Inspection visit

InspectionFebruary 29, 2024

SEYMOUR REHABILITATION AND HEALTHCARECMS #6750428 citations on this visit

8 citations recorded

Inspector’s narrative

What the inspector wrote

This survey cited 8 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

F 0582 Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Level of Harm - Potential for minimal harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide both a Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (Form CMS-10055) and a Notice of Medicare Non-coverage (Form CMS-10123 general notice) for 2 of 3 residents (Resident #6 and Resident #7) reviewed for Medicare Beneficiary Protection Notification when discharged from Medicare Part A Services with benefit days remaining. Residents Affected - Many The facility failed to ensure Resident #6, and Resident #7 were given a Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (Form CMS-10055) in addition to the Notice of Medicare Non-coverage (Form CMS-10123 general notice) when they were discharged from skilled services. These failures could place residents at risk of not being fully informed about services covered by Medicare. The findings included: Record review of Resident #6's Quarterly MDS, dated [DATE], revealed an [AGE] year-old female, admitted to the facility on [DATE]. The resident had a diagnosis of Alzheimer's Disease (A type of brain disorder that causes problems with memory, thinking and behavior). Review of the SNF Beneficiary Protection Notification Review (Form CMS-20052) completed for Resident #6 revealed the facility/provider initiated the discharge from Medicare Part A Services when benefit days were not exhausted. The last day of Part A service was 08/11/23. The form reflected a SNF ABN, Form CMS-10055, was provided and acknowledged by the beneficiary or the beneficiary representative. The form reflected a NOMNC, Form CMS-10123) was provided and acknowledged by the beneficiary or the beneficiary's representative. Record review of the NOMNC form (Form CMS-10123) revealed notification was made to Resident #6 on 08/09/23. A SNF ABN form (Form CMS-10055) was not completed as the facility used the Advance Beneficiary Notice of Noncoverage (Form CMS-R-131) instead. Record review of Resident #7's Quarterly MDS, dated [DATE], revealed a [AGE] year-old male, admitted to the facility on [DATE]. The resident had a diagnosis of dementia (A group of symptoms that affects memory, thinking and interferes with daily life). Review of the SNF Beneficiary Protection Notification Review (Form CMS-20052) completed for Resident #7 revealed the facility/provider initiated the discharge from Medicare Part A Services when benefit days were not exhausted. The last day of Part A service was 09/09/23. The form reflected a SNF (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 11 Event ID: 675042 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 675042 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Seymour Rehabilitation and Healthcare 1110 Westview Dr Seymour, TX 76380 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 0582 Level of Harm - Potential for minimal harm Residents Affected - Many ABN, Form CMS-10055, was provided and acknowledged by the beneficiary or the beneficiary representative. The form reflected a NOMNC, Form CMS-10123) was provided and acknowledged by the beneficiary or the beneficiary's representative. Record review of the NOMNC form (Form CMS-10123) revealed notification was made to Resident #7 on 09/07/23. A SNF ABN form (Form CMS-10055) was not completed as the facility used the Advance Beneficiary Notice of Noncoverage (Form CMS-R-131) instead. In an interview on 02/29/24 at 11:03 AM, the BOM and MDS Regional Consultant both stated they have been giving the resident's the wrong form. They stated the facility was giving the residents Form CMS-R-131 instead of the correct Form CMS-10055. Record review of the facility policy Resident Rights Under Federal Law, in the admission Agreement, not dated revealed the following [in part]: The Resident has the right to be fully informed in advanced about care and treatment and any changes in that care or treatment that may affect the Resident's well-being. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675042 If continuation sheet Page 2 of 11 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 675042 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Seymour Rehabilitation and Healthcare 1110 Westview Dr Seymour, TX 76380 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to develop and implement care plans for necessary treatments and conditions for one of two residents (Resident #13) reviewed for Comprehensive Care Plans. The facility failed to develop Resident #13's care plan dated 12/04/2023 that addressed Resident 13's diagnosis of altered mental status and psychotic medication as ordered. This failure could place residents at risk of not receiving care that was thoughtful, planned, and relevant to their condition(s) which could lead to complications in resident health and quality of life and care. The findings included: Record review of Resident #13's face sheet, dated 02/28/24, revealed a [AGE] year-old female, admitted to the facility on [DATE] and was re-admitted to the facility on [DATE]. Resident #13 had a diagnosis of altered mental status (a symptom of a brain malfunction that affects behavior and awareness). Record review of Resident #13's Annual MDS, dated [DATE], revealed in Section I diagnoses included Psychotic Disorder. Section N showed 7 days of antipsychotic medications given. Record review of Resident 13's Order Summary Report, dated 02/28/24, revealed an