Inspection·June 11, 2025

F 0644 Level of Harm - Minimal harm or potential for actual harm qualifies for mental illness on a PASRR level one screening. She said that she would need to complete a 1017 form for a new diagnosis that a resident received after their admission and after their PASRR level one screening. She said that since Resident #31 needed to be re-assessed when a qualifying diagnosis was received. She said Resident #31 was placed at risk of not receiving the services he may have been eligible for. Residents Affected - Few During an interview on 6/11/2025 at 11:22 a.m., the Assistant Director of Nurses said that PASRR evaluations are the responsibility of the MDS nurse. She said that residents who are not evaluated properly are at risk of not receiving the services they may qualify for. During an interview on 6/11/25 at 11:34 a.m., the Director of Nurses said that the MDS nurse is responsible for PASRR services. She said that residents may not get a proper evaluation and receive services they could qualify for if the PASRR evaluation was not completed properly. During an interview on 6/11/25 at 11:44 a.m., the Administrator said that Major Depressive Disorder does trigger for a PASRR level two evaluation. She said that the evaluation should have been completed for Resident #31. She said that the MDS Nurse is responsible for completing PASRR. She said that residents were placed at risk of not receiving the services they could be eligible for. Record review of facility policy titled PASRR Level 1 Screen Policy and Procedure and dated 3-6-2019 indicated, The Facility will review the PL1 Screening Form for completion and correctness prior to admission and submit the PL1 form per regulation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675620 If continuation sheet Page 2 of 18 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 06/11/2025 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 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASRR) Level I assessment accurately reflected the resident's status for 2 of 8 residents (Resident #4 and Resident #13) reviewed for PASRR Level I screenings. Residents Affected - Few 1. The facility failed to ensure the accuracy of the PASRR Level 1 screening for Resident #4. The PASRR Level 1 screening did not indicate a diagnosis of mental illness, although the diagnosis (Disorganized Schizophrenia) was present upon Resident #4's admission date on 01/15/21. 2. The facility failed to ensure the accuracy of the PASRR Level 1 screening for Resident #13. The PASRR Level 1 screening did not indicate a diagnosis of mental illness, although the diagnosis (Schizophrenia) was present upon Resident #13's admission date on 02/02/24. This failure could place residents who had a mental illness at risk of not receiving a needed assessment (PASRR Evaluation), individualized care, or specialized services to meet their needs. Findings included: 1. Record review of Resident #4's face sheet, dated 06/09/25, indicated she was an [AGE] year-old female, admitted to the facility on [DATE]. Her diagnoses included disorganized schizophrenia (a chronic brain disorder characterized by symptoms like hallucinations, delusions, and disorganized thinking). The onset date for this diagnosis was 01/08/2005. Record review of Resident #4's quarterly MDS assessment, dated 03/21/25, indicated she had a BIMS score of 03, which indicated severe cognitive impairment. She was sometimes able to make herself understood and she was sometimes able to understand others. She received an antipsychotic and an antianxiety medication routinely. Record review of Resident #4's PASRR Level 1 Screening, dated 01/15/21, indicated that in Section C, Mental Illness was marked as no, which indicated Resident #4 did not have a mental illness. 2. Record review of Resident #13's face sheet, dated 06/09/25, indicated he was a [AGE] year-old male, admitted to the facility on [DATE]. His diagnoses included schizophrenia (a chronic brain disorder characterized by symptoms like hallucinations, delusions, and disorganized thinking). The onset date for this diagnosis was 02/18/14. Record review of Resident #13's quarterly MDS assessment, dated 02/22/25, indicated he had a BIMS score of 15, which indicated intact cognition. He was able to make himself understood and he was able to understand others. He received an antipsychotic routinely. Record review of Resident #13's PASRR Level 1 Screening, dated 06/03/22, indicated that in Section C, Mental Illness was marked as no, which indicated Resident #4 did not have a mental illness. During an interview on 06/11/25 at 09:32 AM, the MDS Coordinator said she had worked at the facility about 7 years. She said both Resident #4 and Resident #13 should have been marked yes for mental illness on the PASRR Level 1. She said it was possible for these two residents to have received services since their admission if they had been marked positive for MI on admit. She said she was going (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675620 If continuation sheet Page 3 of 18 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 06/11/2025 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 0645 to submit a 1017 form to notify the local health authority about their diagnoses. Level of Harm - Minimal harm or potential for actual harm During an interview on 06/11/25 at 11:21 AM, the ADON said she does not deal with PASRR. She said it was