Below average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Jefferson Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
The facility did not obtain food from approved or satisfactory sources and failed to ensure that food was stored, prepared, distributed, and served according to professional standards.
A resident with multiple health conditions, including muscle weakness and osteoporosis, was observed struggling to stand safely due to a wobbly dining table, which caused her cup to slide. Further inspection found that 9 of 22 dining tables were unstable, and the maintenance process relied on staff reporting issues rather than routine checks, resulting in ongoing unsafe conditions in the dining area.
The facility did not establish or maintain an infection prevention and control program, resulting in a deficiency related to the lack of required measures to prevent and control infections.
A resident with a history of cerebral infarct and severe cognitive impairment was not accurately assessed in the MDS, as her ongoing anticoagulant therapy with rivaroxaban was omitted from both the assessment and care plan. Staff interviews and record reviews confirmed the medication was administered daily, but the omission was attributed to oversight by the MDS nurses responsible for completing the assessments.
A resident with a history of cerebral infarct and severe cognitive impairment was prescribed and administered rivaroxaban, an anticoagulant, but the facility failed to include this medication in the resident's care plan. Staff interviews and record reviews confirmed the omission was due to oversight, and the required care plan revisions were not made, leaving staff without documented guidance for monitoring anticoagulant side effects.
Multiple residents with severe cognitive impairment and behavioral issues engaged in repeated physical altercations after wandering into each other's rooms, resulting in injuries and emotional distress. Staff were not always present or able to intervene promptly, and care plan interventions for monitoring and redirecting wandering behaviors were not consistently followed, leading to ongoing incidents of abuse and neglect.
Multiple residents with severe cognitive impairment and behavioral issues engaged in repeated physical altercations after wandering into each other's rooms, resulting in injuries. Despite care plans identifying risks and interventions such as redirection and monitoring, the facility did not consistently implement or update these measures. Staff interviews revealed lapses in supervision, with only one CNA present at times and residents left unsupervised, leading to further incidents of abuse and accidents.
A CNA was observed roughly handling a resident with severe cognitive impairment, but the allegation of physical abuse was not immediately reported to the Abuse Coordinator or state authorities. The accused CNA and the LVN on duty were not promptly removed from resident care, and the required protective measures were not implemented as outlined in facility policy.
Two residents with moderate cognitive impairment were involved in an alleged sexual abuse incident observed by staff, who redirected the involved parties and notified facility leadership. Although internal notifications occurred, the incident was not reported to the State Survey Agency within the required two-hour window, as mandated by facility policy and state regulations. The state agency was notified nearly 24 hours after the event, resulting in a deficiency for failure to ensure timely reporting of abuse allegations.
The facility failed to ensure accurate assessments for three residents, leading to deficiencies in care plans. A resident's smoking habit was not documented, another's continuous oxygen use was omitted, and a third resident's hospice care status was not recorded. These oversights were acknowledged by the MDS Nurse, potentially affecting the residents' care and services.
A facility failed to adhere to its policy for administering medications through a G-tube, risking improper care for a resident with a gastrostomy. An LVN did not mix crushed tablets with warm water before administration, contrary to facility policy. Although the LVN later followed the correct procedure, the initial oversight was noted. The DON acknowledged the policy but cited a Pharmacy Consultant's differing guidance.
A facility failed to follow its smoking policy for a resident with schizoaffective disorder and major depressive disorder, who required supervision while smoking. The facility did not complete the required quarterly smoking safety screen assessment due to a system error, despite the resident being assessed daily for changes. Interviews with staff revealed confusion over responsibility for the assessments, which were not completed as per the facility's policy.
A LTC facility failed to complete and transmit a discharge MDS assessment for a resident with cerebral infarction, aphasia, and peripheral vascular disease within the required 14-day period after discharge. The oversight resulted in a 128-day delay, as revealed during a record review. Interviews with staff indicated the assessment was missed, despite expectations for timely and accurate completion.
Noncompliance with Food Procurement and Handling Standards
Penalty
Summary
The facility failed to procure food from sources that are approved or considered satisfactory and did not store, prepare, distribute, and serve food in accordance with professional standards. This deficiency was identified during the survey process, indicating noncompliance with established food safety and handling requirements. No additional details regarding specific residents, staff, or events leading to the deficiency are provided in the report.
