Average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Port Lavaca Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
Failure to sanitize a BP cuff between residents during med pass. An MA used the same cuff on two residents without cleaning it in between, and an LVN later used a cuff from another resident on a third resident without sanitizing it first. Both staff said they knew the cuff should be sanitized between residents but forgot, and the DON confirmed cuffs need to be sanitized between each use; the affected residents had multiple chronic conditions including HTN, DM, CKD, and neurologic impairments.
Care plan missing dementia diagnosis: A resident with primary cerebral infarction and vascular dementia had an MDS showing intact cognition and an active non-Alzheimer's dementia diagnosis, but the care plan did not include the vascular dementia diagnosis, related goals, or interventions. An MDS nurse stated the diagnosis had been added to the EMR earlier and the care plan should have been updated then, but it was overlooked until later.
An RN failed to maintain sterile technique while providing trach care for a resident with severe neurologic impairment, chronic respiratory failure, and tracheostomy status. During the procedure, the sterile field was broken when the RN crossed her non-sterile arms over it while reaching for saline, and her PPE sleeves were rolled up exposing her arms while the resident was on enhanced barrier precautions. The RN acknowledged the break in sterility, and the DON stated trach care should be performed using sterile procedure.
Blocked Handwashing Sink in Kitchen Dish Room: Food service staff placed two rolling carts for clean dishes in front of the only hand sink in the dish room, making it inaccessible during observations. The [NAME] stated the sink should be accessible at all times and said the blockage occurred because staff were running out of space while doing dishes, creating a cross-contamination concern from not handwashing.
A resident’s personal refrigerator contained an unlabeled, undated container of grilled chicken and Spanish rice that remained there during repeated observations. The resident, who had COPD, major depressive disorder, alcohol-related dementia, and moderately impaired cognition, said she was unaware the food was in the refrigerator and believed family had dropped it off during a visit. CNA and LVN staff confirmed the item was present, and the DON stated perishable food in residents’ refrigerators should be labeled and dated.
A resident’s face sheet listed BPH even though she was female and identified as female at birth. The MDS nurse said the admitting nurse likely entered the diagnosis incorrectly and that the error was missed during audits; the DON stated the inaccurate diagnosis could confuse other providers and may result in the resident not receiving appropriate care.
Surveyors found that plastic cups and bowls were stored damp without air-drying nets, a can opener was covered in grime, expired salad mix with rotted leaves was not discarded, and an opened bag of grits was improperly sealed with spilled contents in dry storage. The Dietary Manager confirmed these practices did not meet facility policy or federal food safety standards.
A resident's Out of Hospital Do Not Resuscitate (OOH-DNR) form was not signed by the attending physician, rendering the document invalid despite being signed by the resident and witnesses. Staff were aware of the resident's DNR wishes and had a verbal order from the physician, but the required physician signature was missing from the form, as confirmed by record review and staff interviews.
A resident with multiple medical conditions and moderate cognitive impairment was exposed during incontinent care when two CNAs did not fully close the privacy curtain, leaving the resident's genital area visible while a roommate was present. Both CNAs confirmed the lapse, despite having received recent training on resident rights, and the facility's policy affirms the right to privacy.
A resident with multiple medical conditions was incorrectly documented as not using tobacco on a significant change MDS assessment, despite records and a smoking safety screen indicating the resident was an unsafe smoker. The MDS nurse confirmed the error and could not explain the incorrect coding, even though the RAI manual was available electronically.
A resident was admitted to the facility, but a baseline care plan was not created within 48 hours as required. The DON confirmed that the care plan had not been initiated, citing an interruption in the usual process due to the start of a survey. The responsibility for initiating the care plan typically falls to the admitting nurse, with oversight from the ADONs or DON.
A RN left a medication cart unlocked and unattended while administering medications to a resident, with various medications accessible inside. The RN admitted forgetting to lock the cart, and the DON confirmed staff are trained to keep carts locked at all times per facility policy.
The facility did not serve lunch meals according to the posted menu on two consecutive days, instead serving meals from previous days without proper documentation or notification. Staff interviews revealed a lack of awareness regarding menu substitution procedures, and required forms were not completed for the changes made.
A resident's medical record was found to be incomplete, as their facesheet did not include a list of diagnoses. The DON stated that the admitting nurse is responsible for entering diagnoses, with oversight from the ADONs or DON, but this process was interrupted when the survey began. The expectation was that records be complete and accurate to address resident needs.