mostly the MDS Coordinator that deals with that. Residents Affected - Few During an interview on 06/11/25 at 11:34 AM, the DON said she does not deal with PASRR. During an interview on 06/11/25 at 11:44 AM, the Administrator said she expected the PASRR Level 1 form to have the mental illness section marked yes for both Resident #4 and Resident #13. She said that she expected the person that did the admission for these residents to have ensured the PASRR Level 1 was completed accurately. She said the risk was that the resident could have had PASRR services since they were admitted with this diagnosis. Record review of the Facility's policy, PASRR Level 1 Screen Policy and Procedure, last revised 03/06/19, stated: .The Facility will review the PL1 Screening Form for completion and correctness prior to admission and submit the PL1 form per regulations. The Type of admission is reviewed for correctness. Ensure the Name, SS number, Medicare/Medicaid numbers and DOB is correct. The Date of the PL1 is correct (i.e. correct day, month and year) and review each item on the PL1 to ensure accuracy and prevent a regulatory problem FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675620 If continuation sheet Page 4 of 18 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 06/11/2025 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 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. During an observation on 06/09/25 at 12:35PM the pureed food served in the facility was observed. On each puree tray there was a main plate with 3 foods including a brown ground meat, a white food, and a yellow food. The consistency of all three foods was mechanical soft. During an interview on 06/09/25 at 02:30 PM, [NAME] F said he made the puree this day. He said he was not trained on how to make the puree. He said he was not sure if there was a recipe for the puree. He said he did not follow a recipe for the puree this day. He said his puree usually comes out more like mashed potatoes. He said he was running behind today and he was in a hurry. He said the old Dietary Manager left about a month ago. He said the risk to the resident was possible choking. During an interview on 06/11/25 at 11:34 AM, the DON said she expected [NAME] F to have been trained to make puree foods. She said he came from a sister facility. She said he has been here a few months. During an interview on 06/11/25 at 11:44 AM, the Administrator said she expected the cook to make the puree properly. She said a Dietary Manager should train and be able to expect the staff to do the puree correctly. She said she expected [NAME] F to have been trained on puree preparation. She said he normally does the puree when he works. She said he was trained at another facility on the puree. Record review of [NAME] F's Dietary Staff/Cook Proficiency, dated 04/11/25, indicated he was marked as satisfactory on the section pertaining to the following topic: Demonstrates understanding of: *Therapeutic and mechanically altered diets, including regular with mech/ground meat vs. mechanical soft . The proficiency did not specifically address pureed diets. Record review of the Facility's undated policy, Employee Orientation, stated: All individuals will have the basic information to perform their job efficiently and effectively. All new employees will receive orientation to the facility an especially to the Dietary Department. Procedure 1. The Dietary Service Manager conducts orientation on an individual basis with the new employee before being assigned a schedule. 2. In-Service Training sessions are scheduled monthly and conducted by either the dietitian or the dietary service manager. All dietary employees on duty are required to attend, with the goal of at least two hours of inservice training each quarter .training is also assigned to dietary employees monthly and must be completed by month's end. Possible topics include: - General and Therapeutic diets . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675620 If continuation sheet Page 5 of 18 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 06/11/2025 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 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of the Texas Administrative Code chapter 228 subchapter (b) (d) indicated: All food employees, except for the certified food protection manager, shall successfully complete an accredited food handler training course, within 30 days of employment . Based on interview and record review, the facility failed to employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service for 4 out of 6 dietary staff (Cook F, Kitchen Staff BB, Kitchen Staff CC, and Kitchen Staff DD) The facility failed to ensure Kitchen Staff BB, CC, and DD had a current food handlers certificate The facility failed to ensure [NAME] F was trained and competent to prepare the pureed food. This failure could place residents who consumed food prepared from the kitchen at-risk of foodborne illness or nutritional deficiencies. Findings included: During an observation of the kitchen on 6/9/2025 at 8:45 a.m., [NAME] F was preparing for the lunch meal. Review of the food handler's certificates of completion provided by the facility on 6/10/2025, revealed Kitchen Staff BB, Kitchen Staff CC, Kitchen Staff DD did not have a food handler's certificate. Kitchen Staff BB had a hire date of 5/1/2025, Kitchen Staff CC had a hire date of 2/6/2025 and Kitchen Staff DD had a hire