Inspection·June 11, 2025

F 0755 -04/09/25 at 8:00 p.m. MA P administered 1 tablet leaving 26 tablets Level of Harm - Minimal harm or potential for actual harm -04/14/25 at 4:00 p.m. MA F administered 1 tablet leaving 25 tablets -04/15/25 at 6:00 p.m. MA F administered 1 tablet leaving 24 tablets Residents Affected - Few -04/16/25 at 6:00 p.m. MA F administered 1 tablet leaving 23 tablets -04/22/25 at 6:00 p.m. MA G administered 1 tablet leaving 22 tablets For a total of eight tablets being administered without an active physician order, and the count indicated 22 remained out of 30. Record review of Resident's #60's Medication Administration Record for the month of 04/2025 indicated no order for Lorazepam and no indication that Lorazepam was administered to Resident #60 for the month of 04/2025. Observation of a random narcotic count with LVN K on 06/10/25 at 1:30 p.m. indicated Resident #60's Lorazepam 1 mg, Narcotic Count Sheet indicated there were 22 tablets of Lorazepam 1 mg, Further observation indicated a line drawn through LVN E's name and error written beside her name for 04/07/25, 8:00 p.m. During an interview on 06/10/25 at 1:30 p.m., LVN K said she had not given Resident #60 any Lorazepam and noticed the scratch thru name, but the narcotic count was correct, so she thought nothing of it. She said per the facility protocol if the narcotic count was off, staff must stay at the facility, the DON must be notified to re-count the narcotics and attempt to locate the narcotics. The staff involved in any missing narcotics would be required to take a drug test. She said the risk to residents could be drug diversion if meds were not accounted for or signed out as administered on the medication administration record. During an interview on 06/11/2025 at 9:30 a.m., the ADON said she was not aware of Resident #60 not having an order for Lorazepam for the month of April 2025. She said she monitored administration of narcotics by doing random counts of the medication cart and she would look at the narcotic record sheets for any mistakes. The ADON said medication carts were to be counted at shift change. She said she expected staff to count the medication carts, make sure medication orders were there before administering and to document correctly, notify the DON and herself immediately if there was a problem, staff were to remain at the facility until administrative staff arrived. The ADON stated no medications were to be given without a physician's order, because residents could receive the wrong dose of medications. During an interview on 06/11/2025 at 10:30 a.m., MA C said she never administered the medication to Resident #60 because she didn't have and order and she drew a line thru her name but did not administer the medication. She said if she would have seen it on the medication administration record she would have given it. MA C said she did not notify her nurse Resident #60 didn't have an active order because she didn't give the Lorazepam. MA C said giving medication without a physician order put them at risk of taking medications they didn't need. During an interview on 06/11/2025 at 12:18 p.m., MA F said medications carts were supposed to be counted at the time of shift change. She said staff were to count all narcotic pills in the medication (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455757 If continuation sheet Page 2 of 11 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 06/11/2025 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)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few carts one staff to check the paper record and the other staff to check the medication to ensure they matched. She said the facility in-serviced all nurses and medication aides on counting all narcotic medication in the medication carts and how to document on the medication administration record. She was not sure why she did not document in the eMAR for Resident #60 to show she received the Narcotic she logged out on the individual narcotic record. MA F said she knew better than to administer Resident #60 Lorazepam without it being on the medication administration record. MA F said because Resident #60's Lorazepam blister card was on her cart she thought there was already an order for the medication on the eMAR but she did not sign it out. MA F said administering medication without an doctor's order could mean giving residents medication they could be allergic too. MA F said next time she would report it to her ADON or DON. During an attempted interview on 06/11/25 at 12:25 p.m., MA G did not answer the phone call, or reply to the voice message that was sent to her regarding the investigation. During an attempted interview on 06/11/25 at 12:30 p.m., LVN E did not answer the phone call, or reply to the voice message that was sent to her regarding the investigation. During an interview on 6/11/25 at 2:00 p.m., the DON said she was not aware of any concerns with Narcotics not being given or any documentation discrepancies until state surveyor intervention. The DON explained her expectation was for anyone administering to sign out on the individual narcotic record and then immediately sign the eMAR after the resident took the medication. The DON said she expected the nurses to do follow-up