Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Lavaca Bay Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
Failure to Maintain Required RN Coverage: The facility failed to provide an RN for at least 8 consecutive hours a day on multiple days, including days with zero RN hours and days with less than 8 hours of RN coverage. The administrator said RN coverage could not be confirmed and that nurses had called in late or not shown up, while the DON stated an RN was needed for assessments and situations beyond what an LVN could provide.
Inaccurate MDS Coding for Medications and Active Psychiatric Diagnoses: The facility failed to accurately code the MDS for a resident’s anxiolytic and hypoglycemic meds and for two residents’ schizoaffective disorder diagnoses. Records showed active orders, MAR administration, physician diagnosis documentation, psychiatric assessments, and care plans that were not fully reflected in the MDS active diagnosis and medication sections. Staff stated the MDS should match the chart and be accurate before submission.
Improper Terms of Endearment Used During Care: A CNA referred to a resident as "honey" and "sweetie" during incontinent care while asking him to lower his legs. The resident, who had aphasia, mixed receptive-expressive language disorder, depression, and severe cognitive impairment, indicated he was offended and that he should be addressed by his name. The CNA acknowledged the terms were inappropriate, and the DON stated staff were expected to use residents' proper names unless a nickname was agreed upon.
Sharps Left in Resident Room: A resident with anxiety, depression, and muscle weakness was observed with scissors and nail clippers on her bedside table. The resident said she was unsure whether staff knew about the items and reported she could clip her fingernails but not her toenails. Staff stated residents were not allowed to keep sharps in their rooms, and the DON said sharps were generally kept in the med room or a lock box, with the admission packet listing sharps as prohibited items.
An undated insulin pen was found in a nurse med cart, and the DON stated insulin should be dated when removed from refrigeration and not used if undated. A resident with COPD, anxiety, allergy, and HF was also found keeping a bottle of allergy pills in her nightstand drawer and said she had been taking them herself, while staff stated she was not care planned or assessed to self-medicate those pills.
A resident with multiple chronic conditions and a history of falls had bruises on the knee and cheek that were not documented in weekly skin assessments, despite being observed by staff and required by the care plan. Staff interviews revealed inconsistent reporting and documentation practices, and the facility's policy for thorough head-to-toe skin assessments was not followed.
The facility failed to implement its policies to prevent abuse and misappropriation for two residents. One resident reported missing money, and another had a discrepancy in narcotic medication. The facility did not conduct required training following these incidents, contrary to its policies. The lack of timely training and communication among staff contributed to the deficiencies observed.
Two residents received inadequate incontinence care, risking infections. A female resident with severe cognitive impairment was improperly cleaned by CNAs, leaving stool residue. A male resident with an indwelling catheter was not fully cleaned, as CNA-L forgot to clean his penis. The facility's policy outlines proper care procedures, but these were not followed, potentially risking infections.
The facility failed to maintain RN coverage for at least 8 consecutive hours a day, 7 days a week, as required by policy. In November 2024, RN coverage was insufficient on 5 days, with hours ranging from 5 to 6.23. Interviews with staff revealed that consulting nurses began in December, and the acting DON acknowledged potential delays in resident care due to this deficiency.
A facility failed to maintain complete and accurate clinical records for several residents placed in a secure unit. Consents and physician orders were missing for residents with severe cognitive impairments and elopement risks. The absence of these documents was acknowledged by the DON as a potential violation of residents' rights.
The facility failed to provide mandatory restraints training for five staff members, including the Activity Director, two CNAs, a PTA, and a Speech Therapist. This deficiency was identified through interviews and a review of the training log, which showed no evidence of completed training. The acting HR Coordinator expressed uncertainty about training oversight responsibilities, highlighting a lack of clarity in roles. The absence of required training could potentially place residents at risk of being cared for by untrained staff.
The facility failed to provide mandatory QAPI training to 10 staff members, including a housekeeper, MA, CNA, food service director, RN, LVNs, speech therapist, social worker, and occupational therapist. This deficiency was confirmed through a review of the training log and interviews with the HR Manager and acting HR Coordinator, who acknowledged the lack of training oversight. The facility's policies require effective training programs and sufficient staff competencies, which were not met due to the missing QAPI training.
The facility failed to provide required behavioral health training for two staff members, RN V and a Physical Therapist, as identified through a review of training logs and confirmed by interviews with HR personnel. There was a lack of clarity regarding training oversight, with the Administrator temporarily responsible until a new HR Coordinator is appointed. This deficiency could impact resident safety and well-being.
A facility failed to respect residents' rights to privacy and dignity when a laundry aide entered multiple rooms without knocking. A resident expressed discomfort with this practice, highlighting the invasion of privacy. The aide admitted to not knocking, assuming open doors meant no residents were present, despite being trained to announce herself. The facility's Administrator acknowledged this as a violation of resident rights.
The facility failed to distribute mail to residents on Saturdays, as the Receptionist did not work weekends and mail remained in the mailbox until Monday. This practice was confirmed by both the Receptionist and the Activity Director, and the Administrator acknowledged that residents should receive mail daily. The facility's policy mandates mail delivery within 24 hours, including Saturdays, but this was not adhered to, potentially impacting residents' quality of life.
