Lavaca Bay Nursing And Rehabilitation Center

Penalties

• May 3, 2024 — Fine ($8,827)
• Sep 11, 2023 — Fine ($12,893)

Inspection findings

1. Mar 27, 2026 Fire Safety · 16 findings
   • Not serious Scope/severity F

     E0007 Emergency Preparedness Deficiencies

     Address patient/client population and determine types of services needed.

     Corrected Apr 3, 2026 · CMS fire safety

   • Not serious Scope/severity D

     F0550 Resident Rights Deficiencies

     Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

     Corrected Mar 28, 2026 · CMS health inspection

   • Not serious Scope/severity E

     F0641 Resident Assessment and Care Planning Deficiencies

     Ensure each resident receives an accurate assessment.

     Corrected Mar 28, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0689 Quality of Life and Care Deficiencies

     Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

     Corrected Mar 28, 2026 · CMS health inspection

   • Not serious Scope/severity F

     F0727 Nursing and Physician Services Deficiencies

     Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.

     Corrected Mar 28, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0761 Pharmacy Service Deficiencies

     Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

     Corrected Mar 28, 2026 · CMS health inspection

   • Not serious Scope/severity E

     K0211 Egress Deficiencies

     Keep aisles, corridors, and exits free of obstruction in case of emergency.

     Corrected Apr 3, 2026 · CMS fire safety

   • Not serious Scope/severity E

     K0321 Smoke Deficiencies

     Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

     Corrected Apr 3, 2026 · CMS fire safety

   • Not serious Scope/severity F

     K0324 Smoke Deficiencies

     Provide properly protected cooking facilities.

     Corrected Apr 3, 2026 · CMS fire safety

   • Not serious Scope/severity F

     K0345 Smoke Deficiencies

     Have approved installation, maintenance and testing program for fire alarm systems.

     Corrected Apr 3, 2026 · CMS fire safety

   • Not serious Scope/severity F

     K0353 Smoke Deficiencies

     Inspect, test, and maintain automatic sprinkler systems.

     Corrected Apr 3, 2026 · CMS fire safety

   • Not serious Scope/severity E

     K0355 Smoke Deficiencies

     Properly select, install, inspect, or maintain portable fire extinguishes.

     Corrected Apr 3, 2026 · CMS fire safety

   • Not serious Scope/severity E

     K0511 Services Deficiencies

     Have properly installed electrical wiring and gas equipment.

     Corrected Apr 3, 2026 · CMS fire safety

   • Not serious Scope/severity E

     K0741 Miscellaneous Deficiencies

     Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

     Corrected Apr 3, 2026 · CMS fire safety

   • Not serious Scope/severity F

     K0918 Gas, Vacuum, and Electrical Systems Deficiencies

     Have generator or other power source capable of supplying service within 10 seconds.

     Corrected Apr 3, 2026 · CMS fire safety

   • Not serious Scope/severity D

     K0923 Gas, Vacuum, and Electrical Systems Deficiencies

     Have proper medical gas storage and administration areas.

     Corrected Apr 3, 2026 · CMS fire safety

2. Nov 25, 2025 Health · 1 finding
   • Not serious Scope/severity D Complaint

     F0842 Resident Assessment and Care Planning Deficiencies

     Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

     Corrected Nov 26, 2025 · CMS health inspection

3. Dec 19, 2024 Health · 19 findings
   • Not serious Scope/severity D

     F0550 Resident Rights Deficiencies

     Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

     Corrected Dec 20, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0576 Resident Rights Deficiencies

     Ensure residents have reasonable access to and privacy in their use of communication methods.

     Corrected Dec 20, 2024 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0607 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Develop and implement policies and procedures to prevent abuse, neglect, and theft.

     Corrected Dec 20, 2024 · CMS health inspection

   • Not serious Scope/severity E

     F0690 Quality of Life and Care Deficiencies

     Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

     Corrected Dec 20, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0726 Nursing and Physician Services Deficiencies

     Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

     Corrected Dec 20, 2024 · CMS health inspection

   • Not serious Scope/severity E

     F0727 Nursing and Physician Services Deficiencies

     Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.

