Health inspection·April 12, 2023

F 0645 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few (LIDDA) was coming to the facility this afternoon to evaluate Resident #36 for services and complete the screening PASRR II (PE). During an interview on 04/12/23 at 8:30 a.m., MDS Nurse H said that LIDDA had evaluated Resident #36 on 04/11/23 and reported he did not qualify for PASRR services because he had no hospitalizations or incarcerations related to his PTSD diagnosis in the last two years. MDS Nurse H said that LIDDA had not yet entered the PE into the PASRR portal, so no written report was available for review. During an interview on 04/12/23 at 09:40 a.m., the DON said he was the direct supervisor of MDS Nurse H, and he checks over PASRR evaluations and makes rounds with LIDDA for PL 1 positive residents. He said his expectation was that all P1 evaluations would be completed accurately to reflect resident diagnosis and if answered incorrectly they would be corrected. He said possible negative outcome of the P1 being answered incorrectly was the resident might not get services he qualified for under PASRR. He said the facility did not have a PASRR policy but followed all HHS guidelines for completing PL 1. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676218 If continuation sheet Page 2 of 10 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 676218 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jefferson Nursing and Rehabilitation Center 3840 Pointe Parkway Beaumont, TX 77706 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 a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 2 of 19 residents (Residents #63 and #78) reviewed for comprehensive care plans. 1. The facility failed to ensure Resident #63 was care planned for tracheostomy care. 2. The facility failed to follow physician orders related to enteral feeding (a form of nutrition that is delivered into the digestive system as liquid) through a gastrostomy tube(g-tube) (a surgically placed device used to give direct access to the stomach for supplementally feeding, hydration and medication) for Resident #78. These failures could place the residents at risk of not receiving the appropriate care and services to maintain their highest level of well-being. Findings included: 1. Record review of physician orders dated April 2023 indicated Resident #63, admitted [DATE], was [AGE] years old with diagnoses of tracheostomy (a small surgical opening that is made through the front of the neck into the windpipe) and other specified disease of the respiratory tract. The order initiated on 03/06/23 indicated change tracheostomy collar and tubing with oxygen condensation trap at bedtime every Thursday. Record review of an admission MDS dated [DATE] indicated Resident #63 was alert with a BIMS of 13 (score of 8 to 12 indicates mild cognitive impairment) and received tracheostomy care. Record review of care plans revised 03/06/23 did not indicate Resident #63 had a tracheostomy collar and required tracheostomy care . During an observation and interview on 04/11/23 at 10:00 a.m., Resident # 63 was observed with a tracheostomy. Resident #63 said she has had the tracheostomy since she was admitted to the facility. During an interview on 04/11/23 at 1:00 p.m., LVN B said Resident #63 had a tracheostomy since she admitted on [DATE]. During an interview on 04/11/23 at 1:24 p.m., MDS Nurse C said Resident #63 had a tracheostomy. MDS Nurse C said Resident #63's tracheostomy was not indicated on her care plan. MDS Nurse C said Resident #63's tracheostomy should have been indicated on her care plan. MDS Nurse C said she was responsible for ensuring care plans were completed . MDS Nurse C said the possible negative outcome of not having tracheostomy care planned would be the resident might not receive appropriate care and services because direct care staff would not know the appropriate care to administer. During an interview on 04/12/23 at 10:28 a.m., the DON said the MDS Nurse was responsible for care planning concerns identified in the MDS assessment. The DON agreed tracheostomy care should have (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676218 If continuation sheet Page 3 of 10 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 676218 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jefferson Nursing and Rehabilitation Center 3840 Pointe Parkway Beaumont, TX 77706 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 been care planned for Resident #63. The DON agreed concerns identified in the MDS assessment such as tracheostomy care should be indicated on the care plan . The DON said there would not be much of a potential negative outcome because orders guide the care , and the care plan is only a picture of what is being done for the resident. During an interview on 04/12/23 at 10:35 a.m., the Administrator said concerns identified on the MDS assessment such as tracheostomy care should be care planned. 