Failure to Maintain Stable and Safe Dining Tables
Penalty
Summary
The facility failed to provide a safe, sanitary, comfortable, and homelike environment for one resident and for multiple tables in the dining room. Specifically, a resident with multiple medical conditions, including atherosclerotic heart disease, schizoaffective disorder, major depressive disorder, muscle weakness, and osteoporosis, was observed attempting to stand up from a wobbly dining table. The instability of the table caused her coffee cup to slide across the surface, and she reported that the wobbly table made it difficult for her to stand up safely after meals. Her care plan identified her as a fall risk and required a safe environment, but the unstable table compromised her safety during daily activities. Additionally, observations revealed that 9 out of 22 dining tables in the dining room were unstable or wobbly when touched. The Maintenance Supervisor confirmed the issue, noting previous complaints and a completed work order several months prior, but stated that tables were not routinely checked for stability and repairs were only made upon receiving work order requests. Both the DON and Administrator acknowledged that all staff were responsible for reporting unsafe furniture and that the maintenance system relied on staff-initiated work orders. The facility did not have a routine process in place to regularly check the stability of dining tables, contributing to the ongoing presence of wobbly tables in the dining area.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, indicating that the required measures to prevent and control infections were not established or maintained as per regulatory standards. The report notes the absence or inadequacy of a structured program designed to minimize the risk of infection transmission among residents and staff.
Failure to Accurately Document Anticoagulant Use in Resident Assessment
Penalty
Summary
The facility failed to ensure that a resident received an accurate assessment reflective of her current status. Specifically, the most recent quarterly MDS assessment did not indicate that the resident, who had a diagnosis of cerebral infarct and severely impaired cognition, was receiving the anticoagulant medication rivaroxaban, despite physician orders and the medication administration record confirming daily administration of the drug. Additionally, the resident's care plan did not include any reference to anticoagulant therapy. Multiple staff interviews confirmed that the omission was an oversight, and the responsible MDS nurses acknowledged that the anticoagulant was not marked on the MDS or included in the care plan. The Director of Nursing, MDS nurses, and the Regional Case Manager all confirmed their roles in the MDS process and acknowledged the error, stating that the facility did not have a specific MDS policy but followed the RAI manual. The resident was observed to be confused and unable to answer questions, with no visible signs of bruising or bleeding. The failure to accurately document the use of anticoagulant medication on the MDS assessment and care plan was identified through record review, staff interviews, and observation.
Failure to Care Plan Anticoagulant Use for Resident with Cerebral Infarct
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan to address the use of the anticoagulant medication rivaroxaban for one resident with a history of cerebral infarct and severely impaired cognition. Despite physician orders and medication administration records confirming the resident was receiving rivaroxaban daily, the care plan did not include any interventions or monitoring related to anticoagulant therapy. Multiple staff interviews revealed that the omission was due to oversight by the MDS nurse and backup staff responsible for care planning, and that the care plan was not updated to reflect the resident's anticoagulant use. Observations and record reviews confirmed that the resident was confused and unable to answer questions, and that there was no visible bruising or bleeding at the time of observation. Staff acknowledged that the lack of a care plan for anticoagulant use could result in other staff, such as CNAs, not being aware of the need to monitor for side effects like bruising or bleeding. Facility policy required care plan revisions upon status change, but this process was not followed in this case, resulting in the deficiency.
Failure to Prevent Resident-to-Resident Abuse and Neglect
Penalty
Summary
The facility failed to protect multiple residents from abuse and neglect, as evidenced by a series of resident-to-resident altercations involving individuals with severe cognitive impairments and behavioral issues. Several incidents occurred in which residents with dementia and wandering behaviors entered other residents' rooms, leading to physical altercations. In one instance, a male resident with dementia and a history of wandering entered another resident's room and began rummaging through personal belongings, resulting in a physical fight where both sustained minor injuries. Staff interviews confirmed that the resident was known to wander and should have been monitored to prevent such incidents, but monitoring was insufficient at the time. Another incident involved a resident with severe cognitive impairment and behavioral symptoms who was found holding another resident against the wall and hitting him in the face after the latter entered his room and refused to leave. The altercation resulted in visible injuries, including a scratch and swelling, and required staff intervention. Staff accounts indicated that only one CNA was present on the unit at the time, as the other was on break, leaving the area inadequately supervised. This lack of supervision contributed to the escalation of the situation before staff could intervene. Additional altercations occurred when residents with known wandering and aggressive behaviors entered each other's rooms, leading to further physical confrontations. In several cases, staff were not immediately present or were occupied with other duties, resulting in delayed intervention. The care plans for these residents identified their behavioral risks and the need for monitoring and redirection, but these interventions were not consistently implemented, allowing repeated incidents of physical abuse and neglect to occur among residents.