A CNA failed to properly clean a resident's genital area during catheter care, despite having passed a skills checklist. The resident, with severe cognitive impairment and other health issues, was at risk for infection due to this oversight. The DON confirmed the proper procedure was not followed.
A facility failed to provide adequate pharmaceutical services, resulting in two missing hydrocodone tablets for a resident with a history of joint replacement, cancer, and pain. The LVN responsible left the medication cart unsecured and failed to document the administration of the medication, leading to a discrepancy in the narcotic count. The facility's policy on securing and accounting for controlled substances was not followed.
The facility failed to act on pharmacist recommendations for two residents. One resident's Mirtazapine dose reduction was not communicated to the physician, and another resident's Diltiazem 'Do Not Crush' instruction was not added to the medication record. The DON acknowledged the oversight, citing a recent leadership change.
A facility failed to secure drugs properly, as five loose pills were found in a nurse medication cart. An LVN and the acting DON acknowledged the risks of residents consuming unprescribed medications, which could lead to adverse effects or allergic reactions. The facility's policies emphasized the need for control and surveillance of medications.
A facility failed to coordinate hospice care and maintain documentation for a resident receiving hospice services. The resident, with severe cognitive impairment due to Alzheimer's, required hospice aide and nurse visits twice a week. However, the visit log showed only one documented visit, and interviews revealed a lack of communication and documentation between facility staff and hospice representatives. The DON acknowledged the absence of a specific hospice policy and the responsibility of facility nurses to communicate and document hospice care.
A CNA in an LTC facility failed to change gloves during incontinent care for a resident with severe cognitive impairment and multiple medical conditions, leading to a breach in infection control. The CNA admitted to the oversight, and the DON confirmed the proper procedure was not followed.
The facility failed to provide mandatory effective communications training to an RN, as required by their training program. A review of the training log showed no evidence of such training for the RN, and interviews confirmed the oversight. The acting HR Coordinator was unsure who was responsible for training oversight, indicating a lack of clarity in roles. This failure could place residents at risk of being cared for by untrained staff.
A facility failed to accurately document a resident's showers in the electronic record system, leading to discrepancies in the resident's care records. The resident, with severe cognitive impairment, was supposed to receive showers on specific days, but the records inaccurately showed missed showers. A CNA admitted to possibly forgetting to document the showers, and the administrator acknowledged the requirement for documentation but was unaware of the oversight.
The facility did not update the Daily Nurse Staffing Report for four consecutive days, displaying outdated information from 11/6/2024. The Administrator attributed this to a new staffing coordinator unfamiliar with requirements. This oversight could risk residents, families, and visitors by not providing current staffing and census data.
A resident with multiple health conditions was transferred to a psychiatric facility without proper written notification to the resident's representative or the LTC Ombudsman. The facility did not update the discharge notice recipients promptly, and interviews revealed that the necessary parties were not informed about the discharge, leading to an appeal allowing the resident to return.
A resident's DNR wishes were not honored due to an invalid OOHDNR form lacking a physician's signature. Despite the resident's electronic chart indicating a DNR status, LVN and RN administered CPR, believing the resident was a full code. The resident was pronounced dead after EMS continued CPR due to the invalid form. The deficiency was identified as Immediate Jeopardy and corrected before the survey began.
Failure to Maintain Required RN Coverage
Penalty
Summary
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. Review of RN timecards from 10/01/2025 through 03/23/2026 showed no RN hours on 11/08/2025 and 11/30/2025, and less than 8 hours of RN coverage on 11/22/2025, 11/27/2025, and 01/31/2026. The census records showed resident populations of 96 on 11/08/2025, 94 on 11/22/2025, 96 on 11/27/2025, 95 on 1/30/2025, and 95 on 01/31/2026. During interview, the administrator stated he could not confirm RN coverage on the identified dates and reported that nurses had either called in late or did not show up, with RN coverage falling under the DON's responsibility. The administrator also stated he did not have a policy for RN coverage and followed CMS rules. During interview, the DON stated that on days without RN coverage, someone may have called in sick, and explained that an RN was needed for situations requiring assessment or something more than an LVN could provide; she also stated that if an RN was not available, staff could call her if there was a problem.