2. Record review of Resident #78's face sheet, dated 04/10/23, indicated Resident #78 was a [AGE] year-old- male readmitted to the facility on [DATE] with diagnoses which included brain cancer, dysphagia (swallowing problems), stroke and gastrostomy status (presence of a g-tube). Record review of Resident #78's physician orders, dated 04/10/23, indicated he was prescribed enteral feeding (a form of nutrition delivered into the digestive system as a liquid) Jevity 1.5 (calorically dense fiber fortified therapeutic nutrition providing complete balanced nutrition for tube feeding) at 80cc / hr (hour) x 22 hours with 55 cc/ hr water flush for 22 hours a day by g-tube per stationary pump (enteral feeding pump) and turned off from 12 p.m. to 2 p.m. Record review of Resident #78's quarterly MDS assessment, dated 01/23/23, indicated he had a BIMS score of 99, which indicated (severely impaired cognition), diagnoses included brain cancer, stroke dysphagia and gastrostomy status and received nutrition by a feeding tube. Record review of Resident #78's care plan revised 03/27/23 indicated he required tube feeding of Jevity 1.5 at 80 cc/hr with 55 cc/hr flush for 22 hours a day by a g-tube to a stationary pump with the feeding stopped from 12 p.m. to 2 p.m. daily. During an observation on 04/10/23 at 09:40 a.m., Resident #78 was in bed with his g-tube connected to a stationary pump. (Jevity) Feeding set at 90cc/hr and water flush set at 60 cc/hr, were settings on the pump. Documentation handwritten on the Jevity bottle attached indicated 90 cc/hr per LVN F hung at 5:00 a.m. on 04/10/23. Documentation handwritten on the water bottle attached on the pump indicated 60 cc/hr hung at 5:00 a.m. on 04/10/23 by LVN F. Record review of Resident #78's Skilled Administration record dated 04/12/23 indicated Resident #78 received Jevity 1.5 at 80 cc/ hr with 55 cc/ hr water flush for 22 hours a day by g-tube to stationary pump with a stop time of 12 p.m. to 2 p.m. daily from 4/1/23 through 4/12/23. During an observation and interview on 04/12/23 at 09:45 a.m., Resident #78 was in bed with his g-tube connected to a stationary pump. (Jevity) Feeding set at 90cc/hr and water flush set at 60 cc/hr, were settings on the pump. Documentation handwritten on the Jevity bottle attached indicated 90 cc/hr per LVN F hung at 5:00 a.m., on 04/12/23. Documentation handwritten on the water bottle attached to the pump indicated 60 cc/hr hung at 5:00 a.m. on 04/12/23 by LVN F. Resident #78 denied pain in abdomen, feeling too full or shortness of breath by shaking his head no and indicated he was good with a thumbs up signal. During an observation and interview on 04/12/23 at 09:48 a.m., LVN E, said she was Resident #78's nurse today. She said physician orders indicated Resident #78's enteric feeding should have been set at 80 cc/ hr and water flush at 55cc/hr. She said the night nurse hung the bags at 90 cc/hr and water flush at 60 cc/hr. LVN E said she had just missed double checking it, she said she had not given medication yet . LVN E said all the nurses providing care for the resident were responsible for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676218 If continuation sheet Page 4 of 10 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 676218 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jefferson Nursing and Rehabilitation Center 3840 Pointe Parkway Beaumont, TX 77706 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 double check orders. LVN E said Resident #78 was on a different formula set at 90 cc/hr but on 03/16/23 the order changed . She said it was just overlooked this week. LVN E said she received the new order and hung the first bag of Jevity and changed the rate to 80 cc/hr for formula and water 55 cc/hr on 03/16/23. LVN E said Resident #78's Jevity should have been set at 80 cc/hr and water flush at 55cc/hr. LVN E changed the rate of Jevity and water after surveyor intervention. LVN E said she was educated on tube feeding and following orders. LVN E said the risk of not following orders and too much nutrition and water given was stomach pain. She said Resident #78's lung sounds were clear and bowel sounds were normal with no abdominal distention. During an interview on 04/12/23 at 10:02 a.m., the DON said Resident #78 had weight loss and received a different formula at 90 cc/hr when he was admitted but had a recent change in formula and rate. The DON said LVN F, the nurse that hung the feeding may have thought it was a mistake and set the feeding up at 90/hr . The DON said the nurses had been educated on g-tube feedings, medication pass and following physician orders (4/1/23). He said the ADONs made rounds daily on each hall. When asked the risk of not followed physician orders and nutrition given at an increased rate, the DON said the risk was weight gain. The DON said his expectation was nurses followed physician orders. During an interview on 04/12/23 at 