Inspection·July 30, 2025

F 0760 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few hypoglycemia (low blood sugar-level). Record review of Resident #1's hospital records dated 07/25/25 indicated Resident #1 presented to the emergency department via EMS with complaints of hypoglycemia. Staff reported Resident #1 had a glucose of 99 and facility administered 8 units of insulin causing Resident #1 glucose to drop to 25. EMS administered 250 ml of D10 (dextrose/sugar), raised glucose to 169. Resident remained responsive to painful stimuli only. Record review of Resident #1's hospital records dated 07/26/25 Blood glucose earlier this a.m. was 58. Continue to monitor glucose and hold diabetic medications and insulin. Record review of Resident #1's hospital records dated 07/27/25 indicated hypoglycemia was resolved. Discharge plan for tomorrow. Record review of Resident #1's progress nurse noted dated 07/28/25 at 5:37 p.m., completed by LVN J indicated Resident #1 was readmitted to the facility in stable condition. During an interview on 07/29/25 at 10:50 a.m., the DON said she was not aware LVN A administrated Resident #1's insulin outside of parameters on 07/24/25. She said she was aware the physician was notified of Resident #1's change of condition and transport to hospital for evaluation and treatment. She said she reviewed Resident #1's clinical record for a change of condition but did not investigate the possible reasons for hypoglycemia. She said it was her expectation LVN A would have held Resident #1's insulin on 07/24/25 due to the BG being out of parameters. She said the risk for Resident #1 receiving insulin out of parameters were hypoglycemia leading to coma and possible death. During an interview on 07/29/25 at 11:18 p.m., LVN A said she must have made a mistake on 07/24/25 when she administered Resident #1's insulin outside of parameters. She said she did not recall if Resident #1 ate her supper meal. She could not recall if she gave Resident #1 a supplement. She said she did not recall if staff reported a change of condition. She said she left the facility at 6:00 p.m. on 07/24/25 after working a 4 hour shift. She said she was not aware Resident #1 had a change of condition, became unresponsive, or was sent to the hospital for evaluation and treatment for hypoglycemia. She said she was aware of the proper medication administration procedures. She said the risk for Resident #1 receiving insulin out of parameters were hypoglycemia leading to coma and possible death. During an interview on 07/29/25 at 1:27 p.m., the DON said she did not know why LVN A administered insulin outside of parameters on 07/24/25 was missed as a med error. She said she missed that LVN A documented Resident #1's BG at 99 and the parameters indicated to hold if BG was less than 100. She said it was an oversight. During an interview on 07/29/25 at 2:28 p.m., CNA C said Resident #1 was sleeping in her wheelchair after the supper meal. She said Resident #1 would not wake up so she could transfer her to bed. She said she called for LVN B to come and assist. She said LVN B could not wake Resident #1 and called for another nurse and ambulance. She said she was trained on recognizing the signs of diabetes and hypoglycemia and figured something was wrong with Resident #1 when she could not wake her up to get ready for bed. During an interview on 07/29/25 at 3:30 p.m., CNA D said Resident #1 was awake when she gave her supper tray on 07/24/25. She said Resident #1 did not eat her supper meal. She said she advised LVN A Resident #1 did not eat her meal. She said she believed LVN A gave Resident #1 a supplement. She said she moved Resident #1 closer to her room to get ready for bed. She said CNA C was getting Resident #1 ready for bed and couldn't wake her up. I thought she was deep sleeping because she was snoring loud. She said CNA C and LVN B could not wake Resident #1 so they called for the crash cart and EMS. She said Resident #1 was sent to the hospital because her BG had dropped. She said she was trained to call for the nurse immediately if a resident was unresponsive or the residents were not at their normal. During an observation on 07/29/25 at 3:37 p.m., Resident #1 was lying in bed. She pulled the blanket over her face and did not respond to questions from the surveyor. During an interview on 07/29/25 at 5:05 p.m., LVN B said she arrived for her shift on 07/24/25 at 6:00 p.m. She said LVN A did not report Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455757 If continuation sheet Page 2 of 6 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 07/30/2025 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 0760 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few #1 was not at her normal baseline. LVN A did not report Resident #1 did not eat her supper meal. She said CNA C reported she could not wake Resident #1 to get her ready for bed. She said Resident #1 did not respond to anything, not even painful stimuli. She said she called for another nurse and the crash cart just in case it was needed and EMS. She said she tested Resident #1's BG and it was 46. She said EMS arrived and tested Resident #1's BG and the result was 25. She said EMS transported Resident #1 to the hospital for evaluation and treatment. She said giving insulin when not following parameters was dangerous. She said