Port Lavaca Nursing and Rehabilitation Center

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 3 of 18 residents (Residents #2, #7 and, #24) reviewed for infection control: 1. The facility failed to ensure MA B sanitized the blood pressure cuff in between use with Residents #24 and #7 on 06/18/2026.2. The facility failed to ensure LVN C sanitized the blood pressure cuff before using it on Resident #2 on 06/18/2026 These failures could place residents at-risk for infection due to improper care practices.

Inspectors wroteBased on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 8 Residents (Resident #24) whose records were reviewed. The facility failed to include Resident #24's diagnosis of vascular dementia in her comprehensive care plan including care and services the facility would provide between the dates of 8/1/2025 and 6/17/2026. This deficient practice could result in residents not receiving the care and services needed.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents who needed tracheostomy care were provided such care, consistent with professional standards of practice, for tracheostomy care for 1 of 1 residents (Resident #4) reviewed for tracheostomy care. The facility failed to ensure RN A provided tracheal care and suctioning according to professional standards for Resident #4 on 06/18/2026. These deficient practices could result in the residents not receiving the care and services ordered by the physician and a decline in health status and infection.

Inspectors wroteBased on observation, interview, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen (Kitchen 1) reviewed for food safety requirements. The facility failed when a sink for hand washing was not accessible at all times when the food service staff placed rolling carts for clean dishes in front of the hand sink dish room used by kitchen staff making the sink inaccessible for use on 6/16/2026 and 6/19/2026. These failures could place residents at risk for the spread of infections, food contaminations, food-borne illnesses, and diminished quality of life.

Inspectors wroteNumber of residents sampled: Number of residents cited: Based on observations, interviews, and record reviews, the facility failed to ensure the safe and sanitary storage of residents' food items in 1 of 5 residents' refrigerators reviewed. The personal refrigerator in the resident's #84 room contained an unlabeled, undated food item. This deficient practice could put residents at risk of foodborne illness from consuming spoiled food.

Inspectors wroteNumber of residents sampled: Number of residents cited: Based on the interview and record review, the facility failed to ensure, in accordance with accepted professional standards and practices, that medical records were accurately maintained for each resident, as documented for 1 of 4 residents (Resident #83) whose medical records were reviewed for accuracy. The facility failed to ensure the accuracy of Resident #83's clinical record. Review of the medical record revealed a diagnosis of benign prostatic hyperplasia (BPH) despite the resident being female. The presence of inaccurate diagnoses in the medical record has the potential to affect clinical decision-making, care planning, and treatment interventions.

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. 1. The facility failed to store plastic cups and bowls to allow for air-drying in the dish room. 2. The facility failed to ensure the tabletop can opener blade and base were free of grime and debris. 3. The facility failed to discard a bag of salad mix dated 03/24/2025 containing brown and rotted leaves in the reach-in cooler. 4. The facility failed to ensure an opened bag of grits in the dry storage room was properly sealed. These failures could place residents at risk for food borne illness.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents' right to formulate an advance directive for 1 of 27 residents (Resident #188) reviewed for advanced directives, in that: The facility failed to ensure Resident #188's Out of Hospital Do Not Resuscitate (OOH-DNR) dated [DATE] was signed by a physician, which made the document invalid. This failure could place residents at risk of having their end of life wishes dishonored, and of having CPR performed against their wishes.

Inspectors wroteBased on interview, record review, and observation, the facility failed to ensure residents have a right to personal privacy for 1 of 6 resident (Resident #84) reviewed for privacy, in that: CNA A and CNA B did not close Resident #84's privacy curtain while providing incontinent care on 4/17/25. This deficient practice could place residents at-risk of loss of dignity due to lack of privacy.

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident assessment accurately reflected the resident's status for 1 of 10 residents (Resident #39) whose assessments were reviewed. Resident #39's significant change MDS assessment incorrectly documented the resident as not using tobacco. This failure could place residents at-risk for inadequate care due to inaccurate assessments.