date of 4/3/2025. During an attempted interview on 6/10/2025 at 10:00am Kitchen Staff BB, Kitchen Staff CC and Kitchen Staff DD were not available for interview. During an interview on 6/11/2025 at 9:20 a.m., the travelling CDM H said the dietary manager was responsible for making sure staff got their food handlers certification but since the facility did not have a dietary manager it was the Administrators responsibility. The Dietary Manager stated the failure could potentially put residents at risk for food borne illness and cross contamination. During an in interview on 6/11/2025 at 9:58 a.m., Registered Dietician G said by Kitchen Staff BB, Kitchen Staff CC, and Kitchen Staff DD working without having their food handler's certification was they could possibly handle food inappropriately which could cause residents to become sick by food borne illness. During an interview on 6/11/2025 at 11:44 a.m., the Administrator said he expected the dietary staff have their food handler certificates within 30 days of hire. The Administrator said the importance of obtaining the food handler certificate training was to teach staff to follow proper procedures and prevent infection control issues. The Administrator said the facility did not have a specific policy for obtaining food handler's certifications and they followed the Texas Administrative Code. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675620 If continuation sheet Page 6 of 18 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 06/11/2025 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 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the each resident received food prepared in a form to meet their individual needs for 4 of 4 residents (Residents #4, #31, #30, and #16) reviewed for pureed diet consistency. The facility failed to ensure Resident #4 was served a pureed diet as ordered by the physician. The facility failed to ensure Resident #31 was served a pureed diet as ordered by the physician. The facility failed to ensure Resident #30 was served a pureed diet as ordered by the physician. The facility failed to ensure Resident #16 was served a pureed diet as ordered by the physician. These failures could place residents at risk of choking, aspiration, and/or death. Findings included: 1. Record review of Resident #4's face sheet, dated 06/09/25, indicated she was an [AGE] year-old female, admitted to the facility on [DATE]. Her diagnoses included dysphagia (difficulty swallowing food or liquids), dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), and cognitive communication deficit (communication problem stemming from difficulties with cognitive processes, rather than with speech or language itself). Record review of Resident #4's quarterly MDS assessment, dated 03/21/25, indicated she had a BIMS score of 03, which indicated severe cognitive impairment. She was sometimes able to make herself understood and she was sometimes able to understand others. She was completely dependent on staff for the activity of eating. The assessment indicated she has signs and symptoms of a possible swallowing disorder including holding food in mouth/cheeks or residual food in mouth after meals and coughing or choking during meals or when swallowing medications. She required a mechanically altered diet (require change in texture of food or liquids) while a resident at the facility. Record review of Resident #4's Order Summary Report, dated 06/09/25, indicated she had an order for: *Fortified/Enhanced diet. Pureed Texture. The start date was 02/12/24. Record review of Resident #4's care plan, last revised 05/23/25, indicated a focus of Resident #4 has a fortified/enhanced diet with pureed texture. Interventions included the resident has a pureed diet, and speech therapy and treatment per physician's orders as condition warrants. Record Review of Resident #4's Food Tray Ticket for Lunch 06/09/25 indicated .Regular/Puree Fortified Enhanced Diet . .Entrée .Smashburger [with] grilled onions (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675620 If continuation sheet Page 7 of 18 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 06/11/2025 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 0805 Starch .Zesty Fry Sauce . Level of Harm - Minimal harm or potential for actual harm .waffle fries Vegetable .Tomato Juice . Residents Affected - Some Dessert .Apple Fried Pie . During an observation on 06/09/25 at 12:35 PM, Resident #4 was being fed lunch in the dining room by CNA A. There were 3 foods on the plate including a brown ground meat, a white food, and a yellow food. The consistency of all three foods was mechanical soft. During an interview on 06/09/25 at 12:43 PM, Speech Therapist B said that the food on Resident #4's plate was a mechanical soft consistency. She said Resident #4 was supposed to have pureed consistency. She said the resident being served the wrong consistency could cause her to choke or aspirate. During an interview on 06/09/25 at 12:46 PM, CNA A said the pureed food consistency varies. She said the DON and LVN C checked the tray before she took the tray to Resident #4. She said since the nurse checked the tray, she thought it was okay. She said the resident did not cough or choke. She said the risk was that the resident could choke or aspirate on her food. 2. Record review of Resident #31's face sheet, dated 06/09/25, indicated he was a [AGE] year-old male, admitted to the facility on [DATE]. His diagnoses included Huntington's disease (a progressive neurodegenerative disorder that affects movement, thinking, and emotional abilities). Record review of Resident #31's quarterly MDS assessment, dated 04/18/25, indicated he had a BIMS score of 11, which indicated moderate cognitive impairment. He was able to make himself understood and he was able to understand others. He was completely dependent on staff for the activity of eating. He required a mechanically altered diet (require change in texture of food or liquids) while a resident at the facility. Record review of Resident #31's Order Summary Report, dated 06/09/25, indicated he had an order for: *Fortified/Enhanced diet. Pureed Texture. The start date was 05/30/25. Record review of Resident #31's care plan, last revised on 06/09/25, indicated a focus of Resident #31 has a diet order other than regular and may be at risk for unplanned weight loss or gain. Interventions included the resident has a pureed diet and serve diet and snacks as ordered. Record Review of Resident #31's Food Tray Ticket for Lunch 06/09/25 indicated .Regular/Puree Fortified Enhanced Diet . .Entrée .Smashburger [with] grilled onions Starch .Zesty Fry Sauce . .waffle fries (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675620 If continuation sheet Page 8 of 18 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 06/11/2025 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 0805 Vegetable .Tomato Juice . Level of Harm - Minimal harm or potential for actual harm Dessert .Apple Fried Pie . Residents Affected - Some During an observation on 06/09/25 at 12:43 PM, Resident #31's lunch tray was in his room on his bedside table. There were 3 foods on the plate including a brown ground meat, a white food, and a yellow food. The consistency of all three foods was mechanical soft. 3. Record review of Resident #30's face sheet, dated 06/09/25, indicated she was a [AGE] year-old female, admitted to the facility on [DATE]. Her diagnoses included cerebral infarction (occurs when the blood supply to the brain is interrupted, leading to brain tissue death), and dementia (a general term for the loss of cognitive function, including memory, language, problem-solving, and reasoning, which can interfere with daily life). Record review of Resident #30's quarterly MDS assessment, dated 03/31/25, indicated a BIMS was not conducted due to the resident being rarely/never understood. She was rarely/never able to make herself understood and she was rarely/never able to understand others. She was completely dependent on staff for eating. The assessment indicated she had signs and symptoms of possible swallowing disorder including loss of liquids/solids from mouth when eating or drinking and holding food in mouth/cheeks or residual food in mouth after meals. She required a mechanically altered diet (require change in texture of food or liquids) while a resident at the facility. Record review of Resident #30's Order Summary Report, dated 06/09/25, indicated she had an order for: * Fortified/Enhanced diet. Pureed Texture. Divided plate. Pleasure feedings as tolerated. The start date was 01/24/25. Record review of Resident #30's care plan, last revised 05/27/25, indicated a focus of Resident #30 is at risk for unplanned weight loss or gain. Resident #30 is prescribed a fortified/enhanced diet, pureed texture. Interventions included serve diet and snacks as ordered and the resident has a pureed diet. During an interview on 6/9/25 at 12:50 p.m., LVN D said that she already fed Resident #30. She said that Resident #30 was on a pureed diet. She said that pureed food should look like baby food. She said that the food that she fed Resident #30 looked like the food in the picture the surveyor showed her. She said that it was not pureed food. 4. Record review of Resident #16's face sheet, dated 06/09/25, indicated he was an [AGE] year-old male, admitted to the facility on [DATE]. His diagnoses included profound intellectual disabilities (Intellectual disability so severe that they are unable to live independently, require close supervision, and often have physical limitations), and cervicalgia (pain in the neck). Record review of Resident #16's annual MDS assessment, indicated a BIMS was not conducted because he was rarely/never understood. He was rarely/never able to understand others. He required setup or clean-up assistance with eating. He required a mechanically altered diet (require change in texture of food or liquids) while a resident at the facility. Record review of Resident #16's Order Summary Report, dated 06/09/25, indicated he had an order for: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675620 If continuation sheet Page 9 of 18 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 06/11/2025 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 0805 *Regular diet, Pureed texture. The start date was 05/30/25. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #16's care plan, last revised 03/21/25, indicated a focus of Resident #16 has a diet order other than regular and may be at risk for unplanned weight loss or gain. Regular diet, puree texture. Interventions included the resident has a pureed diet. Residents Affected - Some Record review of Resident #16's Food Tray Ticket for Lunch 06/09/25 indicated .Regular/Puree Fortified Enhanced Diet . .Entrée .Smashburger [with] grilled onions Starch .Zesty Fry Sauce . .waffle fries Vegetable .Tomato Juice . Dessert .Apple Fried Pie . During an observation on 06/09/25 at 12:44 PM, Resident #16 was sitting in his room eating his lunch. There were 3 foods on the plate including a brown ground meat, a white food, and a yellow food. The consistency of all three foods was mechanical soft. There was also a separate plate on the tray that had a regular slice of apple pie on the plate. It was regular consistency and was not altered. Record review of the Facility's recipes for 06/09/25 at lunch stated: .Beef Smashburger [with] [grilled] onion . .To get the actual serving size, puree the number of portions needed, adding adequate liquid needed to achieve desired consistency as appropriate for resident, then divide the total amount equally by the number of portions pureed. Measure number of servings using the regular prepared recipe portion. Drain well to minimize the use of thickener to obtain appropriate consistency. Place in a blender or food processor. Add liquid, if needed .to assist with pureeing. Puree with a blender or food processor until smooth . .If needed, gradually add thickener . .The desired thickness should be mashed potato or pudding. There should be no large lumps or particles . .Waffle Fries . .The desired thickness should be mashed potato or pudding. There should be no large lumps or particles . .Pie, Fried Fruit Apple . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675620 If continuation sheet Page 10 of 18 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 06/11/2025 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 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some .Desired thickness should be mashed potato, pudding, or applesauce texture. There should be no large lumps or particles . During an interview on 06/09/25 at 12:55 PM, Dietary Supervisor E said she was in the facility helping them out on this day. She said she normally works in another facility. She said the pureed diet food served at lunch on 06/09/25 was mechanical soft consistency. She said the risk was that the residents could choke or aspirate. During an interview on 06/09/25 at 01:10 PM, LVN C said she checked the trays as they came out of the kitchen. She said she did not question the consistency of the pureed food because the dietary supervisor had just added some liquid to the pureed food before the tray came out. She said she thought the food was closer to mechanical soft than puree. She said the resident could choke or aspirate if they ate the wrong consistency food. She said her and the DON were checking the trays before they came out of the kitchen. During an interview on 06/09/25 at 02:30 PM, [NAME] F said he made the puree this day. He said he was not trained on how to make the puree. He said he was not sure if there was a recipe for the puree. He said he did not follow a recipe this day. He said his puree usually comes out more like mashed potatoes, he said he was running behind today and he was in a hurry. He said the old Dietary Manager left about a month ago, He said the risk to the residents was possible choking. During an interview on 06/09/25 at 02:33 PM, Regional Dietician G said she expected the kitchen staff to give the proper consistency food to the residents that require an altered diet. She said they have standardized recipes for the puree. She said she usually will visit the facility once a month and observe the puree. She said the risk of the residents not getting the pureed food as ordered was they could choke or aspirate or potentially die. During an interview on 06/09/25 at 02:51 PM, the DON said she did not check off any of the pureed trays. She did not see the consistency of the pureed meals. She said she expected the staff to give the proper consistency of the meal to the residents that required an altered diet. She said the risk of the wrong consistency being served was the resident could aspirate or choke. She said she was not aware of any of the 4 residents who get pureed food choking. She said the kitchen should give the proper consistency, the nurse should check it and then the CNA should also check it. During an interview on 06/09/25 at 05:06 PM, [NAME] F said no one in management had questioned him regarding the puree before this day. He said he thought he usually had a good consistency but this day he was rushing. During an interview on 06/11/25 at 09:20 AM, Travel Certified Dietary Manager H said she was not in the facility on 06/09/25. She looked at the picture this surveyor showed her, and she said she did not think the puree was smooth enough and it was too dry. She said the risk to the resident's was choking and aspiration. She said she was last in the facility in Mid-May 2025. She said the typical procedure was that the cook would make the puree and the Dietary Manager would then check while it is on the line. During an interview on 06/11/25 at 09:38 AM, Regional Dietician G said she thought the puree diet tray served at lunch on 06/11/25 was mechanical soft in consistency and the risk was potential choking and aspiration. She said the typical procedure was that the cook would make it and the Dietary Manager would check it off. She said the facility has not had a Dietary Manager as of recent, so she (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675620 If continuation sheet Page 11 of 18 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 06/11/2025 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 