Inaccurate MDS Coding for Medications and Active Psychiatric Diagnoses
Penalty
Summary
The facility failed to ensure resident assessments accurately reflected resident status for 3 of 12 residents reviewed. For Resident #13, the quarterly MDS did not record the use of anxiolytic or hypoglycemic medications in Section N0415, even though the record showed active orders for Temazepam 15 mg at bedtime and Janumet 50-1000 mg twice daily, and the MARs showed both medications were administered daily during the 7-day lookback period. Resident #13’s record also included diagnoses of dementia, type 2 diabetes mellitus, depression, paranoid schizophrenia, and anxiety, and the care plan addressed diabetes and psychosocial well-being concerns. For Resident #65, the quarterly MDS identified non-Alzheimer’s dementia, anxiety disorder, and depression as active diagnoses, but did not include schizophrenia-related diagnoses in Section I. The resident’s record documented schizoaffective disorder on the face sheet, physician review of active diagnosis forms signed by the physician, an order summary showing Olanzapine for schizophrenia related to schizoaffective disorder and Trazodone related to schizoaffective disorder, and an initial psychiatric assessment describing treatment for schizoaffective disorder, depressive type. The MDS also indicated the resident was treated with antipsychotic medications on a routine basis. For Resident #12, the MDS did not include schizoaffective disorder in the active diagnosis section for schizophrenia-related disorders. The resident’s record showed a diagnosis of schizoaffective disorder, unspecified on the face sheet, a BIMS score of 4 indicating severe cognitive impairment, and MAR orders for Sertraline related to schizoaffective disorder, unspecified. The care plan identified use of Sertraline related to schizoaffective disorder, the admission history and physical documented schizoaffective disorder, and a psychiatric periodic evaluation from the prior facility listed F25.9 schizoaffective disorder, unspecified condition. During interviews, the Administrator, MDS RNs, and DON stated they relied on the RAI manual and expected the MDS to reflect the resident chart and be accurate before submission.
Improper Terms of Endearment Used During Care
Penalty
Summary
The facility failed to treat a resident with respect and dignity during incontinent care when CNA F referred to him as "honey" and "sweetie" while asking him to lower his legs. The resident was a [AGE]-year-old male with diagnoses including mixed receptive-expressive language disorder, aphasia following cerebrovascular disease, dysphagia, and depression. His MDS reflected that his speech clarity was clear, he was sometimes understood, he responded adequately to simple, direct communication, and he was severely cognitively impaired for daily decision-making skills. His care plan directed staff to use his preferred name, face him when speaking, and make eye contact, and noted that he understood consistent, simple, directive sentences. During the observation, the resident had to be assisted to lower his legs. In an interview shortly afterward, the resident nodded to indicate he had been offended when referred to as "honey" and "sweetie" and nodded yes when asked if he should be addressed by his name. CNA F stated she should not have used those terms because it was a dignity issue and the resident should have been addressed with respect, perhaps by saying his name. The DON stated staff were expected to refer to residents by their proper name unless the resident agreed to a nickname, and that terms of endearment should not be used unless residents agreed to it.
Sharps Left in Resident Room
Penalty
Summary
The facility failed to ensure Resident #82’s environment remained as free of accident hazards as possible when scissors and nail clippers were found in the resident’s room. Resident #82 was a [AGE]-year-old female readmitted to the facility with diagnoses including anxiety disorder, major depressive disorder recurrent mild, and muscle weakness. Her MDS showed a BIMS score of 15 out of 15 and need for setup or clean-up assistance with personal hygiene, and her care plan included assistance for personal hygiene related to weakness and impaired mobility. During observations on 03/24/2026 and 03/25/2026, Resident #82 had 1 pair of scissors and 2 nail clippers lying on her bedside table. In interview, the resident stated she was not sure whether staff knew about the items and said she had clipped her fingernails but could not do her toenails. Staff interviews reflected that residents were not allowed to have nail clippers or scissors in their rooms, that such items should be kept in the nurse’s cart or medication room if independently used, and that the resident should not have had them in her room. The DON later stated residents cannot have anything sharp in their room unless kept in a lock box, and the facility’s admission packet listed sharps as prohibited items.
Undated insulin pen and resident-kept allergy pills
Penalty
Summary
The facility failed to ensure drugs and biologicals were labeled in accordance with accepted professional principles when an undated insulin pen was observed in the top drawer of the 400/right side 600 nurse medication cart. During the observation, no opened date was written on the pen itself or on its label. LVN E stated the opened date was important because of the pen’s longevity and said she would discard the undated pen. The DON stated insulin should be dated when removed from refrigeration and that staff should not use insulin from a medication cart if it was undated or if it was unknown how long it had been out of the refrigerator. The facility also failed to ensure Resident #37 did not have a bottle of allergy pills at the bedside. Resident #37 was an [AGE]-year-old female admitted with diagnoses including lack of coordination, COPD, anxiety disorder, allergy, heart failure, and need for assistance with personal care. Her quarterly MDS reflected impaired vision, use of corrective lenses, and cognitive intactness for daily decision-making. Her order summary included cetirizine 10 mg by mouth daily for allergy, and her care plan included administering medications as ordered. During observations, a bottle of allergy pills was seen in the top drawer of the nightstand next to Resident #37’s recliner, and the resident stated she had taken an allergy pill from the bottle the prior night and kept the medication at the bedside. Med Aide H stated she was not aware the resident had the pills and said medications left at the bedside could be consumed by another resident or the resident could take too many. LVN I stated self-medication required a doctor’s order, assessment, observation, and care plan, and that Resident #37 could not self-medicate with medications staff were not aware she had. The DON later stated Resident #37 had an assessment to self-medicate for eye drops and, after learning about the allergy pills, said the resident was okay to use them.
