Health inspection·March 24, 2025

F 0842 and CNA B. Level of Harm - Minimal harm or potential for actual harm Observation and interview on 3/21/25 at 4:40 PM, Resident #1 was sitting in a W/C (wheelchair) in the hall, verbally vocal. There were no injuries, skin tears or bruises present. The resident's mental state was one of verbal aggression. The resident was alert and oriented to person only. Resident #1 stated, .I can reach my call light .they take too long to respond .left wet sometimes .no skin breakdown or skin [concerns]. Residents Affected - Few During an interview on 3/24/25 at 11:24 AM, RN C stated: the Resident #1's refusal of care could explain the redness to the abdominal folds on the last skin assessment (3/17/25). RN C stated, no evidence existed that staff (CNA A and CNA B) refused to provide the resident with peri-care. However, RN stated that documentation was not present on 3/17/25 (night shift: 7:00 PM to 7:00 AM) and 3/18/25 (day shift (7:00 AM-7:00 PM) that resident refused peri-care or that peri-care was given. RN C stated that documentation needed to exist to back-up that refusal was made by the resident; or that peri-care was not necessary. RN C stated that documentation was necessary for continuity of care between shifts. During telephone interview on 3/24/25 at 11:30 AM, CNA A stated that she forgot to document on 3/18/25 that peri-care was given to both Resident #1 and Resident #2 because she was too involved with other residents. CNA A stated documentation was important in POC so as to show that services were given to the residents. During telephone interview on 3/24/25 at 2:05 PM, CNA B (night shift 7:00 AM to 7:00 PM) stated peri-care was given to both Resident #1 and Resident #2, but documentation was not done because she was involved in getting residents ready for the breakfast meal. CNA B stated documentation was required to show that services were given. During an interview on 3/24/25 at 1:40 PM, the ADON stated CNAs were required to document peri-care to serve as evidence that the service was given. Also, the ADON stated documentation was needed as a means of communications between shifts and evidence of continuity of care. The ADON stated that she could not provide an explanation for the lack of documentation for Resident #1 and Resident #2 on 3/17/25 and 3/18/25. Record review of Resident #2' face sheet, dated 3/24/25, reflected resident was a male age [AGE] re-admitted on [DATE] with diagnoses that included: cerebral palsy (a group of disorders that affect movement, muscle tone and coordination due to damage to the developing brain), post-polio (a condition that causes gradual muscle weakness and muscle atrophy), and dementia (memory loss). The RP was listed as a family member. Record review or Resident #2's quarterly MDS dated [DATE], reflected the resident's BIMS score was 5 (severely impaired in cognition). In the area of toileting the resident required substantial/maximum assistance by one nursing staff. Record review of Resident #2's CP, undated, in the ADL section for toileting reflected substantial/maximum assistance. Record review of Resident #2's skin assessment dated [DATE] reflected, pinkness on the left ankle. Record Review of Resident #2's POC for March 2025 reflected: no documentation for 3/17/25 (night) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455549 If continuation sheet Page 2 of 3 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455549 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jourdanton Nursing and Rehabilitation 1504 Highway 97e Jourdanton, TX 78026 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 and 3/18/25 (morning) involving peri-care. Level of Harm - Minimal harm or potential for actual harm Observation and interview on 3/21/25 at 4:48 PM, Resident #2 was sitting on a W/C being prepared for the dinner meal. Resident was impaired to upper and lower extremities. The resident had difficulty in speech. There were no injuries, skin tears or bruises present. Mental status was one of happiness. The resident was alert and oriented to person only. The Resident stated, .call light works .yes, they come [to provide peri-care] .yes, [not left soiled]. Residents Affected - Few Record review of facility's policy titled Charting and Documentation, dated revised July 2017, read: All services provided to the resident .shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455549 If continuation sheet Page 3 of 3