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some expected the Administrator to watch at least one meal a day. She said she expected the Dietary Manager to remove the Puree tray if it was the wrong consistency. During an interview on 06/11/25 at 09:45 AM, Dietary Supervisor E said she did not see the puree tray before it went out of the kitchen on 06/09/25. She said she did not check the puree that [NAME] F made on 06/09/25. She said [NAME] F was plating the food that day. She said she should have checked the puree trays. During an interview on 06/11/25 at 11:21 AM, the ADON said she expected the cook to ensure that the puree was the proper consistency. She said she expected the nurse and CNA to check the tray as well. She said the picture that this surveyor showed her looked like it was too thick for puree. She said the risk was that the resident could choke or aspirate and get pneumonia. During an interview on 06/11/25 at 11:34 AM, the DON said she expected the kitchen to verify they made the proper consistency, and the nurse and CNA should also check the consistency before it was served to the residents. During an interview on 06/11/25 at 11:44 AM, the Administrator said she expected the cook to make the puree properly. She said a Dietary Manager should train and be able to expect the staff to do the puree correctly. She said the Dietary Manager should check the puree to ensure the food consistency was correct. She said on 06/09/25 she expected Dietary Supervisor E to check the puree. She said she expected the nurse to check the tray before it was sent out. She said she expected the CNA if they are feeding a resident to stop the tray if they feel it is not the proper consistency. She said the risk was choking and aspiration and/or pneumonia. Record review of the facility's undated policy, Consistency Modification, stated: We will adequately meet nutritional needs of the resident and provide food in a consistency that the resident can tolerate . .3. The pureed diet is given to residents with chewing, swallowing or choking problems. The desired consistency for blended foods is that of applesauce to mashed potatoes. Small grains may be present in some foods, but these are acceptable as long as they are no larger than the grains present in applesauce and of a consistent size. If a resident requires a smoother consistency, per speech therapist recommendation, an order for a strained puree diet can be obtained FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675620 If continuation sheet Page 12 of 18 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 06/11/2025 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, interviews, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food safety requirements and kitchen sanitation. The facility failed to ensure all foods stored in the refrigerators were not kept past their expiration dates and did not contain mold. These failures could place residents at risk of foodborne illness and food contamination. Findings included: During an observation of the refrigerator on 6/09/2025 at 8:45 AM, the following items were observed: (1) 1 gallon of milk that was full with an expiration date of 6/8/2025. (2) 1 container ¾ full with green beans dated 5/31/2025. (3) 2 cucumbers with mold spots, 3 red onions with mold spots. During an observation and interview on 6/9/2025 at 8:45 AM, [NAME] F said they should have checked the refrigerator and removed expired items. He said he did not know the cucumbers and onions had molded and they should have been removed from the refrigerator. He took the milk, cucumbers, and red onions out of the refrigerator and disposed of them. [NAME] F said they have not had a Dietary Manager for about 1 to 1 ½ months. He said the staff just do not care and do not check for expired foods. He said the residents could get sick by consuming expired foods. During an interview on 6/11/2025 at 9:20 AM, the Travelling CDM H said the dietary manager or whoever is responsible should be making a walk through daily, but the cook should be checking for expired foods daily. She said if there is no dietary manager the Administrator should be checking daily. She said the residents could possibly get sick by consuming expired foods. During an interview on 6/11/2025 at 9:32 AM, Registered Dietician G said that the dietary manager should be responsible for checking for expired food. She said if the facility did not have a dietary manager, then the Administrator was ultimately responsible for checking for expired foods, but all kitchen staff should be checking for expired foods. She said the resident could get sick by a food borne illness by consuming expired foods. During an interview on 6/11/2025 at 11:44 AM, the Administrator said all foods should be used or disposed of by the use by date. She said food in the kitchen should be checked daily and weekly, to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675620 If continuation sheet Page 13 of 18 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 06/11/2025 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete ensure foods are disposed of by the expiration date. She said food borne illness was a potential risk to the resident for consuming expired foods. Record review of facility policy titled Food Storage and Supplies undated, indicated: .6. Any product with a stamped expiration date will be discarded once that date passes . 