Failure to Accurately Document Resident Skin Assessments
Penalty
Summary
The facility failed to ensure that skin assessments accurately reflected the resident's current condition for one resident reviewed. Specifically, the skin assessments completed on two separate dates did not document the presence of a bruise on the resident's knee or a bruise on the resident's cheek, despite these being observable during care and reported by staff and the resident's representative. The resident's care plan required regular skin inspections and documentation of any redness, open areas, scratches, cuts, or bruises, but these requirements were not met in this instance. Interviews with staff revealed that both CNAs and nurses were responsible for checking and reporting skin issues during routine care, such as bathing or dressing. However, the staff involved either did not notice the bruises or failed to document them in the resident's medical record. The treatment nurse and DON confirmed that weekly skin assessments were required and that any findings should be documented and reported, but there was a lack of clarity among staff regarding monitoring and reporting procedures. The skin assessment policy required a thorough head-to-toe examination and documentation of any skin conditions, including bruising, which was not followed in this case. The resident involved had multiple diagnoses, including Alzheimer's disease, heart failure, COPD, diabetes, major depressive disorder, hypertension, delusional disorder, and dementia, and was at risk for falls as noted in the care plan. The failure to document observed bruises meant that the resident's medical record did not accurately reflect his condition, and the facility did not follow its own policy and care plan requirements for skin assessment and documentation.
Failure to Implement Policies on Abuse and Misappropriation
Penalty
Summary
The facility failed to implement its written policies and procedures to prevent abuse, neglect, and misappropriation for two residents. The first incident involved a resident who reported that $20 was missing from his belongings after a hospital visit. The resident's family informed the past interim Administrator about the missing money, but the facility did not conduct the required abuse and neglect training following the allegation. The past Administrator acknowledged that the training should have been conducted as part of the facility's policy, but it was not done until after the surveyor's entrance. The second incident involved another resident who was prescribed hydrocodone for pain management. A discrepancy in the narcotic count revealed that two pills were missing. The past Administrator was informed of the missing narcotics during a shift change, and the medication cart was secured pending an investigation. The investigation found that the cart had been left unsecured by an LVN, who accepted responsibility for the missing pills. However, no in-service training was conducted for the staff regarding this incident, contrary to the facility's policy. Both incidents highlight the facility's failure to adhere to its policies for preventing and addressing abuse, neglect, and misappropriation. The lack of timely training and communication among staff members contributed to the deficiencies observed. The facility's policies require immediate training and investigation following such allegations, but these were not adequately implemented, leaving residents at risk.
Inadequate Incontinence Care Leads to Potential Infection Risks
Penalty
Summary
The facility failed to provide appropriate incontinence care for two residents, leading to potential risks of urinary tract infections. Resident #23, a female with severe cognitive impairment and chronic kidney disease, was observed receiving improper incontinence care. CNA Y, assisted by CNA Z, wiped Resident #23's anal area in the wrong direction, from back to front, on three occasions, leaving copious amounts of stool. This improper technique was acknowledged by the CNAs, who admitted they had not received training on incontinence care at the current facility, although they had been trained at a sister facility. The Director of Nursing (DON) confirmed that the facility had recently provided competency training on incontinence care and emphasized the importance of wiping from front to back to prevent infections. Resident #74, a male with severe cognitive impairment and an indwelling urinary catheter, also received inadequate care. During an observation, CNA-L and CNA-M were seen providing catheter care but failed to clean the resident's penis, which is a necessary step to prevent urinary tract infections. CNA-L admitted to being nervous and forgetting to clean the resident's penis, despite having passed a clinical skills checklist for perineal care earlier in the month. The DON stated that the previous DON had completed the checklist and that it was her responsibility to monitor the CNAs' skills. The facility's policy on perineal care, dated October 2022, outlines the correct procedures for cleaning residents to prevent infections and skin breakdown. However, the observed deficiencies in care for Residents #23 and #74 indicate a failure to adhere to these procedures, potentially placing residents at risk for infections. The report highlights the need for proper training and adherence to established care protocols to ensure resident safety and well-being.
Deficiency in RN Coverage
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) was on duty for at least 8 consecutive hours a day, 7 days a week, as required by their policy. This deficiency was observed for 5 days in November 2024, specifically on 11/10, 11/16, 11/18, 11/23, and 11/30, where the RN coverage was less than 8 hours. The timesheets revealed that on these days, the RN coverage ranged from 5 to 6.23 hours. This lack of adequate RN coverage could potentially result in residents not receiving the necessary services to meet their needs. Interviews conducted with facility staff, including the VP of Clinical and the acting Director of Nursing (DON), highlighted the facility's staffing challenges. The VP of Clinical mentioned that nurses began entering the facility on a consulting basis in early December 2024, and the acting DON assumed their role on 12/09/24. The acting DON acknowledged that the absence of an RN for the required hours could lead to residents needing to be transferred to a hospital for services or experiencing delays in receiving necessary care. The facility's policy, dated 10/24/22, mandates the use of RN services for at least 8 consecutive hours per day, 7 days a week, which was not adhered to during the specified days in November 2024.