A storage room on 500 Hall was found unlocked and contained items such as body soap, shampoo labeled as eye irritants, and disposable razors. The Housekeeping Supervisor confirmed the room was unsecured and contained potentially unsafe items. The DON stated storage rooms should be locked when not in use, and the Administrator reported there was no facility policy regarding the physical environment.
The facility failed to notify physicians when two residents missed their scheduled dialysis appointments due to transportation issues. The residents refused to go after waiting for almost two hours, and there was no documentation of physician notification in the progress notes or 24-hour nursing report.
The facility failed to document missed dialysis appointments for two residents due to transportation issues, with no entries in the electronic medical records, 24-hour nursing reports, or dialysis communication forms, and no physician notifications.
Failure to Sanitize Blood Pressure Cuff Between Residents
Penalty
Summary
The facility failed to maintain an infection prevention and control program when staff did not sanitize a blood pressure cuff between use on different residents. During a medication pass observation, MA B checked Resident #24’s blood pressure and then went to Resident #7’s room, sanitized her hands, but did not sanitize the blood pressure cuff before using the same cuff on Resident #7. Resident #24 had diagnoses including cerebral infarction, major depressive disorder, alcoholic cirrhosis of the liver, vascular dementia, and hypertension, and had an order for lisinopril-hydrochlorothiazide with blood pressure hold parameters. Resident #7 had diagnoses including chronic kidney disease, cellulitis, type 2 diabetes mellitus, and hypertension, and had an order for metoprolol tartrate with blood pressure and pulse hold parameters. A second observation showed LVN C coming from another room with the blood pressure cuff in hand, sanitizing her hands, but not sanitizing the cuff before checking Resident #2’s blood pressure. Resident #2 had diagnoses including hemiplegia, aphasia, dysphagia, type 2 diabetes mellitus, hyperlipidemia, and hypertension, and had an order for metoprolol tartrate with blood pressure and pulse hold parameters. In interviews, MA B and LVN C each stated they knew the cuff was supposed to be sanitized between residents but forgot, and both stated that not sanitizing equipment between residents could spread infection. The DON stated all blood pressure cuffs need to be sanitized between uses with each resident, and the facility policy required reusable items and equipment to be cleaned in accordance with the procedure for soiled or contaminated equipment.
Care Plan Missing Dementia Diagnosis
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident with vascular dementia. Record review showed the resident was admitted and later readmitted to the facility, and her admission information identified primary cerebral infarction and vascular dementia, mild, with mood disturbance. Her quarterly MDS documented a BIMS score of 15 out of 15, indicating she was cognitively intact, and also listed an active diagnosis of non-Alzheimer's dementia. However, the resident's care plan dated 6/2/2026 did not include the diagnosis of vascular dementia or related focus, goals, and interventions. During interview, the MDS Nurse stated the diagnosis of vascular dementia had been added to the EMR on 8/1/2025 and that the care plan should have been updated at that time, but it was not updated until 6/18/2026. She stated she could not explain why it was overlooked. The facility policy required comprehensive care plans to include measurable objectives and timeframes to meet the resident's medical, nursing, mental, and psychosocial needs, and to be reviewed and revised after each comprehensive and quarterly MDS assessment.
Broken Sterile Technique During Tracheostomy Care
Penalty
Summary
Facility staff failed to provide tracheostomy care to a resident with anoxic brain damage, contractures, aphasia, vascular dementia, chronic respiratory failure, quadriplegia, hypertension, and tracheostomy status in accordance with professional standards. The resident was nonverbal, dependent on staff for all activities of daily living, and had a care plan directing trach care as ordered. Physician orders required the disposable Shiley size 6 inner cannula to be changed every day shift. During observation, an RN performed tracheostomy care but placed the sterile field on a side table and positioned normal saline on the top left of the sterile field, causing her non-sterile arms to cross over the sterile field each time she reached for the saline and breaking sterility. The RN also had her PPE gown sleeves rolled up, exposing her arms while the resident was on enhanced barrier precautions due to the tracheostomy and indwelling catheter. The RN stated she had broken the sterile field but did not realize it, and the DON stated tracheostomy care should be done using sterile procedure and that crossing the sterile field with non-sterile arms constituted breaking the sterile field.