Failure to Prevent Resident-to-Resident Altercations Due to Inadequate Supervision
Penalty
Summary
The facility failed to ensure that multiple residents received adequate supervision to prevent accidents and abuse, resulting in a series of resident-to-resident altercations. Several residents with severe cognitive impairment and behavioral issues, including wandering and aggression, were involved in repeated incidents where they entered each other's rooms, leading to physical altercations. For example, one resident with dementia and wandering behaviors entered another resident's room and began rummaging through personal belongings, which escalated into a physical fight resulting in minor injuries. In another instance, a resident with a history of wandering and aggression entered a peer's room, leading to a confrontation where one resident was pinned against the wall and struck in the face, causing visible injuries. The report documents that the care plans for these residents identified their behavioral risks, such as wandering and aggression, and included interventions like redirection, monitoring, and structured activities. However, the facility did not consistently implement or update these interventions following incidents. Staff interviews revealed that at times, only one CNA was present on the secure unit, and supervision lapses occurred when staff were occupied with other residents or on break. This lack of adequate supervision allowed residents with known behavioral issues to interact unsupervised, resulting in further altercations and injuries. Additionally, the facility did not review or update care plans or implement new interventions after repeated incidents, even when residents continued to display aggressive or wandering behaviors. The report details multiple occasions where residents were left unsupervised, leading to further physical altercations, including instances of inappropriate sexual contact and repeated physical abuse. These failures were observed through record reviews, staff and resident interviews, and direct observation, demonstrating a pattern of inadequate supervision and failure to prevent resident-to-resident abuse and accidents.
Failure to Immediately Report and Respond to Alleged Physical Abuse
Penalty
Summary
The facility failed to implement its written abuse policy when an allegation of physical abuse was made involving a resident with vascular dementia, anxiety, delirium, and severely impaired cognition. The incident occurred when a CNA was observed by another CNA to have roughly pulled the resident's arms off a hallway rail and pushed her into a chair. Despite the allegation, the accused CNA was not immediately removed from resident care and continued to work the remainder of the shift. The incident was not reported to the Abuse Coordinator or the State Agency immediately as required by facility policy. The resident involved had a history of aggressive behaviors and impaired communication, making her particularly vulnerable. The care plan noted her potential for physical aggression and refusal of medications, and she was known to be verbally aggressive due to dementia. On the night of the incident, the resident refused a head-to-toe assessment and was unable to be properly interviewed due to her cognitive status. The staff member who witnessed the alleged abuse left a written statement for the DON at the end of the shift, as administrative staff were not present at the time. Interviews with staff revealed that the LVN on duty did not report the allegation to the Abuse Coordinator as required, and both the accused CNA and the LVN continued their duties until the following day. The facility's policy required immediate protection of the resident and notification of the appropriate authorities, but these steps were not followed. The failure to act promptly and according to policy resulted in non-compliance and placed residents at risk of further abuse.
Failure to Timely Report Alleged Sexual Abuse Incident
Penalty
Summary
The facility failed to ensure timely reporting of an alleged incident of sexual abuse between two residents, as required by both facility policy and state regulations. On the date of the incident, a male resident with moderate cognitive impairment and a history of dementia and Alzheimer's disease was observed by an LVN touching a female resident's breast over her clothes in a common area. The LVN redirected the male resident and notified the ADON and the administrator. Shortly after, a medication aide witnessed the same male resident reaching under a blanket near the female resident's private area. Both residents were fully dressed, and neither recalled the incident when questioned. The female resident involved had moderate cognitive impairment related to dementia and was unable to participate in a psychosocial assessment following the incident. She was observed to be restless but showed no signs of distress or agitation. The facility social worker notified the resident's power of attorney about the incident, and the male resident was placed on one-to-one monitoring to ensure safety. Documentation in the nurse's notes and care plans confirmed the cognitive status and relevant medical history of both residents. Despite the immediate internal reporting to facility leadership, the incident was not reported to the State Survey Agency within the required two-hour timeframe. The facility's own policy mandates that all allegations of abuse be reported to the appropriate authorities immediately, but not later than two hours after the allegation is made if abuse is involved. The actual report to the state agency was made nearly 24 hours after the incident occurred, constituting a failure to comply with regulatory requirements for timely reporting of abuse allegations.