Inspectors wroteBased on interview and record review, the facility failed to create a baseline care plan within forty-eight hours of admission for 1 (Resident #240) of 1 residents reviewed for baseline care plans, in that: Resident #240 admitted to the facility on the evening of 04/14/2025, and her baseline care plan was not in place as of the afternoon of 04/17/2025. This deficient practice could result in newly admitted residents having their needs unmet.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all drugs and biological were stored in locked compartments for 1 of 6 medication carts (Hall 600 Medication Cart) reviewed for storage. During medications administration, RN D left Hall 2600 Medication cart unlocked on 1 occasion (04/17/2025). This deficient practice could place residents at risk of misappropriation of medications or harm due to accidental ingestion of unprescribed medications.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to follow menus for 2 of 2 resident meals reviewed for menus in that: The facility failed to follow the menu for residents on regular and modified diets for the lunch meals on 04/15/2025 and 04/16/2025 This failure could place residents who consume food prepared by the facility kitchen at risk of not having their nutritional needs met and/or weight loss.

Inspectors wroteBased on interview and record review, the facility failed to maintain medical records that were accurate and complete for 1 (Resident #240) of 25 residents reviewed for accuracy and completeness of records in that: Resident #240's facesheet did not include a list of diagnoses. This deficient practice could result in unmet resident needs due to missing information.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public, for 1 (500 Hall) of 7 hallways reviewed for environment, in that: The storage room on 500 Hall was not secured and contained potentially unsafe items. This deficient practice could result in residents coming into contact with potentially unsafe items.

Inspectors wroteBased on observation, interview, and record review the facility failed to immediately inform the resident,consult with the resident's physician and notify, consistent with his or her authority, the resident representative when there a significant change in the resident's physical, mental, or psychosocial status for 2 of 4 residents (Residents #1 and #2) reviewed for notification of change of condition, in that: The facility failed to ensure the MD was notified of a missed dialysis appointment when Resident #1 and Resident #2 missed scheduled dialysis appointments on 3/30/24 due to transportation being late. This failure could place residents at risk for not having their change of condition addressed appropriately by their attending physician which could cause serious harm.

Inspectors wroteBased on interview and record review, the facility failed to maintain in accordance with accepted professional standards and practices medical records on each resident that were complete and accurately documented for 2 of 4 residents (Residents #1 and #2) reviewed for accuracy of medical records. in that: The facility failed to ensure Electronic Medical Records documented of Residents #1 and #2 not receiving transportation to dialysis treatment on 3/30/2024. This deficient practice could place Residents at risk for errors in care and treatment.

Inspectors wroteBased on observations, interviews, 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. 1. Dietary Aide D was not properly wearing a hair restraint. 2. A food item in the kitchen storage area was not properly dated and labeled. 3. A refrigerator shelve was broken 4. The floor in the dish machine room had broken floor tiles. 5. The vent inside the dish machine was dirty with grease. 6. The ceiling vent across from the dish machine had mold around the edges of the vent. 7. The wall above the dish machine tray line had mold on the wall surface. 8. The bilateral floor moulding leading into the kitchen storage area was missing. 9. The ceiling vent in the office of the Food Service Director was dirty. [...]

Inspectors wroteBased on interviews and record reviews the facility failed to develop and implement a comprehensive person-centered care plan for each resident, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 28 residents (Residents #47) reviewed for care plans. 1. The facility failed to care plan Resident #47's diabetes insulin administration. This failure could have placed residents at risk of not having their needs met.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 1 of 6 resident (Resident #50) reviewed for incontinent care, in that: While providing incontinent care for Resident #50, CNA B did not clean between Resident #50's buttocks'' cheeks. This deficient practice could place residents at-risk for infection and skin break down due to improper care practices.

Inspectors wroteBased on observations, interviews and record reviews the facility failed to ensure that nurse aides were able to demonstrate competency in skills and techniques to provide nursing and related services for 1 of 6 residents (Resident #50 ) by 1 of 4 certified staff (CNA B) reviewed for competent staff, in that: While providing incontinent care for Resident #50, CNA B did not clean between Resident #50'sc intergluteal cleft (between buttocks).and did not use the proper technique to sanitize her hands between change of gloves. These failures could place residents at risk for not receiving nursing services by adequately trained and certified aides and could result in a decline in health and infection.

Inspectors wroteBased on observations, interviews, and record reviews, 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 #50) reviewed for infection control, in that: CNA B did not use the proper technique to sanitize her hands while providing incontinent care for Resident #50. These deficient practices could place residents at-risk for infection due to improper care practices.