Blocked Handwashing Sink in Kitchen Dish Room
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in Kitchen 1. During observations on 6/16/2026 at 11:11 AM and 6/18/2026 at 9:17 AM, the hand sink in the dish room was blocked by two rolling carts used for clean dishes, making the only hand sink in the food preparation room inaccessible. The report states that the sink was not accessible at all times when food service staff placed the carts in front of it. During an interview on 06/19/2026 at 11:21 AM, the [NAME] stated the hand sink should be accessible at all times and explained that the sink was blocked because staff were running out of space while doing dishes. She also stated that the impact to a resident was that cross-contamination can occur from not handwashing. The facility policy on hand washing required hand-washing stations in food preparation, service, dishwashing, and restroom areas, and the FDA Food Code cited in the report states that a handwashing sink must be maintained so it is accessible at all times for employee use.
Unlabeled Food Left in Resident Refrigerator
Penalty
Summary
The facility failed to ensure the safe and sanitary storage of a resident’s food items in 1 of 5 residents’ refrigerators reviewed. In Resident #84’s room, the personal refrigerator contained an unlabeled, undated container with grilled chicken and Spanish rice. The resident’s face sheet showed diagnoses including COPD, major depressive disorder, and alcohol-related dementia, and the BIMS assessment completed 2/10/26 showed a score of 12, indicating moderately impaired cognition. During observations on 6/16/2026 at 10:20 a.m. and again at 11:00 a.m., the unlabeled, undated food container remained in the refrigerator. Resident #84 stated she was unaware the container was there and recalled that family had visited on 6/13/2026 and likely dropped off the food. CNA D and LVN C both acknowledged the presence of the unlabeled, undated food item in the resident’s refrigerator, and LVN C stated nursing and administrative staff assisted residents in removing undated and unlabeled food items daily but she had not checked that day. The DON stated that perishable food and drinks in residents’ personal refrigerators should be labeled and dated, and that staff were responsible for removing undated, unlabeled food items daily.
Inaccurate Diagnosis Listed on Resident Face Sheet
Penalty
Summary
The facility failed to maintain accurate medical records for Resident #83, a female resident admitted with diagnoses including COPD, heart failure, and cirrhosis of the liver. Review of the resident’s face sheet showed a diagnosis of benign prostatic hyperplasia (BPH), even though the resident identified as female and was assigned female at birth. The resident’s BIMS assessment showed a score of 7, indicating severe impairment. During interview, the MDS nurse stated the admitting nurse must have entered the diagnosis incorrectly and acknowledged that the BPH diagnosis should not have been on the face sheet. The MDS nurse said she had audited face sheets for accuracy, but this one had “fallen through the cracks.” The DON stated she was unaware why the inaccurate information remained on the face sheet and noted that listing BPH could cause confusion among other providers and may result in the resident not receiving appropriate care. The facility policy stated that documentation shall be factual, objective, and resident centered.
Deficiencies in Food Storage, Preparation, and Sanitation
Penalty
Summary
Surveyors identified multiple deficiencies in the facility's food service operations. In the dish room, plastic cups and bowls were observed stored face-down on damp trays without air-drying nets, preventing proper air circulation and drying. This practice was acknowledged by the Dietary Manager (DM) as incorrect, noting that staff had been trained to use air-drying nets, which were missing at the time of observation. The facility's policy and the FDA Food Code require air-drying of utensils and equipment to minimize contamination risk. In the kitchen, the tabletop can opener was found with sticky, black and brown grime covering the blade, adjustable bar, and base. The DM confirmed that the can opener should have been cleaned after each use, as per facility policy, and that cooks were responsible for maintaining its cleanliness. The presence of grime on food-contact surfaces was in direct violation of both facility policy and the FDA Food Code, which require such surfaces to be clean to sight and touch. Additional deficiencies included a sealed bag of salad mix in the reach-in cooler that was past its use-by date and contained brown and rotted leaves, and an opened bag of grits in the dry storage room that was not properly sealed, with loose grits spilled inside the storage case. The DM stated that all dietary staff were responsible for discarding expired food and ensuring proper storage of dry goods. These findings were supported by facility policies and federal food safety codes reviewed by surveyors.