Deficiency in Secure Unit Placement Documentation
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for five residents, specifically regarding their placement in a secure unit. For Resident #23, the facility did not obtain consent for her to reside in the secure unit, despite her being severely cognitively impaired and at risk for elopement. The resident's care plan indicated her need for supervision due to her cognitive impairment, but the necessary consent documentation was missing from her electronic health record. Resident #25 was placed in the secure unit without a physician's order, although consent was obtained from the resident's representative. The resident had severe cognitive impairment and was identified as an elopement risk, necessitating his placement in the secure unit. However, the absence of a physician's order was acknowledged by the Director of Nursing (DON) as a potential violation of the resident's rights. Similarly, Residents #73, #74, and #78 were also residing in the secure unit without the required consents and physician orders. These residents were all severely cognitively impaired and had histories of wandering or exit-seeking behaviors, which justified their placement in the secure unit. However, the lack of proper documentation, including consents and physician orders, was noted as a deficiency in maintaining accurate and complete medical records, as required by professional standards.
Failure to Provide Mandatory Restraints Training for Staff
Penalty
Summary
The facility failed to provide mandatory training on restraints for five staff members, including the Activity Director, two CNAs, a PTA, and a Speech Therapist. This deficiency was identified through interviews and a review of the facility's training log, which showed no evidence of completed training for these individuals. The absence of this training was confirmed during multiple interviews with the acting HR Coordinator and the Regional HR Manager, who acknowledged the missing training records. The acting HR Coordinator expressed uncertainty about who was responsible for training oversight at the facility, indicating a lack of clarity in roles and responsibilities. The facility's policies on training requirements and nursing services emphasize the importance of maintaining an effective training program and ensuring sufficient staff with appropriate competencies. However, the failure to provide the required training on restraints could potentially place residents at risk of being cared for by untrained staff, as noted by the acting HR Coordinator.
Failure to Provide Mandatory QAPI Training to Staff
Penalty
Summary
The facility failed to provide mandatory Quality Assurance Performance Improvement (QAPI) training to 10 out of 25 staff members sampled for licensure and training. These staff members included a housekeeper, medical assistant, certified nursing assistant, food service director, registered nurse, licensed vocational nurses, speech therapist, social worker, and occupational therapist. The absence of this training was confirmed through a review of the facility's training log, which showed no evidence of QAPI training for the mentioned staff. Interviews with the Regional HR Manager and the acting HR Coordinator further verified that these staff members were missing the required federal or state QAPI training. During interviews, the acting HR Coordinator and the Regional VP of Operations acknowledged the lack of training oversight at the facility. The acting HR Coordinator admitted uncertainty about who was responsible for ensuring staff received necessary training at this facility. The facility's Training Requirements policy mandates the development and maintenance of an effective training program for all staff, but this was not adhered to, as evidenced by the missing QAPI training. The Nursing Services and Sufficient Staff policy also emphasizes the need for sufficient staff with appropriate competencies to ensure resident safety and well-being, which was compromised due to the training deficiency.
Failure to Provide Behavioral Health Training to Staff
Penalty
Summary
The facility failed to provide required behavioral health training for two of the 25 employees sampled for licensure and training, specifically RN V and the Physical Therapist. This deficiency was identified through a review of the facility's training log, which showed no evidence of the mandatory training for these staff members. Interviews conducted with the Regional HR Manager and the acting HR Coordinator confirmed that several employees were missing required federal or state trainings, including the behavioral health training for the two staff members in question. During interviews, it was revealed that there was a lack of clarity regarding who was responsible for overseeing training at the facility. The acting HR Coordinator, who is responsible for training at another facility, was unsure of the oversight at this location. The Regional VP of Operations indicated that the Administrator would be responsible for staff training until a new HR Coordinator was appointed. The facility's policies on training requirements and nursing services emphasize the importance of providing sufficient staff with appropriate competencies to ensure resident safety and well-being, which was not adhered to in this instance.
Violation of Resident Privacy and Dignity
Penalty
Summary
The facility failed to uphold the residents' rights to dignity and privacy, as evidenced by the actions of Laundry Aide X on the 300 unit. During an observation, it was noted that Laundry Aide X entered multiple resident rooms without knocking, which is a violation of the residents' rights to a dignified existence and privacy. Resident #75, who is cognitively intact, expressed discomfort with staff entering her room without knocking, highlighting the invasion of privacy and potential exposure to embarrassing situations. Laundry Aide X admitted to entering rooms without knocking, assuming that open doors indicated no resident presence. However, she acknowledged the importance of knocking and announcing herself before entering, as per her training and facility policy. The facility's Administrator confirmed that staff are expected to knock and announce themselves before entering a resident's room, recognizing this as a resident rights issue. The facility's policy on Resident Rights emphasizes treating residents with respect and dignity, which was not adhered to in this instance.