Inaccurate Resident Assessments in LTC Facility
Penalty
Summary
The facility failed to ensure accurate resident assessments for three residents, leading to deficiencies in their care plans. Resident #1's assessment did not indicate her smoking habit, despite multiple records and observations confirming her daily smoking. The MDS Nurse responsible for the assessment admitted to overlooking this detail, which could result in incomplete smoking assessments and care plans. Resident #36's MDS assessments failed to reflect his continuous use of oxygen therapy, despite physician orders and care plans indicating its necessity. Observations confirmed the resident was on oxygen, but the MDS Nurse did not capture this in the assessments, potentially affecting the resident's care and services. Resident #85's assessment did not document his hospice care status, even though physician orders and care plans indicated he was receiving hospice services. The MDS Nurse acknowledged the oversight, which could lead to discrepancies between the resident's care plan and actual care needs.
Failure to Follow Medication Administration Policy for G-tube
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate administration of medications for a resident with a gastrostomy tube (G-tube). Specifically, the facility did not adhere to its policy of mixing crushed tablets with 5-10 cc of warm water before administering them through the G-tube. This was observed during a medication administration for a resident who required enteral feeding due to conditions such as gastrostomy, heart failure, and stroke. The resident's care plan indicated the need for total assistance with tube feeding and water flushes, and physician orders required flushing the feeding tube with water before and after medication administration. During an observation, an LVN was seen administering medications without mixing the crushed tablets with warm water as per the facility's policy. Instead, the LVN used a swirling motion with the syringe to infuse the medications through the G-tube. Although the LVN later demonstrated the correct procedure after receiving an in-service, the initial failure to follow the policy could have compromised the resident's care. The Director of Nursing (DON) acknowledged the policy but mentioned that the Pharmacy Consultant indicated it was not necessary to dissolve medications completely before administration. However, the facility's policy clearly stated the requirement to dissolve crushed tablets in warm water before administration.
Failure to Follow Smoking Policy for Resident with Cognitive Impairment
Penalty
Summary
The facility failed to adhere to its established smoking policy for a resident with schizoaffective disorder and major depressive disorder, who was identified as a smoker requiring supervision. The facility's policy mandates a smoking safety screen assessment to be completed quarterly, but this was not done for the resident after the last assessment on 10/26/23. The resident, who has moderately impaired cognition, was observed smoking daily, and the facility staff were responsible for keeping her smoking supplies. Despite daily assessments for changes in condition, the quarterly smoking assessment was not completed due to a system error that failed to trigger the assessment as due. Interviews with facility staff, including an LVN, the social worker, the DON, and the Administrator, revealed a lack of clarity and responsibility regarding the completion of the smoking assessments. The DON acknowledged that the assessments should have been completed quarterly and attributed the oversight to a system error. The Administrator and Regional Care Manager also confirmed the system error and the expectation for assessments to be completed accurately and timely. The facility's policy requires smoking evaluations to be conducted upon admission, quarterly, annually, and with any change in condition, but this was not followed, leading to an inaccurate assessment and potential missed changes in the resident's condition.
Failure to Complete and Transmit Discharge MDS Assessment
Penalty
Summary
The facility failed to complete and transmit a required discharge assessment for one resident within the mandated 14-day period following the resident's discharge. The resident, a female with a history of cerebral infarction, aphasia, and peripheral vascular disease, was discharged to a hospital. Despite the requirement, the discharge MDS assessment was not completed or transmitted, resulting in a 128-day delay. This oversight was identified during a record review, which showed no evidence of a discharge MDS assessment for the resident. Interviews with facility staff, including the MDS Nurse, Administrator, and DON, revealed that the discharge assessment was simply missed. The MDS Nurse acknowledged the error, noting that the facility continued to receive quality measures for the resident despite her discharge. The Administrator and DON both expressed that their expectation was for all MDS assessments to be completed accurately and timely, but the discharge assessment for this resident was overlooked. The facility did not have a specific policy on MDS assessments but followed the Long-Term Care Resident Assessment Instrument guidelines.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Beaumont
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Calder Woods | 3.1 mi | ★★★★★ | 10 | 1 |
| Harmony Care At Beaumont | 3.4 mi | — | 42 | 5 |
| Beaumont Health Care Center | 3.8 mi | ★★★★★ | 2 | 0 |
| Spindletop Hill Nursing & Rehab Center | 4.2 mi | ★★★★★ | 1 | 0 |
| College Street Health Care Center | 4.3 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.