Inspection·October 3, 2024

F 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few diagnoses of heart disease. Interventions included adjust provision of ADLS to compensate for Resident #1's changing abilities and if receiving hospice services, to work cooperatively with the hospice team to ensure the resident's spiritual, emotional, intellectual, physical, and social needs were met. Record review of the Order Summary Report dated 08/27 indicated Resident #1 had an order to admit to the facility under care of (named hospice provider). Record review of Resident #1's EHR indicated there was no hospice plan of care, nurse visit notes, and aide visit notes available for review. Record review of the hospice plan of care dated 09/25/24 provided by the Administrator on 10/03/24 indicated there was no communication or coordination of care related to the provision of ADLS and sufficient staff to meet the need of Resident #1 as identified by the facility. During an interview on 10/02/24 at 2:55 p.m., the DON said the administrator was responsible for the residents' medical records. She said if the facility did not have the residents' hospice records, the residents were at risk of not receiving care as required. During an interview on 10/02/24 at 3:27 p.m., RNC A said the facility was responsible to obtain residents' hospice records. She said if the facility did not have the residents' hospice records, the residents were at risk of not receiving care as required. During an interview on 10/03/24 at 4:43 p.m., the Administrator said the hospice providers usually send the residents' plan of care, nurse visit notes, and aide visit notes to the facility monthly. She said she was responsible for residents' medical records and uploading the hospice documents into the EHR. She said (named hospice provider) had not sent Resident #1's care plan, nurse visit notes, or aide visit notes as of 10/02/24. She said she received the hospice care plan on 10/03/24. She said she had not received any hospice nurse visit notes or hospice aide visit notes. She said it was important for the facility to have the hospice documents for the facility to be up to date on the hospice plan of care to ensure coordination of care and ensure residents received care as required. Record review of the facility's Hospice Services policy dated 02/13/07 indicated .11. The DON or designee will be responsible for ensuring that documentation is a part of the current clinical record. At a minimum, the documentation will include: The current and past Texas Medicaid Hospice Recipient Election/Cancellation Form (#3071), Texas Medicaid Hospice-Nursing Facility Assessment Form (#3073), Physician Certification of Terminal Illness (#3074), Medicare Election Statement (if dual eligible), Verification that the recipient does not have Medicare Part A, Hospice Plan of Care, Current interdisciplinary notes to include nurses notes/summaries, physician orders and progress notes, and medications and treatment sheets during the hospice certification period. Record review of the Hospice and Nursing Facility Services Agreement dated 04/01/22, indicated, .a. Hospice and Facility shall communicate with one another regularly and as needed for each particular Hospice patient. Each party is responsible for documenting such communications in its respective clinical records to ensure the needs of the Hospice patients are met 24-hours per day.Coordination of Services. Hospice shall: . c. Provide Facility with the following information specific to each Hospice Patient residing at the facility: (i) the most recent plan of care; (ii) the hospice election form and any advanced directives: (iii) the physician certification and recertification(s) of illness; (iv) the names and contact information for Hospice staff involved in the care of the patient; (v) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675620 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 675620 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/03/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Beaumont Nursing and Rehabilitation 1175 Denton Dr Beaumont, TX 77707 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 0849 Instructions on how to access the Hospice's 24-hour on-call system; (vi) Hospice medication information; and (vii) Hospice physician and attending physician (if any) orders. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675620 If continuation sheet Page 3 of 3