11:00 a.m., ADON G said she was responsible for making rounds on Resident #78's hall. She said she made rounds multiple times a day. ADON G said the pump settings matched the documentation on the bottles. She said she did not double check the orders due to state being in the facility. ADON G said all the nurses were responsible for accurate feeding and following physician orders, it was a group effort. She said the nurses got the order, put the order in the system, and made sure the correct dosage and feeding were given and the ADON's made rounds. ADON G said Resident #78 was previously on a different formula at 90 cc/ hr and was switched to Jevity with the rate lowered to 80 cc/ hr. She said it was just missed. ADON G said all the nurses were in-serviced on enteric pumps, setting the rates, following orders and g-tube feedings. ADON G said the risk of a resident's g-tube feeding given greater than ordered by the physician was potential weight gain. Attempted phone interview on 04/12/23 at 12:17 p.m. with LVN F was not successful. During an interview on 04/12/23 at 12:30 p.m. the administrator said her expectation was the nurses to follow physician orders. The administrator said the ADON's make rounds daily and double the residents. She said the feeding was just missed being double checked. She said the risk of a resident being given a feeding greater than ordered by the physician was possible vomiting and possible aspiration. Record review of a Skills check off sheet provided by the facility dated 9/1/22 indicated LVN E had competency with g-tubes. Record review of a Skills check off sheet provided by the facility dated 11/5/22 indicated LVN F had competency with g-tubes. Record review of an In-service Training Report, titled, G-tube feeding and meds dated 1/4/23, indicated Always check the orders prior to administration of G-tube feeding (bolus or pump) or medications .Pump ensure pump is set to the correct administration rate/flush rate per the MD orders. Record review of a Care Planning policy revised December 2017 indicated: A comprehensive, person-centered care plan is developed and implemented for each resident to meet the resident's physical, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676218 If continuation sheet Page 5 of 10 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 676218 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jefferson Nursing and Rehabilitation Center 3840 Pointe Parkway Beaumont, TX 77706 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 psychosocial and functional needs. Level of Harm - Minimal harm or potential for actual harm Record review of the facility policy titled Enteral Tube Medication Administration, revised 10/01/19, indicated, . The facility assures the safe and effective administration of enteral formulas and medications via enteral tubes. 6. Check the medication administration record (MAR) to confirm the order: . Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676218 If continuation sheet Page 6 of 10 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 676218 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jefferson Nursing and Rehabilitation Center 3840 Pointe Parkway Beaumont, TX 77706 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 provide necessary respiratory care consistent with professional standards of practice, the resident's care plan, goals, and preferences for 1 of 19 residents reviewed for respiratory care and services. (Resident #20) Residents Affected - Few The facility did not provide Resident #20's oxygen concentrator with clean filters. The two filters were covered with thick layers of tan powdery substance. This failure could place residents who required respiratory care at risk of not receiving proper care and treatment and decreased quality of life. Findings included: Record review of physician orders dated April 2023 indicated Resident #20, admitted [DATE], was [AGE] years old with diagnosis of panlobular emphysema (condition of chronic damage to the airways in the lungs which can cause obstruction, making it difficult to breathe). Resident #20 received a new physician order on 03/28/2023 for Oxygen at 2 liters via NC (nasal cannula) while in room daily. Record review of a monthly April 2023 MAR indicated oxygen at 2 liters was in use for Resident #20 daily while in room. Record review of a quarterly MDS dated [DATE] indicated Resident #20 required supervision with most activities of daily living. Section O of the MDS (Special Treatments, Procedures, and Programs), did not include oxygen therapy due to timing of new order and the look-by time frame of MDS. Record review of a care plan dated 04/10/2023 indicated Resident #20 received oxygen therapy r/t (related to) panlobular emphysema. A goal for Resident #20 indicated she would have no signs/symptoms of poor oxygen absorption through the review date. During an observation on 04/10/23 @ 10:15 a.m., Resident #20's oxygen