Health inspection·December 29, 2023

F 0580 Level of Harm - Minimal harm or potential for actual harm Record review of Resident #1's physician orders dated 12/27/23 indicated she was re-admitted to the facility on [DATE]. Record review of progress note dated 12/12/23, completed by NP C indicated there was no review of Resident #1's hospital discharge records dated 11/27/23. Residents Affected - Few During an interview on 12/22/23 at 2:00 p.m., the DON said the admitting nurse should have notified the physician of the recommendation for the referral. He said LVN G should have documented the recommendations in the nurse notes and put an order in for a consult. He said if a resident required a referral, the facility notified the physician and the physician submitted the referral. He said the charge nurse and nurse management would follow up on recommendations and referrals. He said he was not able to locate documentation in Resident #1's e-chart of the recommendation for cardiologist referral. He said it would have been in the 24-hour report for review. He said Resident #1 could have a delay of care if recommendations and referrals were not completed as required. During an interview on 12/27/23 at 11:27 p.m. NP C said she did not receive notification for a recommendation for a referral to a cardiologist for Resident #1. She said she would have submitted the referral to the cardiologist. She said Resident #1's recommendation was for a probable aneurysm. She said the condition would be monitored if the condition was confirmed to determine a course of action. She said the condition was not usually treated surgically due to poor prognosis and outcome. She said Resident #1 could have a delay of care if recommendations and referrals were completed as required. During an observation and interview on 12/27/23 at 12:47 p.m., Resident #1 said she was feeling fine. She said she felt pretty good. She said she had no complaints of her care. Resident #1 said she did not know why she had been in the hospital. She did not appear in distress. During an interview on 12/27/23 at 5:04 p.m. LVN G said she could not recall Resident #1's specific re-admission from the hospital on [DATE]. She said there was more than one admission and LVN F assisted with the process. She said she did not remember reviewing Resident #1's discharge records dated 11/27/23 from the hospital. She said if there was a recommendation for a referral she should have documented the information in a progress note and sent the recommendation to Resident #1's physician. She said Resident #1 could have a delay of care if recommendations and referrals were completed as required. During an interview on 12/27/23 at 5:49 p.m., LVN F said she assisted LVN G with Resident #1's re-admit to the facility from hospital on [DATE]. She said she assisted with completing the forms but did not reviewed the hospital discharge papers. She said if she had reviewed Resident #1's discharge records dated 11/27/23 from the hospital and there was a recommendation for a referral, she would have documented the information in a progress note and sent the recommendation to Resident #1's physician. She said Resident #1 could have a delay of care if recommendations and referrals were completed as required. During an interview on 12/28/23 at 1:45 p.m. MD D said the recommendation for Resident #1's referral was not a STAT (common medical abbreviation for urgent or rush referral). He said her condition was not acute but chronic. He said it the condition was acute, the hospital would have addressed the condition prior to transferring Resident #1 back to the facility. He said the condition was common for Resident #1's age. He said the facility nursing staff should have advised the physician of the referral to the cardiologist in order for the cardiologist to assess and make recommendations or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676218 If continuation sheet Page 2 of 5 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 12/29/2023 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 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few develop a plan of treatment. He said Resident #1 could have a delay of care if recommendations and referrals were completed as required. During an interview on 12/28/23 at 4:09 p.m., MD E said she was not made aware of Resident #1's readmit from hospital of the recommendation for the cardiologist referral. She said Resident #1's referral was not emergent or STAT. She said a ventricular apex aneurism was not an acute condition and would not be treated surgically. She said the condition would be monitored. She said the facility should have notified her of Resident #1's return to the facility on [DATE] and of the recommendation for cardiologist referral. She said Resident #1 could have a delay of care if recommendations and referrals were completed as required. During an interview on 12/28/23 at 4:50 p.m., the DON said the receiving nurse was supposed to notify the physician of a resident's return from the hospital. He said LVN G did not recall if she notified the physician. During an interview on 12/29/23 at 11:55 a.m., NP C she could not recall if she was made aware of Resident #1's re-admission to the facility or the recommendation for a referral to the cardiologist. She said if the hospital thought her condition was critical, then they would have kept Resident #1 in hospital to treat her before sending her back to the facility. During an interview on 12/29/23 at 11:58 a.m., MD D said Resident #1's was admitted to the hospital under the care of a pulmonologist who was also head of the ICU. He said Resident #1 was stabilized and returned to the facility. Record review of the facility's policy Notification of Changes dated 10/24/22 indicated The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification. 