8 .If a food has developed such spoilage characteristics, it should not be eaten . Event ID: Facility ID: 675620 If continuation sheet Page 14 of 18 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 06/11/2025 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 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 observations, interviews, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 2 residents (Resident #37) reviewed for infection control. Residents Affected - Few CNA T did not wash or sanitize her hands or change gloves while performing incontinent care for Resident #37. These failures could place residents at risk of exposure to communicable diseases and infections. Findings included: Record review of an electronic Face Sheet dated 6/10/2025 for Resident #37 indicated she admitted to the facility on [DATE] and was [AGE] years old. Her diagnoses included: hypertensive chronic kidney disease (kidney damage caused by high blood pressure) dementia (a decline in cognitive abilities), acute cystitis with hematuria (irritation of the bladder with blood in the urine), muscle wasting and atrophy (decrease in muscle mass and strength). Record review of a Quarterly MDS dated [DATE] for Resident #37 indicated a BIMS of 06 which indicated severe cognitive impairment. She was dependent on staff with toileting hygiene. She was always incontinent of bowel and bladder. Record review of a Care Plan dated 1/25/2024 for Resident #37 indicated: The resident had an ADL self-care performance deficit with interventions that included: The resident requires assistance wash hands, adjust clothing, clean self, transfer on to toilet, transfer off toilet to use toilet. The care plan also indicated Resident #37 had bowel incontinence with interventions that included: Provide peri care after each incontinent episode. During an observation on 6/9/2025 at 11:52 AM in Resident #37's room revealed, CNA T and CNA R were present to provide incontinent care. Both staff washed their hands in the bathroom of Resident #37's room and donned gloves. CNA T and CNA R positioned Resident #37 in supine position to perform incontinent care. CNA T removed the blanket from Resident #37. CNA T removed a disposable wipe from the container and began cleaning Resident #37. CNA T after cleaning Resident #37's peri area CNA T without changing gloves or washing her hands placed a clean brief on Resident #37. CNA T without changing gloves or washing her hands began repositioning Resident #37 in bed and placed covers back on her. CNA D without changing gloves or washing her hands repositioned Resident #37's pillows behind her head. After CNA T repositioned Resident #37 she doffed gloves washed her hands, gathered the trash, and exited the room. During an interview on 6/9/2025 at 12:06 PM, CNA T said after the incontinent care that she should have changed her gloves and washed her hands when going from dirty to clean during incontinent care. She said by not performing incontinent care properly the resident could get an infection. During an interview on 6/9/2025 at 12:06 PM, CNA R said CNA T should have changed her gloves and washed her hands when going from dirty to clean while providing incontinent care. She said by not providing incontinent care properly the resident could get an infection. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675620 If continuation sheet Page 15 of 18 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 06/11/2025 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 0880 Level of Harm - Minimal harm or potential for actual harm During an interview on 6/11/2025 at 11:21 am, the ADON said her, and the DON observed peri care at times. She said CNA T was normally a good CNA but was nervous due to being watched by state. She said they do competency skills check off yearly. She said CNA T should have changed her gloves and washed her hands when going from dirty to clean during incontinent care. She said by not providing incontinent care properly the resident could get an infection. Residents Affected - Few During an interview on 6/11/2025 at 11:34 am, the DON said they do competency skills check off upon hire and annually. She said her expectation was to wash hands in the beginning of incontinent care and then when going from dirty to clean hands needed to be washed. She said by not providing incontinent care properly they could spread infections to the residents. During an interview on 6/11/2025 at 11:44 am, the Administrator said her expectation was for the CNAs to perform incontinent care the right way every day. She said CNA T should have washed her hands when going from dirty to clean. She said by not performing incontinent care properly they could have spread germs to the resident. Record review of C.N.A Proficiency Audit dated 9/3/2024 for CNA T indicated she had been trained and had demonstrated handwashing and perineal care for females in accordance with the facility's standard of practice. Record review of C.N.A Proficiency Audit dated 12/16/2024 for CNA R indicated she had been trained and had demonstrated handwashing and perineal care for females in accordance with the facility's standard of practice. Record review of a facility policy titled Perineal Care dated 4/27/2022, indicated, .21. Gently perform care to the buttocks and anal area, working from front to back without contaminating the perineal are . 24. Doff gloves and PPE. 25. Perform hand hygiene. 