concentrator was at 2/LPM via nasal cannula. Tubing and humidification bottle were dated. The 2 cabinet filters located on each side of the concentrator contained thick tan substance consistent with dust. When questioned, Resident #20 stated Yes, I wear my oxygen almost all the time. During an observation and interview 04/10/23 at 10:15 a.m., LVN A stated yes they are definitely dirty as she looked at the filters on Resident #20's oxygen concentrator. She further stated she honestly did not know who was responsible for the care of concentrators, maybe maintenance. LVN A said the thick substance on the filters could possibly be a fire hazard and/or residents potentially could inhale dirty particles. During an interview at 10:20 a.m., LVN A provided a requested manufacturer's manual for the Oxygen Concentrator. During an interview at 10:40 a.m., during surveyor interview, the DON was asked regarding negative outcome of contaminated O2 (oxygen) filters. He replied there was no negative outcome for Resident #20. Asked what a potential negative outcome for Resident #20 and he repeated there was no negative outcome. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676218 If continuation sheet Page 7 of 10 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 676218 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jefferson Nursing and Rehabilitation Center 3840 Pointe Parkway Beaumont, TX 77706 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 Residents Affected - Few During an interview on 04/10/23 at 12:10 p.m., the DON said corporate wants facility to use manufacture manuals and he does not have a policy for oxygen concentrators. He stated his expectations were for oxygen concentrators filters to be clean and filters are checked weekly on Thursdays and changed if soiled. During a joint interview on 4/12/23 at 8:45 a.m., LVN B said a negative outcome of soiled oxygen filters could possibly be a respiratory infection. The corporate nurse said her expectation was for oxygen filters, tubing, and humidifier bottles to be inspected daily by staff while in/out of rooms. She added a negative response of soiled filters could possibly result in respiratory concerns. During an interview on 4/12/23 at 2:15 p.m., the administrator said she expected oxygen concentrator filters to be clean, and for staff inspections daily. A user manual provided by the facility dated 08/01/2016, titled [Redacted] Oxygen Concentrator indicated 7.3 Cleaning the Filter.There are two cabinet filters located on each side of the cabinet. 1. Remove the filter and clean as needed. Environmental conditions that may require more frequent inspection and cleaning of the filter include, but are not limited to high dust, air pollutants, etc. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676218 If continuation sheet Page 8 of 10 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 676218 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jefferson Nursing and Rehabilitation Center 3840 Pointe Parkway Beaumont, TX 77706 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 0791 Provide or obtain dental services for each resident. 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 provide or obtain routine dental services from an outside resource to meet the needs of each resident for 1 of 19 residents (Resident #55) reviewed for dental services. Residents Affected - Few The facility did not request dental services for Resident #55, who did not have upper dentures since admission on [DATE]. This failure could place the residents at risk of not receiving the appropriate care and services to maintain their well-being. Findings included: Record review of physician orders dated March 2023 indicated Resident #55, admitted [DATE], was [AGE] years old with diagnoses of dementia, mood disturbance and anxiety. The orders did not indicate the resident had dental services. Record review of the most recent comprehensive significant change MDS assessment dated [DATE] indicated Resident #55 had moderate cognitive impairment and had no natural teeth or tooth fragments. The resident did not have significant weight loss. Record review of a care plan revised 4/5/23 indicated Resident #55 had an ADL self-care performance deficit and required assistance. One of the interventions was for staff to assist with personal hygiene/oral care to ensure food particles are cleaned from the resident's oral cavity due to the resident has own teeth with several missing. After surveyor intervention, a care plan initiated 4/12/23 indicated Resident #55 has oral/dental health problems related to no teeth on top and missing teeth on the bottom, no complaint of pain. Resident's RP was in agreeance to an oral evaluation only, at this time. RP reports that resident had lost dentures prior to admission and that she had contacted her previous dentist to see if she could have them remade and was advised against it due to resident's gum