documentation after the narcotic was given to document effectiveness in the nurse's progress notes. The DON said the ADON was responsible for monitoring the pain management of residents and the narcotic logs looking for discrepancies such as scratch outs, frequency of person giving Narcotics. The DON said administer medications and not signing off on the medication administration record put the resident at risk of double dosing and taking something they didn't need. Record review of the facility's policy titled Medication Administration, dated 10/24/22, read in part: Medications are administered by licensed nurses or other staff who are legally authorized to do so in this state as ordered by the physician and in accordance with professional standards of practice in a manner to prevent contamination or infection so . 11. Document administered medications as they are passed medications not given are logged with an initial and circled in the proper time slot. 12. The medication administration record will be used when passing medications FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455757 If continuation sheet Page 3 of 11 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 06/11/2025 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)

F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. 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 each resident's drug regimen was free of unnecessary drugs for 1 of 20 residents (Resident #41) reviewed for unnecessary medication. Residents Affected - Few The facility failed to monitor Resident #41 for side effects of the antidepressant medication, Duloxetine (used to treat depression). These failures could place the residents at risk for adverse consequences and decline in health. Findings include: Record review of Resident #41's face sheet, dated 06/09/25, indicated Resident #41 was a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted [DATE]. Resident #41 had diagnoses which included bipolar disorder (disorder associated with episodes of mood swings ranging from depressive lows to manic highs), major depressive disorder (disorder of persistently depressed mood or loss of interest in activities causing significant impairment in daily life) and anxiety (intense, excessive and persistent worry and fear about everyday situations). Record review of Resident #41's significant change in status MDS assessment, dated 03/29/25, with a BIMS score of 6, which indicated severely impaired cognition with diagnoses which included bipolar disorder, depression and anxiety. The assessment indicated she received antidepressant medication for the last 7 days. Record review of Resident #41's MAR, dated 06/10/25, indicated Resident #41 received duloxetine 30 mg daily for bipolar disease with a start date of 04/21/25. Record review of Resident #41's physician orders, dated 06/11/25, indicated Resident #41 was prescribed duloxetine 30 mg daily for bipolar disease with a start date of 04/21/25. The orders did not address monitoring the antidepressant medication for side effects. Record review of Resident #41's care plan, with a target date of 06/25/25, indicated Resident #41 was prescribed the antidepressant medication duloxetine with interventions which included administer antidepressant medication as ordered by physician and monitor, document side effects and effectiveness every shift. Record review of Resident #41's electronic medical record, from 05/01/25 to 06/11/25, for Resident #41 did not indicate the nurses' documented monitoring of side effects of the antidepressant medication, duloxetine daily with medication administration. During an observation and interview on 06/11/25 at 8:45 a.m., Resident #41 was lying in bed and nodded in agreement that she received needed medication, received antidepressant medication but was unsure if was monitored for side effects. During an interview on 06/11/25 at 8:46 a.m., LVN B said she was providing care for Resident #41 today, but CMA C gave Resident #41's duloxetine. She said it should be monitored for side effects and documented and was not in the documentation. LVN B said the nurses were responsible for ensuring side effect monitoring was added to the computer system and the ADON was the back up. She said she was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455757 If continuation sheet Page 4 of 11 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 06/11/2025 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)

F 0757 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few in-serviced on and was aware antidepressant medication should be monitored for side effects. She said Resident #41's was overlooked. LVN B said the resident risk was the staff could miss behaviors or side effects if not monitored. During an interview on 06/11/25 at 8:50 a.m., CMA C said Resident #41 should be monitored for side effects for the duloxetine with the medication administrator but was not. She said she was responsible for providing medication to Resident #41 today and her duloxetine should be monitored for side effects but was not. She said the nurses were responsible for adding side effect monitoring to the computer system and the ADONs and DON were the back up to double check. She said Resident #41's side effect monitoring was