26. Provide resident comfort and safety by re-clothing (if applicable-incontinence pad(s) and briefs), straightening bedding, adjusting the bed and/or side rails, and placing call light within resident's reach . 30. Tie off the disposable plastic bag of trash and/or linen. 31. Perform hand hygiene . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675620 If continuation sheet Page 16 of 18 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 06/11/2025 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 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to maintain all essential equipment in safe operating condition, for 1 of 1 stove and dishwasher in the kitchen reviewed for food service in that: Residents Affected - Some The facility did not ensure the gas stove was in working order. Two of six gas stove burners (left front and left back) did not light automatically, when the knob was turned, and all 6 burners had carbon buildup. The facility did not ensure the dishwasher was in working order. The temperature did not reach 120-140 degrees. This failure could place residents who eat out of the kitchen at risk for injury and under cooked food and risk of food borne illnesses by the dishwasher not appropriately sanitizing dishes. Findings include: During an observation on 6/9/2025 at 8:45 a.m., the gas stove had six burners total, two burners located in the left front and left back had excess carbon buildup. The left front and left back burner would not light automatically. During an observation on 6/9/2025 at 8:45 a.m., the dishwasher was ran and reached temperature of 110 degrees. The dishwasher was ran a second time and reached 108 degrees. Observation of manufacturer signage posted on the wall behind the dishwasher indicated dishwasher temperatures should have been between 120-140 degrees. During an interview on 6/9/2025 08:45 a.m., [NAME] F said the 2 burners on the stove that did not automatically light had been that way since he had been employed at the facility for the last 2-3 months. He said they had a lighter they kept in the kitchen that they used to light the burners on the stove. During an observation and interview on 6/9/2025 at 8:45 a.m., Dietary Aide AA said he told the Administrator about a week ago that the dishwasher was not working properly but it had not been fixed. Dietary Aide AA said the dishwasher should be getting up to 125-130 degrees. The dishwasher had a log on the front that had not been completed since May 20, 2025. Dietary Aide AA said they had not been given a new log for June 2025. During an interview on 6/11/2025 at 9:08 a.m., Maintenance Director EE said he had worked at the facility for 23 years. He said no one had notified him that the burner on the stove was not working. He said he had worked on the oven when it was reported to him that the oven was not working, but he was not told that the burners were not lighting. He said that it was reported to him 2-3 weeks ago that the dishwasher was not working properly. He said he looked at the dishwasher and called the manufacturer who was supposed to be sending a booster, but the dishwasher had not been fixed and had not been taken out of commission. He said if the stove burner was not lighting appropriately the kitchen could fill up with gas. During an interview on 6/11/2025 at 9:20 a.m., the Travelling CDM H said the last time she was in the facility was May 2025. She said the last time she was here all equipment was in working order (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675620 If continuation sheet Page 17 of 18 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 06/11/2025 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 0908 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some except for a microwave which she had replaced. She said the potential hazard for the dishwasher not working properly was diseases and cross contamination spreading throughout the building. She said by the stove not lighting properly gas could leak and cause an explosion. During an interview on 06/11/2025 at 9:32 a.m., the Registered Dietician G said this was the first time she had been to the building. She said she was hired on to the company May 12th, 2025, and had not yet made it to the facility for a visit. She said it had not been reported to her that the kitchen equipment was not functioning properly. She said food borne illness was the potential hazard to the residents for the dishwasher not working properly. She said a gas leak, explosion and fire was a danger for the stove not lighting properly. During an interview on 6/11/2025 at 11:44 a.m., the Administrator said she expected staff to notify her of issues with equipment. She said staff should not have to work with equipment that is not operational. She said food borne illness was a potential hazard for the dishwasher not working properly. She said the stove failure could cause food to not be cooked to the proper temperature and the stove could leak gas. Record review of facility policy titled Dishwashing Preparation and Dishwashing undated indicated: .c. The wash period shall be at least 40 seconds with a temperature of 120 degrees Fahrenheit in dish machine. The sanitizing rinse period shall be at least 20 seconds with minimum temperature of 120 degrees Fahrenheit. On 6/9/2025 surveyor requested a policy for the stove, and none was providing by the time of surveyor exit. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675620 If continuation sheet Page 18 of 18