Failure to Obtain Physician Signature on OOH-DNR Form
Penalty
Summary
The facility failed to ensure that a resident's Out of Hospital Do Not Resuscitate (OOH-DNR) order was properly completed and valid. Specifically, the OOH-DNR form for a female resident with a history of wedge compression fracture, hypertension, and chronic obstructive pulmonary disease was not signed by the attending physician, leaving the document invalid. The resident and two witnesses had signed the form, but the required physician's signature was missing in both the physician's statement section and the acknowledgment section. The resident's care plan and order summary indicated DNR status, and staff interviews confirmed awareness of the resident's wishes, but the necessary physician signature was not obtained at the time of review. Staff interviews revealed that the OOH-DNR form was pending the physician's signature and that the facility routinely uploaded DNR forms into the electronic health record while awaiting this signature. Despite a verbal DNR order from the physician and the facility's intention to honor the resident's wishes, the lack of a physician's signature on the OOH-DNR form meant the document was not legally valid. Review of state guidelines confirmed that only the attending physician could sign the form and that all required signatures must be present for the document to be honored by health professionals.
Failure to Ensure Resident Privacy During Incontinent Care
Penalty
Summary
Certified Nursing Assistants (CNAs) A and B failed to ensure personal privacy for a resident during incontinent care. On 04/17/2025, while providing care, the CNAs did not completely close the privacy curtain, resulting in the resident's genital area being exposed. The resident's end of the bed was uncovered, and the resident's roommate was present in the room at the time. Both CNAs acknowledged during interviews that the privacy curtain was not fully closed and confirmed that it should have been. The resident involved had a history of hypertension, asthma, dysphagia, and heart failure, and was moderately cognitively impaired with a BIMS score of 11. The resident was occasionally incontinent of bladder and always incontinent of bowel, with a care plan in place to prevent skin breakdown due to incontinence. The facility's policy on resident rights includes the right to privacy, and both the CNAs and the Director of Nursing confirmed that staff had received training on resident rights within the year.
Inaccurate MDS Assessment of Tobacco Use
Penalty
Summary
The facility failed to ensure that a resident assessment accurately reflected the resident's status for one of ten residents reviewed. Specifically, a significant change Minimum Data Set (MDS) assessment for a resident was incorrectly documented, indicating that the resident did not use tobacco. However, a review of the resident's face sheet and smoking safety screen showed that the resident was an unsafe smoker. The MDS nurse responsible for completing the assessment confirmed during an interview that the resident was a smoker and acknowledged the error in coding the MDS. The resident involved had multiple diagnoses, including hepatic encephalopathy, schizophrenia, type 2 diabetes mellitus, hyperlipidemia, and bipolar disorder. The MDS nurse stated she used the Resident Assessment Instrument (RAI) as a reference and had electronic access to it, but could not explain why the resident was not coded as a smoker. The RAI manual specifies that tobacco use should be coded as 'yes' if there is any indication of tobacco use during the look-back period, which was not followed in this case.
Failure to Initiate Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The facility failed to create and implement a baseline care plan within forty-eight hours of admission for one resident. The resident was admitted on the evening of 04/14/2025, but as of the afternoon of 04/17/2025, no baseline care plan was present in the clinical record. During an interview, the DON confirmed that the baseline care plan had not been initiated and acknowledged that it should have been completed. The DON explained that the admitting nurse was generally responsible for starting the baseline care plan, with oversight from the ADONs or DON, but the process was interrupted due to the start of a survey.
Medication Cart Left Unlocked During Administration
Penalty
Summary
A registered nurse (RN) was observed administering medications and left the medication cart on Hall 2600 unlocked and unattended while entering a resident's room and going behind the privacy curtain. The unlocked cart contained blister packs, bottles, and vials of medications for residents. During an interview, the RN acknowledged leaving the cart unlocked and stated she was aware of the requirement to keep it locked but had forgotten. The Director of Nursing (DON) confirmed that the medication cart should have been locked at all times when not in use and that staff had received training on this policy. Review of the facility's policy indicated that medication carts are to remain locked at all times when not in use.
Failure to Follow Posted Menus and Document Meal Substitutions
Penalty
Summary
The facility failed to follow the posted menus for residents on both regular and modified diets during two consecutive lunch meals. On the first day, residents were served the meal scheduled for the previous day, and on the second day, they received the meal that was supposed to be served the day before, rather than the meals listed on the posted menu. There was no indication of any approved or posted menu changes for these deviations, except for a single substitution of mushrooms with sautéed onions and bell peppers, which was properly documented. Observations confirmed that the meals served did not match the planned menu, and no signs were posted to inform residents of the changes. Interviews with facility staff, including the administrator, dietetic technician registered (DTR), and dietary manager (DM), revealed a lack of awareness and oversight regarding the requirement to serve meals as posted and to document any changes on the Menu Substitution Approval Form. The DM acknowledged the error in serving the wrong meals and admitted that the required documentation and posting of menu changes were not completed. Review of facility policy confirmed that menus should be served as written unless an emergency arises, and all substitutions must be documented and reviewed by the registered dietitian (RD) or DTR.
