Inspection·February 8, 2024

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few them on the bed. Resident #1 said he was cold for the second time. CNA A finished opening the brief and tucked the front down between his legs. CNA A then told Resident #1 the wipes were going to be cold and proceeded to clean him. CNA A left Resident #1 uncovered and exited the room again. Resident #1 said he was cold for the third time. CNA A returned to the room. Resident #1 had urinated on the pad under him. CNA A removed the pad, placed a new pad and brief under him, then closed the brief. CNA A then covered Resident #1 with his gown, the sheet, and a blanket. During an interview on 02/06/24 at 11:45 p.m., CNA A said she should make sure the door or privacy curtain was closed to provide privacy prior to completing incontinent care. She said not providing residents privacy during care cause anxiety and embarrassment. During an interview on 02/07/24 at 10:00 a.m., Resident #1 said staff do not usually cover his upper body during care and he is always cold. He said he would like the staff to cover him during care so he was not cold. He said staff did not always close the privacy curtain during care. He said he would prefer the privacy curtain was closed during care. During an interview on 02/07/24 at 4:44 p.m., the DON said all staff were expected to pull the privacy curtains and shut the doors to resident room while providing care. She said residents could be exposed during care and exposure could cause anxiety and embarrassment. Record review of the facility's Resident Rights policy dated 2001 (revised December 2016) indicated . Employees shall treat all residents with kindness, respect, and dignity. 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. a dignified existence; b. be treated with respect, kindness, and dignity; . Record review of the facility's Quality of Life-Dignity policy dated 2001 (revised February 202) indicated Each resident shall be care for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, feeling of self-worth and self-esteem.1. Resident are treated with dignity and respect at all times.10. Staff promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures. Record review of the facility's Perineal Care (also known as peri-care-involves cleaning the private areas of a patient) policy dated 2001 (revised February 2018) indicated The purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skins irritation, and to observe the resident's skin condition. 2. Assemble the equipment and supplies as needed. 5. Fold the sheet down to the lower part of the body. Cover the upper torso with a sheet. 6. Raise the gown or lower the pajamas. Avoid unnecessary exposure of the resident's body.12. Reposition the bed covers. Make the resident comfortable. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676484 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 676484 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mont Belvieu Rehabilitation & Healthcare Center 14000 Lakes of Champions Blvd Mont Belvieu, TX 77523 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 1 of 14 residents (Resident #1) reviewed for infection control. Residents Affected - Few CNA A did not wash or sanitize her hands or change gloves while performing incontinent care for Resident #1. CNA B entered Resident #1's room wearing gloves she had previously handled trash with and did not wash or sanitize her hands or change gloves. These failures could place residents at risk of exposure to communicable diseases and infections. Findings included: Record review of Resident #1's face sheet dated 02/07/24 indicated he was [AGE] years old, admitted on [DATE], and his diagnoses included hemiplegia (paralysis of one side of the body) and hemiparesis (one-sided muscle weakness) affecting left dominant side, muscle wasting and atrophy (decrease in size and wasting of muscle tissue), depression (common mental disorder), and anxiety (feeling of fear, dread, and uneasiness). Record review of Resident #1's MDS dated [DATE] indicated he was usually understood and understood others, had moderate cognitive impairment (BIMS score 8), and was incontinent of bowel and bladder. Record review of Resident #1's care plan dated 05/18/23 indicated he had an ADL self-care performance deficit. Interventions included the assistance of one staff for toileting and to ensure the resident's dignity was maintained and privacy was provided. During an observation and interview on 02/06/24 at 11:20 p.m., Resident #1 told CNA A that he was soiled and needed to be changed. Outside the doorway to Resident #1's bed area there was a glove box holder and a hand sanitizer dispenser on the wall. CNA A said Resident #1 had to be changed often because he had frequent BMs and Resident #1 agreed. Resident #1 was lying in bed with a hospital gown and thin sheet. He complained he was cold and CNA A said she would get him a blanket. CNA A returned to the room and did not enter the bathroom to wash her hands and did not reach for the hand sanitizer dispenser. CNA A laid a brief and blanket on the small dresser across from the foot of the bed. CNA A stepped out of the room again. CNA B was outside Resident #1's room and placed trash in the container and entered Resident #1's room wearing the same