administering insulin outside of parameters could lead to hypoglycemia, coma, and death. During an observation on 07/30/25 at 2:00 p.m., Resident #1 was sitting in her wheelchair in the common area watching TV. She did not respond to questions from the surveyor. She displayed no signs of anxiety or agitation. During an interview on 07/30/25 at 9:33 a.m. NP D said she was aware Resident #1 was transferred to hospital on [DATE] for change of condition. She said if Resident #1's BG was 99, LVN A should have held the insulin due to the BG being out of parameters. She said Resident #1's BG usually ran high. She said giving insulin when not following parameters was dangerous. She said administering insulin outside of parameters could lead to hypoglycemia, coma, and death. Review of the facility's Medication Administration policy dated 10/24/22, indicated 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. Policy Explanation and Compliance Guidelines: . 8. Obtain and record vital signs, when applicable or per physician orders. When applicable, hold medication for those vital signs outside the physician's prescribed parameters. An Immediate Jeopardy/Immediate Threat was identified on 07/29/25 at 1:05 p.m. The Administrator and the DON were notified of the Immediate Jeopardy and provided the IJ template on 07/29/25 at 1:18 p.m. The facility was asked to provide a Plan of Removal to address the Immediate Jeopardy. The facility's POR was approved on 07/30/25 at 11:15 a.m. and indicated: Actions for Resident Involved: On 7/24/25, Resident #1 was assessed by LVN B and transferred to the hospital as per physician's orders due to a change in condition and returned to the facility on 7/28/25. Resident #1 was treated for Hypoglycemia with EMS and received D10, blood sugar elevated to 169. Resident #1 was treated with IV fluids with dextrose during hospitalization. On 7/29/25, Resident #1 was assessed by ADON and there was no change in condition noted. On 7/29/25, Resident #1's medications were reviewed by the Director of nursing with the physician and Aspart was discontinued. Identify residents who could be affected: On 7/29/2025, the Director of Nursing and/or designee completed 100% audit of all residents with current insulin orders to ensure Insulin is given within ordered parameters in the last 30 days. Any insulin administered outside of ordered parameters will be addressed with physician, Responsible party notified, resident assessment and medication error report completed if error is identified. Any unclear or missing insulin parameters will be clarified with the Attending physician and order changes as needed. 3 residents were identified as insulin administered outside of parameters and 4 residents that had insulin parameters ordered. Identified residents were assessed with no adverse effects, medication error reports completed, and MD/RP notified. No new order for residents that were identified as insulin administered outside of parameters. Action Taken/ System Change: On 7/29/25, the Regional Clinical Specialist re-educated the Director of Nursing and Assistant Directors of Nursing on Medication review and reconciliations to ensure that resident is free of significant medication errors, insulin parameters are followed and review of medication record to identify any errors when resident exhibits change in condition with appropriate notifications to physician and RP. Education includes this process: New physicians order will be reviewed in clinical morning meeting M-F by DON/Designee and RN (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455757 If continuation sheet Page 3 of 6 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 07/30/2025 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 0760 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few supervisor/designee on weekends. The Medication Administration Record will also be reviewed with resident changes of condition to include transfer to hospital during clinical morning meeting M-F by DON/Designee and RN supervisor/designee on weekends. On 7/29/25, All license nurses and Medication Aides were immediately re-educated by the Director of Nursing/Designee on Medication Administration, Medication Errors and Identification of parameters. All license nurses were re-educated by the Director of Nursing/Designee on Insulin administration to include parameters and blood glucose monitoring. Residents experiencing change in condition will have medication administration record reviewed to ensure orders were followed and notify physician if errors were identified. Licensed Nurses will review medication record after medication administration to ensure insulin parameters are followed as ordered. Licensed Nurses were educated on this process and to notify DON/Designee if medication error is identified. A post-test will be completed to ensure comprehension of knowledge of the education provided . If 100% is not achieved, re-education will be completed and re-tested prior to taking an assignment. Licensed Nurses and Medication Aides not in the facility on 7/29/25 and/ or on PTO/ FMLA/ Leave of Absence will have the re-education completed prior to the start of their next scheduled shift. Beginning 7/29/25 and ongoing, newly hired licensed nurses and Certified Medication Aides will receive this training during orientation prior to providing