Health inspection·May 23, 2023

F 0585 turn and reposition q 2 hours and prn. Keep body in good alignment. Level of Harm - Minimal harm or potential for actual harm Record review of care plan dated 01/23/19 indicated Resident #1 was at risk for increased pain due to decreased muscle movement and mobility. Interventions included staff to turn and reposition resident as needed to aid in alleviating pain. Residents Affected - Few Review of the facility's grievances from 03/23, 04/23 and 05/23 indicated there were no grievances documented for Resident #1. During an interview on 05/18/23 at 2:03 p.m., a family member said she called the facility on 05/17/23 at 9:40 p.m. to complain of Resident #1 being left in the same position since she had left the faciity on [DATE] at 3:48 p.m. She said she reviewed the video and Resident #1 was in the same position at 9:09 p.m. She said she should not have to call the facility for them to turn and take care Resident #1. She said she had spoken to the DON previously about Resident #1 being left in the same position for an extended number of hours, however Resident #1 continued to be frequently left in the same position for extended periods. She said the DON told her he would take care of her being turned and repositioned, but it kept happening. She said she was not aware of the formal grievance procedure. She said she was not informed if her concerns were addressed or resolved. During an interview on 05/22/23 at 12:46 p.m., the DON said he had not completed a written formal grievance document related to Resident #1. He said Resident #1's family member made a verbal complaint on 05/18/23 but it was the first one in a while. He said he talked to her almost daily. He said the RP had his direct number and he would address the issues and concerns as they were brought to his attention. During an interview on 05/23/23 at 9:57 a.m., the administrator said she was the designated grievance official. She said any staff could take a grievance. All staff were trained to take grievances. She said if a family member made a complaint, the staff were supposed to get a grievance form, fill it out, and take it to her. She said she would fill out the log and then give it to the appropriate department head to investigate and resolve the issue. She said she would put the grievance on her calendar when it was due back to her. She said she would then speak to the resident or the RP to let them know of the outcome and the resolution. She said if the complainant was not happy, she would invite them to have a meeting and speak directly with them. She said there were no complaints from the Resident Council. She said there were no written complaints from Resident #1's RP or family related to her care. She said she had a soft file for Resident #1. She said it included documentation of a discussion with Resident #1's family member who indicated Resident #1 was not turned enough. The administrator said she did not document the complaint on a grievance form. She said the ambassador and ADON would check on Resident #1 throughout the day. She said there was no documentation of the monitoring. During an interview on 05/23/23 at 10:33 a.m., LVN E said she had not completed or submitted a grievance related to Resident #1 being left in the same position for 7.5 hours. She said she was not aware of the grievance procedures. Record review of the facility's undated Grievance System policy indicated facility administrator is designated as the Grievance Official responsible for overseeing the grievance process. Staff member responsible for maintaining the grievance notebook is the Administrator. Grievance reports will be made available to all staff, residents, and residents family members upon request. When a grievance report is initiated: A copy of the initiated grievance report will be placed in the grievance (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676218 If continuation sheet Page 2 of 12 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 05/23/2023 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 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few notebook as a reminder that the grievance is still being investigated and resolved. The original report will then be forwarded to the department head for the Grievance pertains to (i.e. Dietary Manager for food and dining related issues, DON for any nursing or clinical related issues, Laundry Supervisor for missing clothing issues, etc.) The Department Head assigned the grievance report is responsible for investigating the issue and following up to provide a resolution to the issue within 72 hours of being assigned the grievance. Once resolution of the grievance is achieved, the Department Head assigned the Grievance Report is responsible to follow up with the Complainant and explain the investigation and resolution and document the Complainant's response to the resolution. The facility's undated Statement of Resident Rights indicated You have the right to: . 