order for Abilify 10- at bedtime for psychosis. Record review of Resident #13's care plan, dated as revised on 12/04/23, failed to address Resident #13's diagnosis of altered mental status and failed to address the antipsychotic medication (Abilify) in the comprehensive care plan. In an interview and record review, on 02/28/24 at 2:24 PM, the Regional Nurse Consultant and the Regional MDS Consultant reviewed Resident #13's care plan. They said there was not a care plan that addressed Resident 13's diagnosis of altered mental status and psychotic medication as ordered. In a follow-up interview, on 02/29/24 at 11:56 AM, The Regional Nurse Consultant said the Social Worker was responsible for care plans and she was only at the facility two days a week. She said Resident #13 should have had a care plan addressing the diagnosis of altered mental status and psychotic medication the resident was receiving, it was missed. She said a potential negative outcome would be the resident might not receive the services or care they need. Record review of the facility policy Comprehensive Care Plans, dated 02/10/21, revealed the following [in part]: Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objective and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675042 If continuation sheet Page 3 of 11 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 675042 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Seymour Rehabilitation and Healthcare 1110 Westview Dr Seymour, TX 76380 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 0656 Policy Explanation and Compliance Guidelines: Level of Harm - Minimal harm or potential for actual harm 6. The comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment. The objectives will be utilized to monitor the resident's progress. Alternative interventions will be documented, as needed. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675042 If continuation sheet Page 4 of 11 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 675042 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Seymour Rehabilitation and Healthcare 1110 Westview Dr Seymour, TX 76380 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that a resident who needs respiratory care, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals, and preferences for 1 of 2 Residents (Resident #20) reviewed for respiratory care. Residents Affected - Few The facility failed to ensure Resident #20's nasal cannula and nebulizer were kept in a bag while not in use . These failures could place residents at risk for infections and transmission of communicable diseases. Findings included: Record review of Resident # 20's Face Sheet dated 02/29/2024 revealed an [AGE] year-old male, who was admitted to the facility on [DATE]. Diagnosis included pain, Hypertension (high blood pressure), Muscle wasting, Shortness of breath, Depression, Anxiety, chronic obstructive pulmonary disease (a lung disease that block airflow and make it difficult to breathe). Record review of Resident #20's MDS admission assessment dated [DATE] revealed a BIMS score of 12 (moderate cognitive impairment). Section I: Active diagnosis revealed chronic pulmonary disease. Section O: Respiratory Treatments was marked for Oxygen Therapy. Record review of Resident #20's Physician Orders dated 2/29/2024 revealed an order for Oxygen at 2 liters per minute via nasal cannula continuous to maintain oxygen above 90%. Change oxygen tubing weekly on Sunday. Change out nebulizer tubing weekly on Sunday. Change oxygen water when empty. Record review of Resident #20's admission Care Plan, 01/15/2024, revealed a care plan for Resident #20 has COPD (obstructive pulmonary disease) - Oxygen to keep oxygen saturation above 90%. The Care Plan failed to have an intervention regarding when oxygen tubing needed to be changed. In an observation and interview on 02/26/2024 at 2:00 PM during rounds, Resident #20 was lying in his bed receiving oxygen by ia nasal cannula at 2 liters per minute. His nebulizer was sitting on his nightstand uncovered. He was unable to answer any questions regarding whether his oxygen tubing had been changed. In an observation on 02/28/2024 at 10:07 AM Resident #20 was sitting on side of his bed. His nebulizer was uncovered and hanging over the nightstand in his room with the nebulizer about an inch from the floor. His oxygen tubing was hanging from the straw in his cup. In an interview on 02/28/2024 at 10:25 AM with the DON stated oxygen tubing was changed weekly based on the resident's orders, or as needed if they become contaminated or occluded. The DON stated oxygen tubing and the humidifier bottle should be changed per doctor's orders. If they were not dated, she stated she would discard them and replace them with a new nasal cannula. She stated resident 20's tubing and the nebulizer should have been stored in a plastic bag when not in use to prevent cross contamination and infection. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675042 If continuation sheet Page 5 of 11 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 675042 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Seymour Rehabilitation and Healthcare 1110 Westview Dr Seymour, TX 76380 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 0695 Level of Harm - Minimal harm or potential for actual harm In an interview on 02/28/2024 at 10:40 AM with the Administrator stated, the resident care is handled by the nursing department. Record review of the facility policy Respiratory Therapy -Prevention of Infection, dated 2001 revised November 2011, revealed the following [in part]: Residents Affected - Few Purpose: The purpose of this procedure is to guide prevention of infection associated with respiratory therapy tasks and equipment, including ventilators, among residents and staff. Procedure: Product: Oxygen delivery devices (no-aerosol producing) Ex: venturi masks, nasal cannulas, oxygen supply tubing. Infection Control Considerations Related to Medication Nebulizers/Continuous Aerosol: 7. Store the circuit in plastic bag between uses. 9. Discard the administration set-up every seven (7) days as needed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675042 If continuation sheet Page 6 of 11 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 675042 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Seymour Rehabilitation and Healthcare 1110 Westview Dr Seymour, TX 76380 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 0730 Observe each nurse aide's job performance and give regular training. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review the facility failed to review the work of each Certified Nurse Assistant (CNA) at least once every 12 months, for 3 (CNA A, CNA B and CNA C) of 6 CNAs reviewed for annual competency evaluations. Residents Affected - Some This deficient practice could affect residents and place them at risk of not receiving consistent, appropriate interventions necessary to meet the residents' needs. Findings included: Record Review of Personnel Files revealed the following: - Employee record for CNA A revealed a hire date of 08/02/2022, with no evidence of a competency evaluation in the past 12 months. - Employee record for CNA B revealed a hire date of 10/07/2022, with no evidence of a competency evaluation in the past 12 months. - Employee record for CNA C revealed a hire date of 01/10/2022, with no evidence of a competency evaluation in the past 12 months. In an interview on 02/29/24 at 11:39 AM, the Administrator stated the previous DON quit at the end of January of this year and boxed everything up. Documentation cannot be found confirming evidence of a competency evaluation had been completed. Potential negative outcomes would be the DON would not be aware where the nurses would need further education. Record review of the facility policy titled Nursing Services and Sufficient Staff, dated 4/10/2022, revealed the following in part: Policy: It is the policy of this facility to provide sufficient staff with appropriate competencies and skill set to assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. Policy Explanation and Compliance Guidelines: 6. The facility must ensure that nurse aids are able to demonstrate competency in skills and techniques necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675042 If continuation sheet Page 7 of 11 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 675042 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Seymour Rehabilitation and Healthcare 1110 Westview Dr Seymour, TX 76380 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation and record review the facility failed to, in accordance with accepted professional standards and practices, maintain medical records on each resident that were complete and accurately documented for 1 of 2 residents (Resident #22) reviewed for accuracy of medical records. The facility failed to ensure Resident #22 medical record was complete and included physician orders for oxygen. This failure could place residents at risk of receiving inadequate care and services. Findings included: Record review of Resident #22's face sheet, dated 02/28/24, revealed a [AGE] year-old female who was admitted to the facility on [DATE] with the diagnosis of Chronic Obstruction Pulmonary Disease (chronic lung disease characterized by air flow limitation). In an observation and interview on 02/26/24 at 2:28 PM, Resident #22 was receiving oxygen by nasal cannula said that she has been on oxygen since she was admitted to the facility. Record review of Resident #22's Order Summary Report dated 02/28/24 failed to reflect an order for oxygen. In a record review and interview on 02/28/24 at 3:32 PM, the Regional Nurse Consultant reviewed Resident #22's physical orders and said there was no order for oxygen administration. In an interview on 02/29/24 at 10:15 AM, the ADON said the resident came to the facility on oxygen. It was the responsibly of the admitting floor nurse to assure that all physician orders had been entered and are correct. The floor nurse missed it. She said a potential negative outcome would be the resident would not be provided the care they actually needed. Record review of the facility policy Orders Management, Transcribing or Noting and Discontinuing Orders, dated 3/2014, revealed the following [in part]: Guideline: When a physical order is completed, it is necessary to transcribe or note the information received onto the appropriate forms to ensure care provision. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675042 If continuation sheet Page 8 of 11 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 675042 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Seymour Rehabilitation and Healthcare 1110 Westview Dr Seymour, TX 76380 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to maintain an infection control program designed to prevent the development and transmission of infections. This affected 1 (Resident #27) of 1 resident observed for incontinent care. Residents Affected - Few The facility failed to ensure Resident #27 was provided incontinent care by staff who demonstrated correct infection control procedures on 2/29/2024. This failure could place residents at risk of the spread of infection. Findings included: Record review of Resident #27's Face Sheet dated, 2/29/24, indicated a [AGE] year-old male. He was admitted to the facility initially on 9/25/21 with diagnoses that included Chronic Obstructive Pulmonary Disease (COPD), anxiety disorder, and Essential Hypertension. Record review of Resident #27's admission MDS dated [DATE] indicated a BIMS of 12 or moderate cognitive impairment. Resident #27 required Extensive assist of one to two persons for ADLs and was always incontinent of bowel and bladder. Record review of Resident #27's Care Plan with a revision date of 2/21/24 indicated the following: Incontinent: check Resident #27 every 2 hours and as required for incontinence. Wash, rinse, and dry perineum. During an observation on 2/29/24 at 1:08 pm, CNA A provided incontinent care to Resident #27. The CNA washed her hands and donned gloves prior to starting care. CNA A then placed a trash bag in the resident's trash can, while placing the bag she touched the rim of the trash can and then began incontinent care without removing her gloves and washing her hands that had touched the trash can. CNA A unfastened Resident #27's brief and began incontinent care. CNA A then obtained a clean brief touching the inside of the brief where the brief would be in contact with the resident's perineum. She fastened the brief and assisted with replacing the resident's bed sheets and blanket. CNA A performed the entire incontinent care process on Resident #27 without washing or sanitizing her hands. During an interview with CNA A on 2/29/24 at 1:30 pm, she said that she did not wash or sanitize her hands in between changing gloves while performing incontinent care for Resident #27. She said that was how she usually performed incontinent care. She said gloves should be changed if they become soiled to prevent cross contamination. She was just so nervous with surveyor watching. During an interview with the DON on 2/29/24 at 2:00 pm, she said her expectations were that CNAs wash/sanitize their hands per policy when providing resident care. She further stated, not doing so would cause cross contamination. Record review of the facility's Handwashing/Hand Hygiene policy last revised September 2005 indicated the following: Policy Statement: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675042 If continuation sheet Page 9 of 11 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 675042 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Seymour Rehabilitation and Healthcare 1110 Westview Dr Seymour, TX 76380 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 0880 This facility considers handwashing/hand hygiene as the primary means to prevent the spread of infection. Level of Harm - Minimal harm or potential for actual harm 2. b. After contact with blood, body fluids, secretions, mucous membranes, or non-intact skin; c. handling items potentially contaminated with blood, body fluids, or secretions . Residents Affected - Few 3. If hands are not visibly soiled, use an alcohol-based hand rub containing 60-90 % ethanol or isopropanol for all the following situations: g. After removing gloves Review of Hand Hygiene in Healthcare Settings from the Centers for Disease Control and Prevention (https://www.cdc.gov/handhygiene/providers/index.html) accessed 3/11/20 indicated the following: When to perform hand hygiene? -Before moving from work on a soiled body site to a clean body site on the same patient. -After touching a patient or the patient's immediate environment. -After contact with blood, body fluids or contaminated surfaces. - Immediately after glove removal. When and how to wear gloves -Wear gloves, according to Standard Precautions, when it can be reasonably anticipated that contact with blood or other potentially infectious materials, mucous membranes, non-intact skin, potentially contaminated skin or contaminated equipment could occur. - Gloves are not a substitute for hand hygiene. - Perform hand hygiene immediately after removing gloves. Change gloves and perform hand hygiene during patient care, if - moving from work on a soiled body site to a clean body site on the same patient or if another clinical indication for hand hygiene occurs. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675042 If continuation sheet Page 10 of 11 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 675042 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Seymour Rehabilitation and Healthcare 1110 Westview Dr Seymour, TX 76380 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 0912 Level of Harm - Potential for minimal harm Residents Affected - Some Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide the required minimum of 80 square feet of room space per resident in 1 of 40 double occupancy resident rooms by failing to provide a minimum of 160 square feet in resident room # 13. This deficient practice could place residents who may occupy double occupancy resident rooms at risk of not having the personal living space to meet their needs. The findings included: In an interview on 02/26/2024 at 11:30 AM, during entrance conference, the administrator stated the facility had a room size waiver for resident room [ROOM NUMBER] and wished to continue the waiver. In an observation on 02/26/2024 at 11:45 AM, room [ROOM NUMBER] was measured at 156 square feet and did not meet the required minimum of 160 square feet for a double occupancy resident room. Review of the facility's Bed Classifications Form 3762, signed and dated 02/29/2024 by the facility's administrator, documented resident room [ROOM NUMBER] was licensed and certified as a double occupancy resident room. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675042 If continuation sheet Page 11 of 11

