Inspection·April 16, 2025

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or result in serious bodily injury, or not later than 24 hours if the events that caused the allegation did not involve abuse and did not result in serious bodily injury, to the State Survey Agency in accordance with State law through established procedures for 1 of 8 residents (Resident #1) reviewed for reporting allegations of neglect. The facility failed to ensure a report for an allegation of neglect was submitted within 24 hours to the State Agency after Family Member B alleged Resident #1 was neglected on 04/10/25. This failure could place residents at risk of abuse, physical harm, mental anguish, and emotional distress. Findings included: Record review of Resident #1's face sheet dated 04/16/25 indicated he was a [AGE] year old male, admitted on [DATE], and his diagnoses included diabetes (high blood sugar levels), metabolic encephalopathy (brain dysfunctions due to problems with metabolism), aphasia (disorder that affects communication), hemiplegia (one-sided paralysis) and hemiparesis (one-sided weakness) following cerebral infarction (stroke) affecting right dominant side, dysphagia (difficulty swallowing), and gastrostomy (artificial external opening into the stomach). Record review of a grievance dated 04/10/25 indicated Resident #1's Family Member B alleged neglect due to Resident #1's change of condition. Record review of the facility's undated print-out from TULIP indicated there was no date or time available to confirm the date of the facility's report submission. Record review of the facility's TULIP account indicated there was no report of neglect dated 04/10/25, 04/11/25, 04/12/25, 04/13/25, or 04/14/25. During an interview on 04/16/25 at 9:37 a.m., the DON said the Administrator was the abuse coordinator. She said she was notified by LVN A at approximately 7:15 p.m. on 04/10/25 of the allegation of staff neglect for not suctioning Resident #1. The Administrator made the report in TULIP on 04/10/25 at 7:23 p.m. She said when the facility attempted to obtain the intake number for the 5-day report, (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 455757 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 455757 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Spindletop Hill Nursing & Rehab Center 1020 S 23rd St Beaumont, TX 77707 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)