overlooked. CMA C said she was educated on monitoring antidepressant medication for side effects. She said she gave Resident #41 medication which included duloxetine on 06/06/25, but had not given the duloxetine yet today. CMA C said the resident risk of a resident given an antidepressant medication and not monitored for side effects was the resident could get worse and more depressed. During an interview on 06/11/25 at 9:14 a.m., the DON said Resident #41's antidepressant medication should have been monitored for side effects when the medication was given to the resident. She said LVN A added it after state surveyor intervention. The DON said the nursing who admitted the resident was responsible for addition of side effect monitoring into the computer system and the ADONs were the back up. She said LVN D admitted resident #41 and was responsible, and ADON A was the back up. She said the ADON's ran daily reports to check for new medications, consents and side effect monitoring and did monthly monitoring charts for accuracy of orders. She said Resident #41 was overlooked. The DON said the resident risk was possible not capturing adverse reactions and not immediate intervention to a reaction. She said the side effect monitoring queued the nurses with specific side effects to monitor. The DON said her expectation was daily monitoring of psychotropic medication (drugs that affect mental processes and behaviors and often used to treat mental illness) and any noted side effect and addressed immediately. During an interview on 06/11/25 at 9:23 a.m., ADON A said the nurse who admitted the resident or wrote the order for the psychotropic medication was responsible for addition of the side effect monitoring into the computer system and the ADON was responsible for the resident's Hall she was admitted and for double checking for monitoring. She said she was responsible for hall 200 and memory care residents. ADON A said she was responsible for ensuring Resident #41's monitoring was added for her antidepressant medication. She said the antidepressant monitoring dropped off when the resident readmitted on [DATE] and was not added back into the computer system. She said she ran reports daily to ensure all new medication was reviewed and had monitoring as needed. ADON A said all the nurses were educated on monitoring antidepressant medication for side effects. She said the resident risk of an antidepressant medication not monitored for side effects was staff may not be aware of the specific side effects to monitor for, a side effect could go unnoticed, and the resident may not receive needed interventions for side effects. During an interview on 06/11/25 at 9:47 a.m., LVN D said she readmitted Resident #41 from the hospital on [DATE]. She said the ADON and DON were responsible to ensure all antidepressant medication was monitored for side effects. LVN D said she was educated on side effect monitoring and aware all antidepressant medication should be monitored. She said she did not know how to add side effect monitoring into the computer system but would find out immediately. LVN D said the resident risk was without a specific list of side effects to be monitored a resident could have side effects the nurse could be unaware and may not address the side effect. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455757 If continuation sheet Page 5 of 11 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 06/11/2025 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)

F 0757 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 06/11/25 at 10:00 a.m., the Administrator said the charge nurses were responsible for entering the side effect monitoring into the computer system for psychotropic medication and the ADON and DON were responsible for double checking to ensure side effects were monitored. All the nurses were educated on monitoring psychotropic medication for side effects. He said Resident #41's was overlooked. The Administrator said the resident risk of an antidepressant medication not monitored for side effects was it could possibly affect other medication or cause side effects that may not be treated if staff were unaware of them. The Administrator said his expectation was all psychotropic medication was monitored as required. Record review of the facility's, undated, policy titled, Psychoactive Medication Management Program indicated, . 3. Implement the behavior monitoring / side effects monitoring in PCC on the MAR for psychoactive medications with the target behaviors or not behaviors observed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455757 If continuation sheet Page 6 of 11 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 06/11/2025 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)