Failure to Distribute Mail on Saturdays
Penalty
Summary
The facility failed to ensure that residents received their mail in a timely manner, specifically on Saturdays. During a confidential resident group meeting, three out of ten members reported that they did not receive mail on Saturdays because the Receptionist was off on weekends. The Receptionist confirmed that she worked Monday through Friday and did not collect mail on weekends. She stated that during the week, she collected mail from the mailbox and the local post office, placed it in a designated area, and the Activity Director or Activity Aide distributed it to residents. However, any mail delivered on Saturday remained in the mailbox until the following Monday. The Activity Director corroborated the Receptionist's account, acknowledging that mail delivered on Saturdays was not distributed until Monday. The Administrator confirmed that residents should receive their mail every day, as it is a resident right. A review of the facility's policy on mail and electronic communication revealed that mail and packages should be delivered to residents within twenty-four hours of delivery, including Saturdays. This failure to distribute mail on Saturdays resulted in residents not receiving their mail promptly, which could diminish their quality of life.
Inadequate Perineal Care by CNA
Penalty
Summary
The facility failed to ensure that licensed staff demonstrated the necessary competencies and skill sets to care for residents' needs, specifically in the case of a certified nursing assistant (CNA-L) who did not properly clean a resident's genital area during incontinent and indwelling urinary catheter care. This deficiency was observed during an incident involving a male resident with severe cognitive impairment, dementia, peripheral vascular disease, neuromuscular dysfunction of the bladder, urinary tract infection, and hypertension. The resident required substantial assistance for toileting hygiene and was always incontinent of bowel. During the observation, CNA-L, assisted by another CNA, cleaned the resident's groin area and catheter but failed to clean the resident's penis, which is a critical step in preventing urinary tract infections. Despite having passed a clinical skills checklist for perineal care earlier in the month, CNA-L admitted to forgetting this step due to nervousness. The Director of Nursing (DON) confirmed that the proper procedure was not followed, which could potentially lead to cross-contamination and infections.
Failure in Pharmaceutical Services Leads to Missing Narcotics
Penalty
Summary
The facility failed to provide adequate pharmaceutical services, specifically in the accurate acquiring, receiving, dispensing, and administering of drugs, as evidenced by the case of a resident with missing hydrocodone tablets. The resident, a 74-year-old male with a history of joint replacement, cancer, and pain, was prescribed hydrocodone for pain management. However, two tablets were unaccounted for during a narcotic count on November 27, 2024. The resident's Medication Administration Record (MAR) showed no documentation of the medication being administered on the dates in question, and there were no corresponding nurse notes to verify administration. The investigation revealed that the Licensed Vocational Nurse (LVN) responsible for the medication cart left it unsecured while attending to another resident, potentially allowing access to the narcotics. The LVN admitted to forgetting to document the administration of the medication and leaving the cart unsecured. The Director of Nursing (DON) confirmed that the narcotic count was off by two pills, and the LVN accepted responsibility for the oversight. The facility's Controlled Substances policy mandates that controlled substances be secured and accurately accounted for, which was not adhered to in this instance.
Failure to Act on Pharmacist Recommendations for Drug Regimen
Penalty
Summary
The facility failed to act upon drug regimen irregularities reported by the Pharmacist Consultant for two residents. For one resident, the pharmacist recommended a gradual dose reduction of Mirtazapine for depression, but the facility did not communicate this recommendation to the resident's primary care physician. The resident, who had a diagnosis of dementia and depression, continued to receive the medication without the suggested dose reduction. For another resident, the pharmacist recommended adding a 'Do Not Crush' instruction to the medication administration record for Diltiazem, which was not done. This resident had severe cognitive impairment and was diagnosed with hypertension, among other conditions. The absence of the 'Do Not Crush' instruction could have led to incorrect medication administration. The Director of Nursing (DON) acknowledged the lack of action on these recommendations, noting that the leadership group had recently changed due to a new company acquiring the facility. The DON was unaware of why the previous leadership did not follow the pharmacist's recommendations, and it was noted that it was the DON's responsibility to report all pharmacy recommendations to the physicians.
Medication Security Lapse in Nurse Cart
Penalty
Summary
The facility failed to ensure that drugs and biologicals were properly secured and distributed, as evidenced by the presence of five loose pills in the nurse medication cart for the 300 hall. During an observation and interview, it was revealed that these loose pills were found in the bottom of the cart drawers that held blister packs. LVN F acknowledged that if these pills were consumed by a resident for whom they were not prescribed, it could lead to severe consequences, including allergic reactions. The acting DON confirmed that the presence of loose pills could result in residents not receiving their necessary medications, leading to a delay in therapy. Additionally, if a resident consumed medication not prescribed to them, it could cause adverse effects or allergic reactions. The facility's policy on medication carts and supplies emphasized the importance of appropriate control and surveillance of resident-assigned medications, and the policy on disposal of medications highlighted the need to secure unused and unwanted medications until they are destroyed.