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Citations

8 citations recorded^*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

0582GeneralS&S Cno actual harm
F582 - The facility must—
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
0656GeneralS&S Dpotential for harm
F656 - Comprehensive Care Plans
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
0695GeneralS&S Dpotential for harm
F695 - Respiratory care, including tracheostomy care and tracheal suctioning
Provide safe and appropriate respiratory care for a resident when needed.
0730GeneralS&S Epotential for harm
F730 - Regular in-service education
Observe each nurse aide's job performance and give regular training.
0842GeneralS&S Dpotential for harm
F842 - Resident-identifiable information
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
0912GeneralS&S Bno actual harm
F912 - Measure at least 80 square feet per resident in multiple resident
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
0880GeneralS&S Dpotential for harm
F880 - Infection Control
Provide and implement an infection prevention and control program.
0521GeneralS&S Cno actual harm
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

FAQ · About this visit

Common questions about this visit

What happened during the February 29, 2024 survey of SEYMOUR REHABILITATION AND HEALTHCARE?

This was a inspection survey of SEYMOUR REHABILITATION AND HEALTHCARE on February 29, 2024. The surveyor cited 8 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at SEYMOUR REHABILITATION AND HEALTHCARE on February 29, 2024?

Yes, 8 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

SourceView on CMS Care Compare

Next steps

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Data from CMS Care Compare public records. Dataset last refreshed June 8, 2026. If you believe any information is inaccurate, report it here.

Inspection·February 29, 2024