7. Complain about the facility and to organize or participate in any program that presents resident's concerns to the administrator of the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676218 If continuation sheet Page 3 of 12 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 05/23/2023 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 1 of 11 residents (Resident #11) reviewed for care plans. Facility staff failed to have two staff when repositioning, providing incontinent care, or transfers using a mechanical lift for Resident #1. Facility staff failed to reposition Resident #1 every two hours. These failures could place residents at risk of inadequate care and injury. The findings included: Record review of a face sheet dated 05/19/23 indicated Resident #1 was a [AGE] year old female, admitted on [DATE] with the diagnoses unspecified sequelae (consequence) of cerebral vascular disease (disease of the heart or blood vessels), dysphagia (swallowing difficulties), gastrostomy status (surgical procedure used to insert a tube, often referred to as a G-tube, through the abdomen and into the stomach), anoxic brain damage (caused by complete lack of oxygen to the brain), diabetes (a disease that occurs when blood glucose, also called blood sugar, is too high), Alzheimer's (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks), pulmonary embolism (sudden blockage in the pulmonary arteries, the blood vessels that send blood to the lungs, pulmonary edema (too much fluid in the lungs), dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), hemiplegia affecting right dominant side (paralysis of one side of the body), cerebral infarction occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it, and muscle wasting and atrophy (the wasting or thinning of muscle mass). Record review of an MDS assessment dated [DATE] indicated Resident #1 was not able to make herself understood, was not able to understand others, had severe cognitive impairment, required extensive 2-person assist for all ADLS. She was incontinent of bladder and bowel. Record review of a care plan dated 12/02/18 (revised 05/25/21), indicated Resident #1 was weak from CVA, had right side weakness, needed staff asst with turning and repositions, and may be up in Geri-chair 1-2 times per week as tolerated. Interventions included Bed Mobility-Resident #1 was dependent on 2 staff for repositioning and turning in bed, as necessary. Record review of Resident #1's [NAME] (the electronic care guide for CNA's) care tasks dated 05/23/23 indicated Resident #1 required two staff for bed mobility and transfers. During an observation of a video dated 04/26/23 (with the DON present on 5/22/23 at 12:46 p.m.) indicated Resident #1 remained in the same position from 8:56 a.m. through 1:22 p.m. and from 6:50 p.m. through 11:42 p.m. The video only records when movement was detected. During an observation of a video dated 4/28/23 at 8:12 p.m. (with the DON present on 5/22/23 at 12:46 p.m.) indicated CNA H entered Resident #1's room and completed incontinent care and repositioned Resident #1. There was not a second staff member to assist during incontinent care or repositioning. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676218 If continuation sheet Page 4 of 12 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 05/23/2023 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 During an observation of a video dated 05/10/23 at 12:39 p.m., (with the DON present on 5/22/23 at 12:46 p.m.) CNA A completed incontinent care and repositioned Resident #1 without a second staff to assist. During an observation of a video dated 05/11/23 at 1:51 p.m., (with the DON present on 5/22/23 at 12:46 p.m.) CNA A used a mechanical lift to transfer Resident #1 from her bed to a Geri-chair without a second staff to assist. During an observation of video (with the DON present on 5/22/23 at 12:46 p.m.) dated 05/17/23 from 2:09 p.m. through 9:40 p.m. (7.5 hrs.) indicated Resident #1 was lying on her right side facing the wall/window side of her room. LVN E and two aides entered the room at 9:45 p.m. Incontinent care was performed and Resident #1 was repositioned on her left side facing the door of her room. During an observation of video dated 05/19/23 from 7:45 a.m., (with the DON present on 5/22/23 at 12:46 p.m.) indicated CNA A completed incontinent care and repositioned Resident #1 without a second staff to assist. During an interview on 05/19/23 at 10:19 a.m., CNA H said she tried to do rounds every 2 hours to check, change and reposition Resident #1. She said it was not always possible. She said Resident #1 was a 2-person assist for bed mobility and incontinence care. She said she tended to do incontinent care and repositioning Resident #1 without a second staff because it was faster, and she did not have to wait for other staff. She said she would ask for assistance sometimes from another CNA or the LVN on