F 0759 Ensure medication error rates are not 5 percent or greater. 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 that the medication error rate was not five percent or greater. The facility had a medication error rate of 7.6% based on 3 errors out of 39 opportunities, which involved 3 of 6 residents (Residents #42, #71 and #90) and 2 of 4 staff observed during medication administration reviewed for medication error. Residents Affected - Some 1. The facility failed to ensure MA P did not administer Tylenol 325 mg instead of Tylenol 500 mg to Resident #45's on 06/10/25 as ordered by the physician. 2. The facility failed to ensure LVN K did not administer Saccharomyes boulardii (Probiotic) 500 mg instead of Probiotic 250 mg to Resident #71 on 06/10/25 as ordered by the physician. 3. The facility failed to hold Resident #90's Metoprolol medication due to low heart rate. These failures could place residents at risk of unwanted side effects and not receiving therapeutic dosage of medications. Findings include: 1. Record review of Resident #45's face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #45 had diagnoses which included hypertension (elevated blood pressure), hyperlipidemia (elevated cholesterol) and cerebral infarction (blood flow to brain is blocked). Record review of Resident #45's Quarterly MDS assessment, dated 05/01/25, reflected a BIMS score of 12, which indicated Resident #45's cognition was intact. Record Review of Resident #45's physician orders, dated 06/11/25, reflected an order for Tylenol extra strength 500mg twice a day for pain. Record review of Resident #45's medication administration record, dated 06/11/25, reflected Tylenol Extra Strength Tablet 500 MG (Acetaminophen) Give 1 tablet by mouth two times a day for Pain at 9:00 a.m. and 9: p.m The medication was signed out as given by MA P on 06/10/25 at 9: a.m. During an observation on 06/10/25 at 6:45 a.m., revealed MA P administered the following medications to Resident #45 : Acidopgilus 75 million, 2 capsules (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455757 If continuation sheet Page 7 of 11 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 06/11/2025 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)

F 0759 Tylenol 325 mg, 1 tablet Level of Harm - Minimal harm or potential for actual harm Carvedilol 3.125 mg, 1 tablet Residents Affected - Some Eliquis 5 mg, 1 tablet Famotidine 20 mg, 1 tablet Gabapentin 400 mg, 1 capsule Lisinopril 20 mg, 1 tablet Furosemide 20 mg, 1 tablet She did not administer Tylenol 500 mg, 1 tablet. During an interview on 06/10/25 at 12:50 p.m., MA P stated the current order in the chart for Resident #45 indicated Tylenol Extra Strength Tablet 500 MG was to be given. MA P searched the medication cart to reveal there was no Tylenol Extra Strength Tablet 500 MG on her cart. She stated she misread the dosage and gave the 325 mg instead. She stated she was not sure how she missed it. Stated she just got nervous. MA P said medications were administered from doctor's order and following the 6 Rights of Medication Administration. MA P said residents could have worsening of their health condition. 2. Record review of Resident #71's face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #71 had diagnoses which included dysphagia (difficulty swallowing), history of cerebral infarction (stroke), tracheostomy (tube in windpipe to provide an airway) and gastrostomy (opening to the stomach to deliver nutrients, fluids and medications). Record review of Resident #71 's annual MDS assessment, dated 03/05/2025, reflected no BIMS was conducted, short-term/long-term memory problems and severely impaired cognitive skills for daily decision making. Record review of Resident #71's physician orders, dated 06/11/25, reflected an order for Saccharomyces boulardii Oral Capsule (Saccharomyces boulardii). Give 250 mg 1 packet via gastrostomy tube one (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455757 If continuation sheet Page 8 of 11 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 06/11/2025 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)

F 0759 time a day for ANTIDIARRHEA. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #71's medication administration record, dated 06/11/25, reflected Saccharomyces boulardii Oral Packet 250 MG (Saccharomyces boulardii), Give 1 capsule via gastrostomy tube daily for ANTIDIARRHEA at 8:00 a.m. The medication was signed out as given by LVN K on 06/10/25 at 8: a.m. Residents Affected - Some During an observation on 06/10/25 at 7:54 a.m., LVN K administered the following medications to Resident #71 via gastrostomy: Amlodipine 5 mg 1 tablet Levetiracetam 100 mg/ml 5ml Pantoprazole oral suspension 40mg 1 packet Probiotic saccharomyces boulardii 500mg 1 capsule Vitamin C 500mg 1 tablet She did not administer Probiotic saccharomyces boulardii 250mg 1 capsule. During an observation on 06/10/25 at 07:54 a.m., revealed LVN K administered medications to Resident #71. LVN K crushed 2 of the medications (Amlodipine and Vitamin C) and mixed them each with 10 ml of water in separate clear 30 ml medication cups. LVN K then opened Probiotic saccharomyces boulardii 500mg 1 capsule and mixed it in 10 ml of water and administered it thru Resident #71's gastrostomy tube. During an interview on 06/10/25 at 09:45 AM, LVN K said prior to administering medications nursing staff must check the medication against the order to verify accuracy. LVN K said she gave the 500mg Probiotic saccharomyces boulardii instead of the 250 mg because none was on the medication cart. LVN K said risk of not giving medications as ordered could have a negative effect on the resident where they may not get better or have prolonged illness. 3. Record review of Resident #90's face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #90 had diagnoses which included dysphagis (difficulty swallowing), hypertension (high blood pressure) and atrial fibrillation (irregular rapid heart rate). Record review of Resident #90 's annual MDS assessment, dated 05/07/25, reflected a BIMS score of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455757 If continuation sheet Page 9 of 11 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 06/11/2025 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)