care to the residents. The training will include the above-stated educational components. Beginning 7/29/25 and ongoing Medication administration audit report and Medication error incidents will be reviewed during the morning clinical meeting to ensure identification of medication errors and that physician is notified if error is identified. Monitoring Beginning 7/29/25 and going forward, DON/Designee will monitor compliance with medication administration policy through review of medication administration record to ensure insulin parameters are followed as ordered and medication pass observations. Beginning 7/29/25 and going forward, the DON/Designee will monitor compliance with the weekday morning review of new medication orders, insulin medication administration record, medication error incidents and change in conditions to ensure medications are administered as ordered and identify medications errors if any and referred to physician timely. The Administrator will attend the morning clinical meeting to ensure the Director of Nursing and/or designee reviews the Incident reports and medication administration report during clinical meetings. On 7/29/25, An Ad Hoc QAPI meeting was held with the Medical Director, Facility Administrator, Director of Nursing, and Regional Clinical Specialist to review the plan of removal. The Surveyor monitored the POR on 07/30/25 by: During observation on 07/30/25 from 1:20 p.m. through 3:54 p.m., LVN F, LVN G, and LVN H checked Residents #2, #3, and #4 BG and administered insulin as required. During interviews on 07/30/25 from 1:20 p.m. through 4:30 p.m., DON, ADON, LVN B, LVN F, LVN G, LVN H, LVN J, CMA K, CMA L, CMA M. MDS LVN N, LVN O, and LVN P who represented all shifts, (6:00 a.m.-6:00 p.m., 6:00 p.m. -6:00 a.m., 6:00 a.m.-2:00 p.m., 2:00 p.m. - 10:00 p.m., 8:00 a.m. - 5:00 p.m.) indicated they were aware to complete medication review and reconciliations to ensure that residents were free of significant medication errors, that insulin parameters were followed and review of medication record to identify any errors when resident exhibits change in condition with appropriate notifications to physician and RP. They were aware new physician orders would be reviewed in clinical morning meeting M-F by DON/Designee and RN supervisor/designee on weekends. They were aware the Medication Administration Record would also be reviewed with resident changes of condition to include transfer to hospital during clinical morning meeting M-F by DON/Designee and RN supervisor/designee on weekends. They were aware insulin administration included parameters and blood glucose monitoring. The indicated residents who experienced change in condition would have medication administration record reviewed to ensure orders were followed and to notify physician if errors were (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455757 If continuation sheet Page 4 of 6 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 07/30/2025 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 0760 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete identified. Nursing staff indicated they would review medication record after medication administration to ensure insulin parameters were followed as ordered and to notify DON/Designee if a medication error was identified. During an interview on 07/30/25 at 3:30 p.m., the Administrator said he would be attending the morning clinical meeting to ensure the Director of Nursing and/or designee reviewed the incident reports and medication administration report during clinical meetings and all errors were addressed as required. He said he expected the nursing staff to administer medications per the facility policy and protocols. Record review of Resident #1's clinical chart indicated On 7/24/25, Resident #1 was assessed by LVN B and transferred to the hospital as per physician's orders due to a change in condition and returned to the facility on 7/28/25. Resident #1 was treated for hypoglycemia with EMS and received D10, blood sugar elevated to 169. Resident #1 was treated with IV fluids with dextrose during hospitalization. On 7/29/25, Resident #1 was assessed by ADON and there was no change in condition noted. On 7/29/25, Resident #1's medications were reviewed by the DON with the physician and Aspart (fast acting insulin) was discontinued. Record review of the facility audit of residents with current insulin orders 3 residents were identified as insulin administered outside of parameters and 4 residents that had insulin parameters ordered. The residents were assessed with no adverse effects, medication error reports completed, and MD/RP notified. There were no new orders for the identified residents that were identified as insulin administered outside of parameters. Record review of in-services dated 07/29/25 indicated the Regional Clinical Specialist re-educated the Director of Nursing and Assistant Directors of Nursing on medication review and reconciliations to ensure that residents were free of significant medication errors, insulin parameters were followed and review of medication record to identify any errors when resident exhibits change in condition with appropriate notifications to physician and RP. Education included new physician orders would be reviewed in clinical morning meeting M-F by DON/Designee and RN supervisor/designee