duty. She said she could not explain why Resident #1 was left in the same position for 7.5 hrs. on 05/17/23. She said she was trained to provide care for the residents per the [NAME] care. She said she was trained to check and change and reposition residents every two hours and as needed. She said residents could develop skin breakdown if they were not repositioned every two hours. During an interview on 05/19/23 at 10:51 a.m., CNA A said Resident #1 was supposed to be checked, changed, or repositioned every two hours. She said Resident #1 was a 2-person assist for bed mobility and incontinent care. She said mechanical lift transfers required two staff. She said she was trained to provide care per the [NAME]. She said she did not ask for assistance to reposition or transfer Resident #1. She said she did not ask for assistance because she did not want to wait. She said she was trained to check and change and reposition residents every two hours and as needed. She said residents could develop skin breakdown if they were not checked, changed, and repositioned as required. During an interview on 05/19/23 at 5:07 p.m., LVN E said Resident #1's family member called before the 2-10 shift ended on 05/17/23 to report Resident #1 had been left in the same position since she had left around 3:48 p.m. She said she did not know why Resident #1 was in the same position that long. She said she had not seen the aide go into Resident #1's room. She said she was not asked to assist with repositioning Resident #1. She said she and 2 aides went to Resident #1's room after the family member called. She said the aides performed incontinent care and repositioned Resident #1. She said residents could develop skin breakdown if they were not checked, changed, and repositioned as required. During an interview on 05/22/23 at 12:35 p.m., the DON said Resident #1 was a 2-person assist for bed mobility and incontinent care. He said there was only one CNA in Resident #1's hall for the 10:00 p.m.-6:00 a.m. shift. He said if 2 staff were needed the CNA was supposed to get the nurse or another CNA from another hall to assist. He said he had in-serviced staff on the [NAME] and following the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676218 If continuation sheet Page 5 of 12 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 05/23/2023 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 care instructions from the care plan. He said staff should follow the [NAME] for resident care. Level of Harm - Minimal harm or potential for actual harm During an interview on 05/23/23 at 11:59 a.m., CNA L said on 5/11/23 at 1:51 p.m., she took the mechanical lift to Resident #1's room assist CNA A to transfer the Resident from her bed to the Geri-chair. She said she was having a conversation with Resident #1's roommate and when she looked over toward Resident #1, CNA A had completed putting Resident #1 into the mechanical lift sling and was in the process of moving her from the bed to the chair. She said she should have assisted CNA A with the transfer. She said Resident #2 was a two-person assist for bed mobility and transfers. She said mechanical lift transfers required two staff. She said she was trained to check and change and reposition residents every two hours and as needed. She said residents could develop skin breakdown if they were not checked, changed, and repositioned as required. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676218 If continuation sheet Page 6 of 12 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 05/23/2023 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. 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 necessary services to maintain grooming and personal hygiene were provided for 1 of 11 residents (Resident #2) reviewed for ADLS. Residents Affected - Few Resident #2 had feces near his scrotum. This failure could place residents at risk of not receiving services/care, decreased quality of life, and decreased self-esteem. Findings included: Record review of a face sheet dated 05/23/23 indicated Resident #12 was [AGE] year old male admitted on [DATE] with the diagnoses cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it) , aphasia (loss of ability to understand or express speech, caused by brain damage), polyneuropathy (simultaneous malfunction of many peripheral nerves throughout the body, convulsions (a sudden, violent, irregular movement of a limb or of the body), muscle wasting and atrophy, (the wasting or thinning of muscle mass), dysphagia (swallowing difficulties), cognitive communication deficit (difficulty with thinking and how someone uses language), and contracture of muscle (muscles, tendons, joints, or other tissues tighten or shorten causing a deformity). Record review of an MDS assessment dated [DATE] indicated Resident #2 was not able to make himself understood or understand others, had severe cognitive impairment, and required extensive 1-2 person assist