F 0759 10, which indicated Resident #90's cognition was moderately impaired. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #90's physician orders, dated 06/11/25, reflected an order for Metoprolol Tartrate Tablet, Give 12.5 mg by mouth two times a day for hypertension hold for systolic blood pressure less than 110 or heart rate less than 60. Residents Affected - Some Record Review of Resident #90's MAR/TAR dated 06/11/25 indicated that Metoprolol 25mg ½ tablet at 8:00 a.m. The medication was signed out as given by MA P on 06/10/25 at 8: a.m During an observation on 06/10/25 at 7:00 a.m., obtained Resident #90's blood pressure according to physician orders. Resident #90's blood pressure was systolic 130 with diastolic 71 and his heart rate was 52. MA P then proceeded to administer the following medications to Resident #90: Vitamin C 500 mg 1 tablet Metoprolol 25mg ½ tablet (12.5 mg) Amiodarone 200mg 1 tablet During an interview on 06/10/25 at 12:40 p.m., MA P acknowledged the current order in the chart for Resident #90 indicated Metoprolol Tartrate Tablet Give 12.5 mg by mouth two times a day for hypertension and hold for systolic blood pressure less than 110 or heart rate less than 60 was not to be given. MA P said she only saw the blood pressure parameter and not the heart rate. MA P said the potential for adverse effects was the heart rate dropping too low. During an interview on 07/25/24 at 03:27 PM, the DON said a pharmacy consultant comes in monthly and reviews medication administration and reports any errors and also provides training to the staff. The DON said she expects the staff to follow the orders as written and the order for Resident #90's Metoprolol should have been held, Resident #45 and #71 were given the wrong dosage of medication. The DON said she expected her nurses to pass medications and do basic medication functions like following the 5 Rights of Medication Administration and notify the Physician for anything out of the ordinary. The DON said the risk to residents would beheart rate dropping and not receiving the correct therapeutic dosages of medications. Record review of the facility policy titled, Medication Administration, dated 10/24/22, read in part: .8. Obtain and record vital signs, when applicable are per physician orders. When applicable, hold medication for those vital signs outside the physician's prescribed parameters .10. Review MAR to identify medication to be administered.11. Compare medication source (bubble pack, vial, etc.) with MAR to verify resident's name, medication name, form, dose, route, and time FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455757 If continuation sheet Page 10 of 11 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 06/11/2025 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)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview and record review the facility failed to ensure in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys for 1 of 5 medication carts (Station 2 Nurse Cart) reviewed for medication storage. The facility failed to ensure Station 2 Nurse Cart did not contain loose pills This failure could place residents at risk of adverse reactions to medications, misappropriation of medications and injury. Findings include: In an observation and interview on 06/10/25 at 12:45 p.m., revealed inventory of the Hall A & B Nurse Cart with LVN S had 16 loose pills. LVN S said nursing staff were expected to check their carts daily as used for inappropriately labeled medication or lose pills. She said all medications were expected to be packaged in the original pharmacy packaging containing all the required pharmacy labels or in the OTC stock bottles to ensure patient safety. She said if mistakenly administered, loose pills could place residents at risk of disastrous side effects since their identification was unknown so they must be crushed and discarded in the sharp's container. In an interview on 06/10/25 at 2:40 p.m., the DON said nursing staff were expected to check their carts daily for loose pills and inappropriately labeled medications. The ADON said all medications should be stored in their original containers. She said loose pills could place residents at risk of adverse reactions, infection from contamination or uncontrolled health conditions. Record review of the facility's policy Administering Medications, revised 10/01/19, read in part: .10. the licensed nurse or medication aide should maintain a clean top surface on the medication cart while passing medications and clean and replenish the medication cart after each use equipment and supplies relating to medication administration are clean and orderly FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455757 If continuation sheet Page 11 of 11