     Corrected Dec 20, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0755 Pharmacy Service Deficiencies

     Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

     Corrected Dec 20, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0756 Pharmacy Service Deficiencies

     Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

     Corrected Dec 20, 2024 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0761 Pharmacy Service Deficiencies

     Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

     Corrected Dec 20, 2024 · CMS health inspection

   • Not serious Scope/severity E

     F0842 Resident Assessment and Care Planning Deficiencies

     Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

     Corrected Dec 20, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0849 Administration Deficiencies

     Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.

     Corrected Dec 20, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Dec 20, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0941 Administration Deficiencies

     Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.

     Corrected Dec 20, 2024 · CMS health inspection

   • Not serious Scope/severity E

     F0943 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.

     Corrected Dec 20, 2024 · CMS health inspection

   • Not serious Scope/severity E

     F0944 Administration Deficiencies

     Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.

     Corrected Dec 20, 2024 · CMS health inspection

   • Not serious Scope/severity E

     F0949 Administration Deficiencies

     Provide behavior health training consistent with the requirements and as determined by a facility assessment.

     Corrected Dec 20, 2024 · CMS health inspection

   • Not serious Scope/severity E

     K0222 Egress Deficiencies

     Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

     Corrected Dec 19, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0353 Smoke Deficiencies

     Inspect, test, and maintain automatic sprinkler systems.

     Corrected Dec 19, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0741 Miscellaneous Deficiencies

     Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

     Corrected Dec 19, 2024 · CMS fire safety

4. Nov 22, 2024 Health · 2 findings
   • Not serious Scope/severity C Complaint

     F0732 Nursing and Physician Services Deficiencies

     Post nurse staffing information every day.

     Corrected Dec 12, 2024 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0842 Resident Assessment and Care Planning Deficiencies

     Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

     Corrected Dec 12, 2024 · CMS health inspection

5. Aug 2, 2024 Health · 1 finding
   • Not serious Scope/severity D Complaint

     F0623 Resident Rights Deficiencies

     Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

     Corrected Aug 16, 2024 · CMS health inspection

6. May 3, 2024 Health · 1 finding
   • Serious Scope/severity J Complaint

     F0578 Resident Rights Deficiencies

     Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

     Corrected Apr 26, 2024 · CMS health inspection

7. Oct 27, 2023 Health · 7 findings
   • Not serious Scope/severity E Complaint

     F0558 Resident Rights Deficiencies

     Reasonably accommodate the needs and preferences of each resident.

     Corrected Nov 15, 2023 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0604 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

     Corrected Nov 15, 2023 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0641 Resident Assessment and Care Planning Deficiencies

     Ensure each resident receives an accurate assessment.

     Corrected Nov 15, 2023 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0645 Resident Assessment and Care Planning Deficiencies

     PASARR screening for Mental disorders or Intellectual Disabilities

     Corrected Nov 15, 2023 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0658 Resident Assessment and Care Planning Deficiencies

     Ensure services provided by the nursing facility meet professional standards of quality.

     Corrected Nov 15, 2023 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0812 Nutrition and Dietary Deficiencies

     Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

     Corrected Nov 15, 2023 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Nov 15, 2023 · CMS health inspection

8. Oct 12, 2023 Health · 3 findings
   • Not serious Scope/severity E Complaint

     F0602 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Protect each resident from the wrongful use of the resident's belongings or money.

     Corrected Oct 10, 2023 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0657 Resident Assessment and Care Planning Deficiencies

     Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

     Corrected Oct 25, 2023 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0755 Pharmacy Service Deficiencies

     Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

     Corrected Oct 25, 2023 · CMS health inspection

9. Sep 11, 2023 Health · 1 finding
   • Serious Scope/severity J Complaint

     F0689 Quality of Life and Care Deficiencies

     Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

     Corrected Oct 10, 2023 · CMS health inspection

Owners and managers (as published by CMS)