for all ADLS, and was always incontinent of bowel. Record review of a care plan dated 10/11/22 (revised 11/28/22) indicated Resident #2 had bowel incontinence. Interventions included to provide peri-care after each incontinence episode. Record review of the Point of Care (where care is documented in the electronic record of care by CNAs) History dated 05/22/23 at 4:04 a.m. indicated Resident #2 had a BM. Record review of CNA F's CNA Orientation Skills checklist indicated she was checked off on pericare for males and females on 6/17/22. During an observation with the DON on 05/22/23 at 12:15 p.m., Resident #2 had feces on the left side of his scrotum in by the crease of his leg. There was no BM in the brief. During an observation and interview on 05/22/23 at 1:47 p.m. Resident #2 still had feces on the left side of his scrotum near the crease of his leg. CNA F said at the time of the observation Resident #2 had not had a BM on her shift. She said she had completed incontinent care a few hours earlier. She provided incontinent care and cleaned the feces. She did not change her gloves during the procedure. During an interview on 5/22/23 at 2:24 p.m., CNA F said she did not see feces near Resident #2's scrotum when she had completed the incontinent care. She said she was trained to complete incontinent care properly. She said skin breakdown could occur if care was not thorough. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676218 If continuation sheet Page 7 of 12 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 05/23/2023 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 05/22/23 at 1:20 p.m., the DON said staff were trained on incontinent care procedures and expected them to do a thorough job and ensure all feces had been cleaned. He said residents were at risk of infection when staff did not follow the proper incontinent care. The nurses should have been monitoring to ensure Resident #1 was being turned and repositioned During an interview on 05/22/23 at 2:24 p.m. CNA F said when she had performed incontinent care for Resident #1, she said she did not observe feces near his scrotum. Record review of the facility's Perineal Care policy dated 10/24/22 indicated It is the practice of this facility to provide perineal care to all incontinent residents during routine bath and as needed in order to promote cleanliness and comfort, prevent infection to the extent possible, and to prevent and assess for skin breakdown. 6. Perform hand hygiene and put on gloves. Apply other personal protective equipment as appropriate.9. If perineum (the area between the anus and the scrotum or vulva) is grossly soiled, turn resident on side, remove any fecal material with toilet paper, then remove and discard.10. Change gloves if soiled and continue with perineal care. 16. Remove gloves and discard Perform hand hygiene. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676218 If continuation sheet Page 8 of 12 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 05/23/2023 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 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 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 2 of 11 residents (Resident #1 and #2) and reviewed for infection control. Residents Affected - Some CNA A did not wash or sanitize her hands or change gloves and threw dirty linens and garbage on the floor while performing incontinent care for Resident #1. TX LVN D placed wound care supplies directly on Resident #1's bed and did not perform hand hygiene or change her gloves prior to applying a clean dressing during wound care. LVN B and TX LVN D did not wash or sanitize their hands or change gloves while performing incontinent care for Resident #1. CNA F completed incontinent care for Resident #2 and did not change her gloves. These failures could place residents at risk of exposure to communicable diseases and infections. Findings included: 1. Record review of a face sheet dated 05/19/23 indicated Resident #1 was a [AGE] year old female, admitted on [DATE] with the diagnoses unspecified sequelae (consequence) of cerebral vascular disease (disease of the heart or blood vessels), dysphagia (swallowing difficulties), gastrostomy status (surgical procedure used to insert a tube, often referred to as a G-tube, through the abdomen and into the stomach), anoxic brain damage (caused by complete lack of oxygen to the brain), diabetes (a disease that occurs when blood glucose, also called blood sugar, is too high), Alzheimer's (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks), pulmonary embolism (sudden blockage in the pulmonary arteries, the blood vessels that send blood to the lungs, pulmonary edema (too much fluid in the lungs), dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), hemiplegia affecting right dominant side (paralysis of one side of the body), cerebral infarction occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it, and muscle wasting and