receding and bone loss. RP does not want any aggressive dental treatment done to resident including drilling, or any traumatic work that could cause resident pain or anxiety. Facility social worker expressed understanding and stated that she would submit referral for an evaluation and let her know the treatment plan prior to proceeding with any treatment. Record review of a dental visit summary dated 11/2/22 indicated Resident #55 was not seen by the dental company. Record review of the admission nurse's note dated 3/23/22 indicated Resident #55 had dentures but had lost them and had her own teeth with several teeth missing. Record review of an initial nurse assessment dated [DATE] indicated Resident #55 had some missing teeth. The initial assessment was signed by LVN D. During observation and interview on 04/10/23 at 8:37 a.m., Resident #55 was lying in bed. The resident did not have a top set of teeth. The resident said she did not know where her top teeth (dentures) were located, but she did have bottom teeth. She said she did not have dental pain. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676218 If continuation sheet Page 9 of 10 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 676218 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jefferson Nursing and Rehabilitation Center 3840 Pointe Parkway Beaumont, TX 77706 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 0791 Level of Harm - Minimal harm or potential for actual harm During an interview on 04/11/23 at 2:39 p.m., the SW said Resident #55 had not been seen by a dentist since admit. The SW said she was not here when the resident was admitted so she did not know why it was not followed up on. She said the dentist came out in November 2022 but, Resident #55 was not seen. She said the nurse who had completed the initial assessment should have let the SW know the resident needed to be seen by the dentist. Residents Affected - Few During an interview on 04/11/23 at 2:50 p.m., the DON said the nurse who completed the initial assessment should have contacted the social worker if they saw there was a dental concern. He said LVN D was the nurse who did the admission assessment, and she no longer worked at the facility. During an interview and record review of the initial nurse's assessment for Resident #55 on 04/11/23 at 3:15 p.m., ADON G said the initial nurse's assessment indicated Resident #55 had dental concerns. She said once the initial assessment was completed, the nurse should have brought the information regarding the resident's dental concerns to the social worker. She said Resident #55 should have been seen by the dentist. She said the possible negative outcome of not ensuring a resident was seen by the dentist could be the resident would experience a decline. During an interview on 04/12/23 at 8:50 a.m., the DON said his expectations were when a resident was admitted with missing teeth, they should be seen by a dentist as soon as possible. He said the facility had several social workers prior to the present one. He said there would not be a negative outcome unless the resident was complaining of pain. He said all residents should be assessed by the dentist within a moderate amount of time. When asked what a moderate amount of time was, he said it would all depend on the circumstances. He did not answer when asked if a moderate amount of time would be since the resident's admission in March of 2022. During an interview on 04/12/23 at 9:29 a.m., the RP said Resident #55 lost her top dentures approximately a month before being admitted to the facility. She said she never told the facility she did not want the resident to be assessed by the dentist. She said the SW called her yesterday and asked if the resident could not be fitted for dentures, did she want the resident to get implants and she told her no, she did not want Resident #55 to get implants. She said she did want her to be assessed by the dentist and to be fitted for dentures if it was possible, so Resident #55 could eat the food she wanted to eat. She said the resident had to eat a soft diet since she lost the dentures. During an telephone interview on 04/12/23 at 10:10 a.m., LVN D she said she did not remember Resident #55. She said she did not remember if the resident had missing teeth or not. She said if she performed an admission assessment on a resident who was missing teeth, she would let the DON and ADON know. She said she was not sure who was responsible for making dental referrals. She said if a resident had dental concerns and did not get seen by the dentist, it could lead to further dental decline. Record review of a Dental Services policy dated December 2017 indicated, Routine and emergency dental services are available to meet the resident's oral health services in accordance with the resident's assessment and plan of care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676218 If continuation sheet Page 10 of 10