Resident #74 on 12/18/2024. This failure could potentially affect residents by placing them for cross contamination and infections due to staff who lack the appropriate skills and competencies to provide minimize infections.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide pharmaceutical services {including procedures that assure accurate acqyuiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of residents for one of four carts reviewed for accuracy. 1. Resident #64 had 2 missing hydrocodone (NARCO)tablets that were not documented as given and could not be accounted for during November 27, 2024. These failures could place residents who received medications, including narcotics at risk for not receiving the intended therapeutic effects of their prescribed medications and experiencing unintended and harmful effects of medications prescribed to others and place the facility at risk for drug diversion.

Inspectors wroteBased on record review and interview, the facility failed to ensure any drug regimen irregularities reported by the Pharmacist Consultant were acted upon, for two residents (Residents #34 and #59) of five residents whose medications were reviewed. 1. The facility's Pharmacy Consultant recommended the physician should consider a gradual dose reduction for Resident #34's Mirtazapine for depression on 11/25/2024. However, the facility failed to ensure communicating to the resident's primary care physician regarding the recommendation. 2. The facility's Pharmacy Consultant recommended adding Do Not Crush to Resident #59's medication administration record for the resident's Diltiazem for hypertension (high blood pressure) on 10/22/2024. However, the facility failed to ensure adding the recommendation to the medication administration record. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that drugs and biologicals used in the facility were secured and distributed properly for one of four nurse medication carts (Hall 200 nurse medication cart and Hall 300 medication cart) reviewed for drug storage and use, as evidenced by: 1. The nurse medication cart for the 300-hall contained 5 loose pills. These failures could place residents who received medications, including narcotics at risk for not receiving the intended therapeutic effects of their prescribed medications and experiencing unintended and harmful effects of medications prescribed to others and place the facility at risk for drug diversion.

Inspectors wroteBased on interview and record review, the facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician, and others participating in the provision of care for 1 of 1 resident (Resident #36) reviewed for hospice services, in that: The facility failed to monitor hospice aide and nursing visit per the hospice plan of care and keep the correct visit log sheet in Resident #36's hospice binder. This failure could place residents who receive hospice services at-risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care and communication of resident needs.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases and infections for 1 (Residents #74) of 18 residents reviewed for infection control. CNA-L touched the new and clean brief with old and dirty gloves while providing incontinent and indwelling urinary catheter care to Resident #74 on 12/18/2024. This failure could place residents at risk for cross contamination and infections.

Inspectors wroteBased on interviews and record review, the facility failed to provide mandatory effective communications training to 1 of 25 (RN V) staff sampled for licensure and training. The facility failed to ensure that RN V had completed effective communications training. This failure could place residents at risk of being care for by untrained staff.

Inspectors wroteBased 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.

Inspectors wroteBased 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. 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.

Inspectors wroteBased 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.

Inspectors wroteBased on interview and record reviews, the facility failed to comply with the requirements specified in 42 CFR part 489, subpart I (Advance Directives). The facility was not relieved of its obligation to provide this information to the individual once he or she was able to receive such information. Follow-up procedures must be in place to provide the information to the individual directly at the appropriate time for 1 of 1 (Resident #1) reviewed for Advanced Directives, in that: Resident #1's RP wished to have a DNR code status for Resident #1. Resident #1's OOHDNR was not valid, and Resident #1 was administered CPR by LVN A and RN B on 4/26/20204. This deficient practice could affect residents with an OOH-DNR and could result in residents not getting their Do Not Resuscitate wishes honored. The noncompliance was identified as PNC. [...]

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to provide reasonable accommodation of resident needs for 3 of 3 (Resident #56, #74 and #77) residents reviewed for call lights in that: The facility failed to ensure Residents #56, #74 and #77's call light was within reach and placed for easy access. The deficient practice could place residents at risk of not receiving care or attention needed and falling. The Findings Include: Record review of Resident #56's face sheet, dated 10/26/2023, revealed the resident was admitted to the facility on [DATE] with diagnoses which included: [...]

Inspectors wroteBased 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: 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.

Inspectors wroteBased 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. 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.

Inspectors wroteBased 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: 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.

Inspectors wroteBased 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: 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.

Inspectors wroteBased 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. 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.

Inspectors wroteBased 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: 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.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that a resident had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 1 of 14 residents (R#6) reviewed for misappropriation of resident property. The facility failed to ensure that R#6 was not subject to financial misappropriation by CNA A from the time period July 6, 2023, to August 8, 2023. CNA A misappropriated checking account funds from R#6 totaling $15,083. This was determined to be Past Non-Compliance from 07/06/23 until 08/08/23, due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the survey. This failure could have the potential to affect the residents in the facility by placing them at risk for misappropriation of resident property.

Inspectors wroteBased on interview and record review, the facility failed to review and revised the Comprehensive Care Plan for 1 of 12 residents (R#1 ) reviewed for revision of the Care Plan. R#1's Care Plan was not revised or documented new interventions after the resident was involved in four residents to resident altercations. This failure could denied the interdisciplinary team information on recommended interventions for dealing with resident to resident altercations.

Inspectors wroteBased on observation, interview and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident, for 1 of 22 residents (R#8) reviewed for drug administration in that: Had this surveyor not intervened, CMA O would have administered R#8 her senna [a medication used to treat constipation] almost 12 hours before its scheduled timeframe. This deficient practice could affect residents who receive medication and place them at risk for not receiving a therapeutic effect.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 9 residents (Resident #1) reviewed for accidents and hazards, in that: CNA A did not request assistance from a second staff when providing incontinent care and changing bed linens for Resident #1, resulting in the resident falling out of bed on 09/05/2023 and fracturing her right leg. An Immediate Jeopardy (IJ) was identified on 9/9/23 at 5:05 p.m. While the IJ was removed on 9/11/23, the facility remained out of compliance at a scope of isolated and and a severity level of no actual harm with potential for more than minimal harm because of residents' safety. This deficient practice could place the residents at risk for serious injury.