atrophy (the wasting or thinning of muscle mass). Record review of an MDS assessment dated [DATE] indicated Resident #1 was not able to make herself understood, was not able to understand others, had severe cognitive impairment, required extensive 2-person assist for all ADLS. She was incontinent of bladder and bowel. Record review of a care plan dated 12/02/18 (revised 05/25/21) indicated Resident #1 had bowel incontinence related to CVA. Interventions included providing peri-care after each episode. Record review of a care plan dated 12/02/18 (revised 05/25/21), indicated Resident #1 was weak from CVA, had right side weakness, needed staff assist with turning and repositions, and may be up in Geri-chair 1-2 times per week as tolerated. Interventions included Bed Mobility-Resident #1 was dependent on 2 staff for repositioning and turning in bed, as necessary. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676218 If continuation sheet Page 9 of 12 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 05/23/2023 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of personnel files indicated CNA A had her competency for infection control during incontinent care was checked 11/5/2022. During an observation on 5/22/23 at 11:40 p.m., LVN B and TX LVN D performed incontinent care for Resident #1. Neither LVN changed their gloves or performed hand hygiene when going from dirty to clean. The clean brief was placed on Resident #1 and the Resident was pulled up in bed, pillows positioned under the Resident's head and legs, and the sheet placed back on Resident #1 using the same gloves used for incontinent care. During an observation of a video dated 05/10/23 at 12:39 p.m., (with the DON present on 5/22/23 at 12:46 p.m.) CNA A walked in Resident #1's room with gloves on and placed her personal drink on Resident #1's bedside table. She completed incontinent care and threw soiled linens on the floor. Without performing hand hygiene or changing her gloves, CNA A took a clean wipe and proceeded to wash Resident #1's face. During an observation of video dated 05/19/23 from 7:45 a.m., (with the DON present on 5/22/23 at 12:46 p.m.) indicated CNA A performed incontinent care on Resident #1. She did not perform hand hygiene or change her gloves prior to putting on Resident #1's clean brief and protective pad. She threw dirty linens, clothes, and the brief on the floor. During an observation of video dated 05/10/23 at 1:14 p.m., (with the DON present on 5/22/23 at 12:46 p.m.) indicated TX LVN D placed wound care supplies on Resident #1's bed without any kind of barrier. TX LVN D left the wound care area and was out of site and returned with a wound dressing and continued with the wound care treatment without performing hand hygiene or changing her gloves prior to applying the clean dressing. She collected the supplies and garbage and left the area. During an interview on 05/19/23 at 10:51 a.m., CNA A said she was trained in incontinent care and infection control. She said she was supposed to wash her hands and put on gloves prior to performing incontinent care. She said she was supposed to change her gloves from dirty to clean before putting on clean undergarments and clothes on Resident #1. She said she was supposed to place all dirty linens and clothes in a bag and not on the floor while performing incontinent care. She stated she received multiple in-services and training related to infection control including hand hygiene and changing gloves. She said residents could be at risk of an infection if they did not wash or sanitize their hands when performing care. During an interview on 05/19/23 at 5:07 p.m., LVN E said CNA A should not have touched dirty and clean briefs with the same gloves. She said CNA A should have changed gloves and performed hand hygiene after performing incontinent care. She stated she received multiple in-services and training related to infection control including hand hygiene and changing gloves. She said residents could be at risk of an infection if they did not wash or sanitize their hands when changing their gloves. During an interview on 05/22/23 at 2:08 p.m., TX LVN D said she was trained in wound care and infection control. She said she should not have placed the wound care supplies on Resident #1's bed. She said there should have been a barrier between the bed and the clean supplies. She said she should have performed hand hygiene and changed her gloves prior to applying the clean dressing. She said not practicing proper infection control could place residents at risk of infection. She also said she and LVN B should have performed hand hygiene and changed their gloves when they performed incontinent care for Resident #1. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676218 If continuation sheet Page 10 of 12 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 05/23/2023 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 2. Record review of a face sheet dated 05/23/23 indicated Resident #2 was [AGE] year old male admitted on [DATE] with the diagnoses cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), aphasia (loss of ability to understand or express speech, caused by brain damage), polyneuropathy (simultaneous malfunction of many peripheral nerves throughout the body, convulsions (a sudden, violent, irregular movement of a limb or of the body), muscle wasting and atrophy, (the wasting or thinning of muscle mass), dysphagia (swallowing difficulties), cognitive communication deficit (difficulty with thinking and how someone uses language), and contracture of muscle (muscles, tendons, joints, or other tissues tighten or shorten causing a deformity). Record review of an MDS assessment dated [DATE] indicated Resident #2 was not able to make himself understood or understand others, had severe cognitive impairment, and required extensive 1-2 person assist for all ADLS, and was always incontinent of bowel. Record review of a care plan dated 10/11/22 (revised 11/28/22) indicated Resident #2 had bowel incontinence. Interventions included to provide peri-care after each incontinence episode. Record review of a care plan dated 10/11/22 indicated Resident #2 required 1-person assist for bed mobility personal hygiene, and toilet use. During an observation with the DON on 05/22/23 at 12:15 p.m., Resident #2 had feces on the left side of his scrotum in by the crease of his leg. There was no BM in the brief. During an observation and interview on 05/22/23 at 1:47 p.m. Resident #2 still had feces on the left side of his scrotum near the crease of his leg. CNA F said at the time of the observation Resident #2 had not had a BM on her shift. She said she had completed incontinent care a few hours earlier. She provided incontinent care and cleaned the feces. She did not change her gloves during the procedure going from dirty to clean. During an interview on 5/22/23 at 2:24 p.m., CNA F said she should not have touched the dirty and clean briefs with the same gloves. She says she should have changed gloves and performed hand hygiene after performing incontinent care. She stated she received multiple in-services and training related to infection control including hand hygiene and changing gloves. She said residents could be at risk of an infection if they did not wash or sanitize their hands when changing their gloves. During an interview on 05/22/23 at 1:20 p.m., the DON said staff were trained in incontinent care procedures and infection control. He said he expected his staff to follow infection control procedures by performing hand hygiene and changing their gloves. He said residents were at risk of infection when staff did not follow the proper incontinent care procedures and infection control procedures. During an interview on 05/22/23 at 4:33 p.m., CNA H said they were supposed to put linens in a bag and not throw them on the floor. She stated she received multiple in-services and training related to hand washing and changing their gloves during care. She said residents could be at risk of an infection if they did not wash or sanitize their hands when changing their gloves Record review of the facility's Infection Prevention and Control Measures for Common Infections in LTC Facilities dated 10/07/22, indicated Standard Precautions are used for all resident care. They are based on a risk assessment and make use of common practices and personal protective equipment that protect staff from infection and prevent the spread of infection among residents and staff. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676218 If continuation sheet Page 11 of 12 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 05/23/2023 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Standard precautions include: hand hygiene, Implementing the use of PPE when exposure to infectious material is expected . Handling Textiles and Laundry carefully . Hand hygiene refers to cleaning your hands by using hand washing techniques (washing hands with soap and water), antiseptic hand wash, antiseptic hand rub (i.e., alcohol-based hand sanitizer, ABHR, including foam or gel), or surgical antisepsis. Record review of the facility's Perineal Care policy dated 10/24/22 indicated It is the practice of this facility to provide perineal care to all incontinent residents during routine bath and as needed in order to promote cleanliness and comfort, prevent infection to the extent possible, and to prevent and assess for skin breakdown. 6. Perform hand hygiene and put on gloves. Apply other personal protective equipment as appropriate.9. If perineum (the area between the anus and the scrotum or vulva) is grossly soiled, turn resident on side, remove any fecal material with toilet paper, then remove and discard.10. Change gloves if soiled and continue with perineal care. 16. Remove gloves and discard Perform hand hygiene. Event ID: Facility ID: 676218 If continuation sheet Page 12 of 12