2. Significant change in the resident's physical, mental or psychosocial condition such as deterioration in health, mental or psychosocial status. This may include: a. Life-threatening conditions, or b. Clinical complications. Circumstances that require a need to alter treatment. This may include: a. a new treatment. B. Discontinuation of a current treatment due to: i. Adverse consequences. ii. Acute condition. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676218 If continuation sheet Page 3 of 5 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 12/29/2023 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure the medical record of each resident was accurately documented in accordance with accepted professional standards and practices for 1 of 10 residents (Resident #1) reviewed for medical records. The facility failed to ensure a recommendation for a cardiologist referral dated 11/27/23 was documented in Resident #1's clinical record. This failure could place residents at risk for delayed care and appropriate interventions. Findings included: Record review of Resident #1's face sheet dated 12/22/23 indicated she was a [AGE] year old female, initially admitted on [DATE], and her diagnoses included dementia (the impaired ability to remember, think, or make decisions that interferes with doing everyday activities), diabetes (high blood sugar), and hypertension (high blood pressure). Record review of Resident #1's MDS dated [DATE] indicated Resident #1 was usually understood and usually understood others, she had severe cognitive impairment (BIMS score 7), and physical and verbal behaviors directed at others occurred 1 to 3 days. Record review of Resident #1's physician orders dated 08/01/23 indicated she was admitted to the facility to SNF level of care. Record review of Resident #1's physician orders dated 12/27/23 indicated she was re-admitted to the facility on [DATE]. Record review of Resident #1's hospital records dated 11/25/23 indicated she was admitted on [DATE] with altered mental status (change in mental function), hypercapnia (buildup of carbon dioxide in your bloodstream), and dehydration (loss of fluid). Record review of Resident #1's hospital records dated 11/26/23 indicated a CT angiography of the chest with IV contrast was completed. Findings indicated the pulmonary arterial vasculature appeared normal, no CT evidence for pulmonary embolism, heart was mildly enlarged, probable 2 cm aneurysm of left ventricle apex, and the aorta was normal in caliber and there was no evidence of dissection. Record review of Resident #1's hospital records dated 11/27/23 *Follow-up/appointments: Needs to follow up (with) cardiologist d/t (due to) suspected left ventricular apex aneurism. Additional MD instructions: Follow up with NH provider. Follow-up with outpatient cardiology. Record review of progress note dated 12/12/23, completed by NP C indicated there was no review of Resident #1's hospital discharge records dated 11/27/23. During an interview on 12/22/23 at 2:00 p.m., the DON said the admitting nurse should have notified the physician of the recommendation for the referral. He said LVN G should have documented the recommendations in the nurse notes and put an order in for a consult. He said if a resident required a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676218 If continuation sheet Page 4 of 5 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 12/29/2023 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few referral, the facility notifies the physician and the physician submits the referral. He said the charge nurse and nurse management would follow up on recommendations and referrals. He said he was not able to locate documentation in Resident #1's e-chart of the recommendation for cardiologist referral. He said it would have been in the 24-hour report for review. During an interview on 12/27/23 at 11:27 p.m. NP C said she did not receive notification for a recommendation for a referral to a cardiologist for Resident #1. She said she would have submitted the referral to the cardiologist. During an observation and interview on 12/27/23 at 12:47 p.m., Resident #1 said she was feeling fine. She said she felt pretty good. She said she had no complaints of her care. Resident #1 said she did not know why she had been in the hospital. She did not appear in distress. During an interview on 12/27/23 at 5:04 p.m. LVN G said she did not remember reviewing Resident #1's discharge records dated 11/27/23 from the hospital. She said if there was a recommendation for a referral she should have documented the information in a progress note and sent the recommendation to Resident #1's physician. During an interview on 12/27/23 at 5:49 p.m., LVN F said she assisted LVN G with Resident #1's re-admit to the facility from hospital on [DATE]. She said she assisted with completing the forms but did not reviewed the hospital discharge papers. She said if she had reviewed Resident #1's discharge records dated 11/27/23 from the hospital and there was a recommendation for a referral, she would have documented the information in a progress note and sent the recommendation to Resident #1's physician. During an interview on 12/28/23 at 4:50 p.m., the DON said LVN G should have documented in Resident #1's chart of her return to the facility and the recommendations for cardiologist referral. He said LVN G did not document in Resident #1's chart. The DON said he was unable to locate a policy regarding documentation of resident referrals. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676218 If continuation sheet Page 5 of 5