gloves. CNA B said she heard someone talking with the resident and came in to see who was talking with him. CNA B did not remove her gloves or sanitize her hands until after the surveyor asked her what she was doing prior to entering the resident's room which she said she was putting trash into the container outside the door. When the surveyor asked CNA B what she was supposed to do prior to entering the resident's room and after she entered the resident room. CNA B said she should have removed the gloves and washed/sanitized her hands. CNA B then exited the resident's room and did not return. CNA A returned to the resident's room. She did not enter the bathroom to wash her hands, did not reach for the hand sanitizer dispenser, and donned gloves. CNA A proceeded to provide Resident #1 incontinent care. CNA A pulled Resident #1's sheet off, pull the hospital gown up, and started opening the brief. CNA A did not cover Resident #1 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676484 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 676484 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mont Belvieu Rehabilitation & Healthcare Center 14000 Lakes of Champions Blvd Mont Belvieu, TX 77523 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 - Few with gown or sheet, removed her gloves, and exited the room. She returned to the resident's room again did not enter the bathroom to wash her hands, and did not reach for the hand sanitizer dispenser, and donned gloves. CNA A pulled wipes from the package and placed them on the bed. CNA A said she pulled some wipes out to clean Resident #1. CNA A finished opening the brief and tucked the front down between his legs. CNA A then told Resident #1 the wipes were going to be cold and proceeded to clean him from the tip of the penis down. CNA A then applied barrier cream to the front part of the genitals. CNA A rolled Resident #1 on to his right side. CNA A cleaned the resident of feces, removed the dirty brief, and removed the gloves. CNA A did not turn him to the left side to clean the left buttock or hip. CNA A looked for the brief and realized she left it on the small dresser. CNA A did not wash or sanitize her hands, grabbed the brief and placed it on the bed. CNA A left Resident #1 uncovered and exited the room. CNA A returned to the room and did not enter the bathroom to wash her hands, did not reach for the hand sanitizer dispenser, and donned gloves. Resident #1 had urinated on the pad under his lower torso. CNA A removed the pad, placed a new pad and brief under him, then closed the brief. CNA A then covered Resident #1 with his gown, the sheet, and a blanket. During an interview on 02/06/24 at 11:45 p.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. CNA A said she would not have done anything different with the incontinent care. CNA A said they could use hand sanitizer 3 times before they need to wash their hands. During an interview on 02/06/24 at 11:50 p.m., LVN C 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 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 02/06/24 at 11:50 p.m., LVN D 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 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 02/07/24 at 4:44 p.m., the DON said CNA A should have washed or sanitized their hands between glove changes and before performing tasks with the resident to prevent infections. She stated she expected infection control measures were followed. She stated she expected all staff to follow infection control and hand hygiene measures with every task to prevent the spread of infections. Record review of the facility's Perineal Care policy dated 2001 (revised February 2018) indicated The purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skins irritation, and to observe the resident's skin condition. 2. Assemble the equipment and supplies as needed.The following equipment and supplies will be necessary when performing this procedure: 1. Wash basin; 2. Towels; 3. Washcloth, Soap (or other authorized cleaning agent: and 5. Personal protective equipment (e.g., gowns, gloves, masks, etc., as needed). Steps in the Procedure 1. Place the equipment on the bedside stand. Arrange the supplies so they can be easily reached. 2. Wash and dry your hands thoroughly. 5. Fold the sheet down to the lower part of the body. Cover the upper torso with a sheet. 6. Raise the gown or lower the pajamas. Avoid unnecessary exposure of the resident's body. 7. Put on gloves. 9. Discard disposable items into designated containers. 10. Remove gloves and discard into designated container. 11. Wash and dry hands thoroughly. 12. Reposition (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676484 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 676484 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mont Belvieu Rehabilitation & Healthcare Center 14000 Lakes of Champions Blvd Mont Belvieu, TX 77523 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 the bed covers. Make the resident comfortable. 13. Place the call light within easy reach of the resident. 14. Clan the wash basin and return to the designated storage area. 15. Clean the bedside stand. 16. Wash and dry your hands thoroughly. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676484 If continuation sheet Page 5 of 5