• BAIRD, DANIEL — indirect ownership interest, NOT APPLICABLE, since 12/16/2024
• CARVAJAL, ANTONIO — indirect ownership interest, NOT APPLICABLE, since 12/16/2024
• CHAVANA, MICHAEL — corporate officer, NOT APPLICABLE, since 03/01/2012
• CLAPP, BARBARA — operational/managerial control, NOT APPLICABLE, since 12/16/2024
• CLAPP, BARBARA — adp of the snf, NOT APPLICABLE, since 12/16/2024
• CLEVENGER, ERIN — adp of the snf, NOT APPLICABLE, since 03/04/2020
• CLEVENGER, ERIN — operational/managerial control, NOT APPLICABLE, since 03/04/2020
• CLEVENGER, ERIN — corporate director, NOT APPLICABLE, since 10/01/2024
• CORTESE, DAREN — indirect ownership interest, NOT APPLICABLE, since 12/16/2024
• CROWLEY, WILLIAM — corporate officer, NOT APPLICABLE, since 04/01/2022
• DEKOWSKI, DONOVAN — operational/managerial control, NOT APPLICABLE, since 12/16/2024
• DEKOWSKI, DONOVAN — adp of the snf, NOT APPLICABLE, since 12/16/2024
• DIERSCHKE, SHELIA — corporate officer, NOT APPLICABLE, since 03/01/2020
• FRANKLIN, DALLAS — corporate officer, NOT APPLICABLE, since 03/01/2020
• GIBSON, PATRICIA — indirect ownership interest, NOT APPLICABLE, since 12/16/2024
• GONZALES, VERONICA — indirect ownership interest, NOT APPLICABLE, since 12/16/2024
• KAUFMAN, NICOLE — indirect ownership interest, NOT APPLICABLE, since 12/16/2024
• MANDELBAUM, ELLIOT — indirect ownership interest, NOT APPLICABLE, since 12/16/2024
• MCPHERSON, KAY — corporate officer, NOT APPLICABLE, since 04/01/2022
• MUTCHLER, STEPHEN — corporate officer, NOT APPLICABLE, since 05/15/2023
• RODRIGUEZ, JESSIE — corporate officer, NOT APPLICABLE, since 05/01/2023
• TEEHAN, ERIC — operational/managerial control, NOT APPLICABLE, since 12/16/2024
• TEEHAN, ERIC — adp of the snf, NOT APPLICABLE, since 12/16/2024
• TUAZON, REYNALDO — corporate officer, NOT APPLICABLE, since 03/01/2020
• WRIGHT, JOHN — adp of the snf, NOT APPLICABLE, since 12/16/2024
• WU, JACK — corporate officer, NOT APPLICABLE, since 11/01/1988
• CSV RHEA MANAGEMENT HOLDCO, LLC — direct ownership interest, NOT APPLICABLE, since 12/16/2024
• DWD TX HOLDINGS LLC — indirect ownership interest, NOT APPLICABLE, since 12/16/2024
• JACK AND NANCY DWYER WORKFORCE DEVELOPMENT CENTER INC — direct ownership interest, NOT APPLICABLE, since 12/16/2024
• MEMORIAL MEDICAL CENTER — adp of the snf, NOT APPLICABLE, since 02/27/2025
• MEMORIAL MEDICAL CENTER — operational/managerial control, NOT APPLICABLE, since 03/04/2020
• MEMORIAL MEDICAL CENTER — 5% or greater direct ownership interest, 100%, since 03/04/2020
• REG LEASED OPCO LLC — direct ownership interest, NOT APPLICABLE, since 12/16/2024
• REG OPERATOR HOLDCO LLC — indirect ownership interest, NOT APPLICABLE, since 12/16/2024
• REGENCY IHS CLINICAL CONSULTING, LLC — adp of the snf, NOT APPLICABLE, since 12/16/2024
• REGENCY IHS REHAB LLC — adp of the snf, NOT APPLICABLE, since 12/16/2024
• REGENCY INTEGRATED HEALTH SERVICES LLC — adp of the snf, NOT APPLICABLE, since 02/27/2025
• REGENCY INTEGRATED HEALTH SERVICES LLC — indirect ownership interest, NOT APPLICABLE, since 12/16/2024
• REGENCY INTEGRATED HEALTH SERVICES LLC — operational/managerial control, NOT APPLICABLE, since 12/16/2024
• REGENCY TEXAS HOLDINGS LLC — indirect ownership interest, NOT APPLICABLE, since 12/16/2024
• WELLSENTIAL OF LAVACA BAY LLC — direct ownership interest, NOT APPLICABLE, since 12/16/2024
• WELLSENTIAL OF LAVACA BAY LLC — adp of the snf, NOT APPLICABLE, since 02/27/2025
• WELLSENTIAL OF LAVACA BAY LLC — operational/managerial control, NOT APPLICABLE, since 12/16/2024