on weekends. The Medication Administration Record would also be reviewed with resident changes of condition to include transfer to hospital during clinical morning meeting M-F by DON/Designee and RN supervisor/designee on weekends. Record review of in-service dated 07/29/25 indicated licensed nurses and Medication Aides were re-educated by the Director of Nursing/Designee on Medication Administration, Medication Errors and Identification of Parameters. All license nurses were re-educated by the Director of Nursing/Designee on insulin administration to include parameters and blood glucose monitoring. Residents experiencing change in condition would have medication administration record reviewed to ensure orders were followed and to notify physician if errors were identified. Licensed Nurses would review medication record after medication administration to ensure insulin parameters were followed as ordered. Licensed Nurses were educated on this process and to notify DON/Designee if medication error was identified. Record review of an in-service post-tests dated 07/29/25 indicated all tested nursing staff and medication aides achieved 100%. The Administrator and DON were notified on 07/30/25 at 4:35 p.m., the IJ had been removed. While the IJ was removed, the facility remained at a level of no actual harm at a scope of isolated that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. Event ID: Facility ID: 455757 If continuation sheet Page 5 of 6 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 07/30/2025 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete 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 interview and record review, the facility failed to ensure the medical record was complete and accurately documented for 1 of 8 residents (Resident #1) reviewed for resident records. The facility failed to ensure Resident #2's BG parameters were updated accurately on the electronic physician orders and MAR as of 07/02/25. This failure could place residents at risk for delayed care and appropriate interventions. Findings included: Record review of Resident #2's face sheet dated 07/29/25 indicated she was a [AGE] year old female, admitted on [DATE], and her diagnoses included Type II diabetes and dementia. Record review of Resident #2's annual MDS dated [DATE] indicated she was usually able to make herself understood and understood others. She had severe cognitive impairment (BIMS-3). Record review of Resident #2's care plan dated 11/20/20 indicated she had Type II diabetes. Interventions included diabetes medications as ordered by a doctor. Monitor/document for side effects and effectiveness. Record review of Resident #2's physician orders dated 07/02/25 indicated -Novolog Injection Solution 100 UNIT/ML Inject 6 unit subcutaneously with meals. Hold if BS is less than 200. Record review of Resident #2's physician orders dated 07/29/25 indicated -Novolog Injection Solution 100 UNIT/ML Inject 6 unit subcutaneously with meals. Hold if BS is less than 200. Record review of Resident #2's MAR dated 07/02/25 through 07/29/25 indicatedNovolog Injection Solution 100 UNIT/ML Inject 6 unit subcutaneously with meals. Hold if BS is less than 200.The insulin was held if BG was less than 100. Record review of Resident #2's MAR dated 07/29/25 from 5:00 p.m. through 07/30/25 indicated Novolog Injection Solution 100 UNIT/ML Inject 6 unit subcutaneously with meals. Hold if BS is less than 100.The insulin was held if BG was less than 100. Record review of Resident #2's nurse progress note dated 07/02/25 at 9:32 a.m., completed by LVN H indicated new orders from NP D Novolog 6 units with meals. Hold if BG less than 100. During an interview on 07/30/25 at 9:00 a.m. the DON said LVN H made a typo error in the Resident #2's electronic record when she was updating the physician orders and it was not noticed. She said NP D was notified on 07/29/25 and she was waiting for confirmation for the new order to hold Resident #2's insulin if her NG was less than 100. During an interview on 07/30/25 at 9:33 a.m., NP D she reviewed Resident #2's physician orders and MARs on 07/02/25. She said it was a typo error for Resident #2's Novolog to be held for BS less than 200. She said insulin was generally held if BG was lower than 100. She said she reviewed Resident #2's BG parameters for the previous months and said it should have been 100 and not 200. She said she ordered it changed to hold insulin if BG was less than 100 on 07/02/25. She said there was no negative outcome. During an interview on 07/30/25 at 1:52 p.m., LVN H said she put the new orders from NP H on 07/02/25 in the electronic for Resident #2's Novolog Injection Solution 100 UNIT/ML Inject 6 unit subcutaneously with meals. Hold if BS is less than 200. She said it was an error at 200 that was supposed to be corrected to read 100. She said it was generally good nursing judgment to hold insulin if BG was less than 100. She said she did not notice the hold if less than 200 on the orders or the MAR when she checked Resident #2's BG or when she administered the insulin. She said she always held the insulin if the BG was less than 100. Record review of the facility's policy Documentation in Medical Record dated 10/24/22 indicated Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation. Event ID: Facility ID: 455757 If continuation sheet Page 6 of 6