Failure to Coordinate Hospice Care and Maintain Documentation
Penalty
Summary
The facility failed to effectively collaborate with hospice representatives and coordinate the hospice care planning process for a resident receiving hospice services. This deficiency was identified through interviews and record reviews, which revealed that the facility did not monitor hospice aide and nursing visits according to the hospice plan of care. Additionally, the facility failed to maintain the correct visit log sheet in the resident's hospice binder. The resident, an elderly female with severe cognitive impairment due to Alzheimer's disease, was admitted to hospice care for Alzheimer's disease. The hospice plan of care required hospice aide and nurse visits twice a week, but the visit log only showed a single visit, and there was no documentation for other visits. Interviews with the hospice clinical director and facility staff indicated a lack of communication and documentation regarding hospice visits. The hospice clinical director confirmed that visits occurred but were not documented in the visit log. Facility staff, including an LVN and the DON, acknowledged the oversight in monitoring and documenting hospice visits. The DON admitted that the facility lacked a specific hospice policy and that facility nurses were responsible for communicating with hospice staff and maintaining hospice documentation. This lack of communication and documentation could potentially lead to inadequate end-of-life care for residents receiving hospice services.
Infection Control Breach During Resident Care
Penalty
Summary
The facility failed to maintain an effective infection control program, as evidenced by an incident involving a certified nursing assistant (CNA) who did not follow proper glove-changing procedures during incontinent and indwelling urinary catheter care for a resident. The resident, a male with severe cognitive impairment and multiple medical conditions including dementia, peripheral vascular disease, and a urinary tract infection, required substantial assistance with personal hygiene. During care, the CNA used old and dirty gloves to handle a new and clean brief, which was against the facility's infection control policy. The incident was observed by surveyors, and the CNA admitted to the oversight, attributing it to nervousness and forgetfulness. The Director of Nursing (DON) confirmed that the CNA should have used clean gloves when handling the new brief. The facility's policy on perineal care clearly outlined the need for glove removal and hand hygiene before handling clean items, which was not adhered to in this instance.
Failure to Provide Mandatory Training for RN
Penalty
Summary
The facility failed to provide mandatory effective communications training to one of the sampled staff members, RN V, as required by their training program. A review of the facility's training log showed no evidence of such training for RN V. Interviews with the Regional HR Manager and the acting HR Coordinator confirmed that RN V was missing this required training. The acting HR Coordinator was unsure who was responsible for training oversight at the facility, indicating a lack of clarity in roles and responsibilities. The facility's Training Requirements policy mandates the development, implementation, and maintenance of an effective training program for all staff, including those under contractual arrangements and volunteers. Additionally, the Nursing Services and Sufficient Staff policy requires the facility to provide sufficient staff with appropriate competencies to ensure resident safety and well-being. The failure to ensure RN V received effective communications training could place residents at risk of being cared for by untrained staff, potentially leading to neglect or adverse outcomes.
Inaccurate Documentation of Resident Showers
Penalty
Summary
The facility failed to maintain accurate medical records for a resident, specifically regarding the documentation of showers in the electronic record system (POC). The resident, a 78-year-old female with severe cognitive impairment and multiple diagnoses including dementia and Alzheimer's disease, was supposed to receive showers on specific days. However, the POC documentation inaccurately reflected that the resident did not receive showers on several scheduled days in October and November 2024. This discrepancy was noted despite the resident being well-groomed and able to confirm receiving assistance with showers, although she could not recall specific dates. Interviews with facility staff revealed that a CNA, who had worked with the resident on many of the listed shower days, admitted to possibly forgetting to document the showers. The facility's administrator acknowledged that nursing staff are required to document when a resident receives or refuses a shower, but was unaware of why the documentation was not completed in this case. This lack of documentation could result in an incomplete view of the resident's care and services.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post daily nurse staffing information for four consecutive days, specifically on 11/19/2024, 11/20/2024, 11/21/2024, and 11/22/2024. During observations on these dates, it was noted that the Daily Nurse Staffing Report displayed was dated 11/6/2024, indicating that the information had not been updated for several days. This report was found in a plastic sheet protector taped inside a glass cabinet on the 100 hall, and it did not reflect the current staffing data or the resident census for the days in question. During an interview on 11/22/2024, the facility Administrator acknowledged the oversight and attributed it to the staffing coordinator being new to her position and not yet familiar with all the staffing requirements. The Administrator confirmed that it is a state requirement to have the staffing information posted daily, although there was no specific policy in place at the facility regarding this requirement. The lack of updated staffing information could potentially place residents, their families, and visitors at risk by not providing access to current staffing levels and resident census data.