Incomplete Medical Record: Missing Diagnoses on Resident Facesheet
Penalty
Summary
The facility failed to maintain accurate and complete medical records for one resident, as evidenced by the absence of a list of diagnoses on the resident's facesheet. Record review showed that the facesheet, dated 04/17/2025, did not include any diagnoses for the resident who had recently been admitted. During an interview, the DON explained that the admitting nurse was typically responsible for entering diagnoses, with oversight from the ADONs or DON, but this process was interrupted due to the commencement of the survey. The DON acknowledged that her expectation was for resident records to be complete, accurate, and updated in a timely manner to ensure resident needs could be addressed.
Unlocked Storage Room with Unsafe Items on 500 Hall
Penalty
Summary
A deficiency was identified when the storage room on 500 Hall was found unlocked during an observation, containing items such as body soap, shampoo, and disposable razors intended for resident showers. The soap and shampoo containers were labeled as eye irritants. The Housekeeping Supervisor confirmed that the storage room was not secured and acknowledged the presence of items labeled as eye irritants. The Director of Nursing (DON) stated that her expectation was for storage rooms to remain locked when not in use to prevent resident access to potentially unsafe items. The Administrator confirmed that the facility did not have a policy regarding the physical environment.
Failure to Notify Physicians of Missed Dialysis Appointments
Penalty
Summary
The facility failed to immediately inform the resident, consult with the resident's physician, and notify the resident representative when there was a significant change in the resident's physical status. Specifically, the facility did not notify the physicians of two residents who missed their scheduled dialysis appointments due to transportation issues. This failure was observed in the cases of two residents who missed their dialysis appointments on the same day because the transport van driver was late, and the residents subsequently refused to go due to the delay. For Resident #1, the electronic medical record indicated that the resident missed a dialysis appointment due to the transport van driver oversleeping. There was no documentation in the progress notes or the 24-hour nursing report indicating that the physician was notified of the missed appointment. The resident confirmed during an interview that he did not go to dialysis because the driver was late, and he did not experience any ill effects from missing the treatment. Similarly, Resident #2 also missed a dialysis appointment for the same reason and refused to go after waiting for almost two hours. The progress notes and 24-hour nursing report also lacked documentation of physician notification. Interviews with the facility staff, including the van driver, DON, ADON, and the administrator, confirmed the transportation issue and the lack of timely notification to the physicians. Both physicians for the residents stated they were not informed until several days later. The facility's policy on notification of changes required contacting the resident's physician in circumstances that necessitate altering treatment, which was not followed in these cases.
Failure to Document Missed Dialysis Appointments
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents who missed their scheduled dialysis treatments. For Resident #1, the electronic medical record did not document the missed dialysis appointment on 3/30/2024 due to late transportation. There was no entry in the progress notes, 24-hour nursing report, or dialysis communication form indicating the missed appointment or notification to the physician. Resident #1's care plan included interventions to encourage dialysis attendance, but these were not documented as followed on the specified date. Similarly, Resident #2's electronic medical record lacked documentation of a missed dialysis appointment on 3/30/2024 due to transportation delays. Although a late entry in the progress notes mentioned the resident's refusal to attend dialysis, there was no record of physician notification. The 24-hour nursing report and dialysis communication form were also blank regarding this incident. Interviews with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) confirmed that staff should have documented the missed appointments and notified the physician, but this was not done.
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Illustrative
What surveyors actually found near you
We read the 22 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
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Illustrative
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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) |
|---|---|---|---|---|
| Lavaca Bay Nursing And Rehabilitation Center | 0.6 mi | ★★★★★ | 17 | 0 |
| Southbrooke Manor Nursing And Rehabilitation Cente | 22.8 mi | ★★★★★ | 2 | 0 |
| The Courtyard Rehabilitation And Healthcare Center | 24.3 mi | ★★★★★ | 1 | 0 |
| Riverside Oaks | 24.3 mi | ★★★★★ | 2 | 0 |
| Twin Pines Nursing And Rehabilitation | 25.5 mi | ★★★★★ | 21 | 0 |
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