Failure to Notify Resident and Representative of Discharge
Penalty
Summary
The facility failed to provide timely and appropriate notification to a resident and their representative regarding the resident's discharge and transfer to a psychiatric facility. The resident, a male with multiple diagnoses including hypertension, diabetes mellitus type 2, cognitive deficit, and mood disorder, was initially admitted to the facility and later discharged to a hospital before being transferred to a psychiatric facility for medication review and behavioral placement. Despite the resident's cognitive intactness, as indicated by a BIMS score of 14, the facility did not provide written notification of the discharge to the resident's representative or the LTC Ombudsman. The deficiency was further compounded by the facility's failure to update the recipients of the discharge notice as soon as practicable once updated information became available. The resident had exhibited aggressive behavior, including hitting another resident, which led to his transfer to a behavioral hospital. However, there was no documentation of written notification to the resident's representative or the LTC Ombudsman regarding the discharge, and the facility did not notify the Ombudsman by phone or in writing. Interviews with facility staff, the resident's representative, and the Ombudsman revealed that the facility did not follow proper procedures for notifying the necessary parties about the resident's discharge. The resident's representative was not informed about the transfer and discharge to another facility, and the Ombudsman was not notified of the discharge, which led to an appeal being accepted, allowing the resident to return to the facility. The facility's policy on transfer or discharge, which requires a 30-day advance written notice and notification to the LTC Ombudsman, was not adhered to in this case.
Failure to Honor Resident's DNR Wishes Due to Invalid OOHDNR Form
Penalty
Summary
The facility failed to comply with the requirements specified in 42 CFR part 489, subpart I (Advance Directives) by not ensuring that Resident #1's Do Not Resuscitate (DNR) wishes were honored. Resident #1's Responsible Party (RP) had requested a DNR code status, but the Out-of-Hospital Do Not Resuscitate (OOHDNR) form was not valid as it lacked a physician's signature. Consequently, when Resident #1 was found unresponsive, Licensed Vocational Nurse (LVN) A and Registered Nurse (RN) B administered Cardiopulmonary Resuscitation (CPR) because they believed the resident was a full code. This action was taken despite the resident's electronic chart indicating a DNR status, which was not properly validated due to the missing physician's signature on the OOHDNR form. The resident was pronounced dead after CPR was continued by Emergency Medical Services (EMS) due to the invalid OOHDNR form. The deficiency was identified as Immediate Jeopardy (IJ) and was corrected before the survey began. Resident #1 had a complex medical history, including end-stage renal disease (ESRD), pulmonary edema, diabetes, altered mental status, anemia in chronic kidney disease, vascular dialysis catheter, peripheral vascular disease, acquired absence of the right leg below the knee, dependence on renal dialysis, and cognitive communication deficit disorder of the brain. The resident was severely cognitively impaired with a Brief Interview for Mental Status (BIMS) score of 2. Despite the resident's electronic chart indicating a DNR status, the lack of a valid OOHDNR form led to the administration of CPR, contrary to the resident's and RP's wishes. Interviews with staff revealed that there was confusion and a lack of clarity regarding the resident's code status. LVN A and RN B both believed the resident was a full code due to the absence of a valid OOHDNR form. The Admission/Marketer and ADON/RN/Medical Records D were involved in the process of obtaining the physician's signature for the OOHDNR form, but the form was never completed. The Director of Nursing (DON) confirmed that without a valid OOHDNR form, the resident would remain a full code. This failure to ensure the proper completion and validation of the OOHDNR form resulted in the resident's DNR wishes not being honored.
Removal Plan
- Staff training on OODNR/CPR/change of conditions conducted
- 84 of 84 direct care staff in-serviced regarding Code Status/change of condition
- Nurses, CNAs, and MAs trained on where to find the location of the code status
- Non-clinical staff instructed to refer to charge nurse for assistance with code status
- Staff instructed to notify ADON, DON, and Administrator immediately if code status does not match
- Administrator trained on where to locate a resident's code status in the electronic medical records system
- RN D trained on finding code status in different locations in the chart and verifying OODNR completion
- CNA E trained on checking residents' POC for code status and notifying charge nurse of changes
- ADON/LVN F trained on advanced directives, code status location, and OODNR validation
- MA G trained on code status location in the electronic medical records system and notifying charge nurse if code status does not match
- CNA H trained on checking residents' POC for code status and asking nurse about code status
- ADON/LVN I trained on finding code status in the electronic medical records system and verifying OODNR completion
- LVN J trained on advanced directives, mock CPR, and notifying ADM, DON, ADON if code status does not match
- LVN K trained on finding code status in the electronic medical records system and verifying OODNR completion
- CNA L trained on finding code status on residents' POC and notifying nurse of any changes
- CNA M trained on finding code status on residents' POC and alerting nurse of any changes
- DON trained on finding code status in the electronic medical records system and verifying OODNR completion
- Facility policy on Emergency Procedure- Cardiopulmonary Resuscitation reviewed and updated
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Port Lavaca
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Port Lavaca Nursing And Rehabilitation Center | 0.6 mi | ★★★★★ | 0 | 0 |
| Southbrooke Manor Nursing And Rehabilitation Cente | 23.1 mi | ★★★★★ | 2 | 0 |
| The Courtyard Rehabilitation And Healthcare Center | 24 mi | ★★★★★ | 14 | 2 |
| Riverside Oaks | 24.1 mi | ★★★★★ | 19 | 0 |
| Twin Pines Nursing And Rehabilitation | 25.3 mi | ★★★★★ | 20 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.