Inspection·September 15, 2023

F 0689 Level of Harm - Immediate jeopardy to resident health or safety perceptions, and fears; consult with pastoral care, social services, or psych services; and when conflict arises, remove to a calm safe environment, and allow to vent/share feelings. Record review of a progress note dated 9/4/2023, from NP D from psychiatric services, indicated the resident was negative for suicidal ideations. Resident #1 was being seen 2-3 times a month by psych services for major depression disorder, insomnia, and medication monitoring. Residents Affected - Few Record review of a progress note for Resident #1, dated 9/10/2023 at 10:10 p.m., LVN A indicated Resident #1 was sitting up in her wheelchair in her room. Resident #1 refused medications at 8:30 p.m. and was yelling at staff to leave her alone, she just wanted to die. LVN A tried to redirect the resident, but the resident continued to yell get out, just leave me alone. LVN A left Resident #1 alone in her room and when she came back to the room, the resident was not yelling. LVN A found Resident #1 with shoestrings tied around her neck. LVN A cut the shoestring off and asked the resident if she did that to kill herself and Resident #1 screamed out I sure did! Resident #1 was placed on 24-hour 1-on-1 monitoring, and the MD, RP, and DON were notified. A call was placed for EMS to transport the resident to the local hospital for evaluation and treatment. When EMS arrived, Resident #1 continued yelling, was aggressive and refused to cooperate with staff and EMS. EMS administered Haldol (antipsychotic medication) intramuscularly, but the medication was ineffective. While EMS transferred Resident #1 from her wheelchair to the stretcher, the resident was alert and yelling and hitting EMS as they exited the facility. The RP was notified. During a telephone interview on 9/13/2023 at 5:05 p.m., LVN A said she was the nurse on duty for Resident #1 the evening of 9/10/2023, the date the incident occurred. She said around 8:45 p.m. - 9:00 p.m. she checked Resident #1's fingerstick blood sugar level, but the resident became aggressive when she returned to give her the scheduled 9 p.m. medications. She said the resident started hollering, screaming, and cussing at her telling her to get the hell out, don't want to live/want to die. She said CNA B was in the room behind the privacy curtain providing care for Resident #1's roommate. LVN A said she left the room to get CNA C who could calm Resident #1 down and get her to take medications and/or allow staff to provide care. LVN A said as she was leaving the room, she told CNA B to keep an eye on Resident #1. LVN A said she returned to Resident #1's room with CNA C around 9:15 p.m. and found the resident had 2 shoestrings tied together around her neck tightly. She said the resident was combative (slapping the nurse's hands back), but she was able to release tension of the shoestrings from around the resident's neck. LVN A said she directed for CNA C to get scissors to cut the string. She said when CNA C returned to the room with the scissors from the nurses' station, she cut the shoestrings and removed them from the resident's neck. She said after cutting the string, there were red marks to the left side of Resident #1's neck. LVN A said she asked the resident if she did that to kill herself and the resident screamed out I sure did! She said Resident #1's MD, the DON, administrator, and RP were notified. She said Resident #1 was placed on 24-hour 1-on-1 monitoring at 9:30 p.m. until the ambulance arrived at 9:45 p.m. to transport her to the hospital for evaluation. She said when EMS arrived, the resident was combative and hollering out. LVN A said EMS administered Haldol to Resident #1, but it was ineffective as she continued yelling and hitting the EMS staff as they exited the facility. LVN A said she did not recall this resident ever being this aggressive and combative. LVN A said the resident had a history of episodes of hollering and fighting staff at times with episodes of crying saying she wanted to die. LVN A said when she was upset or had those behaviors, she usually would be calmed down by certain staff. During a telephone interview on 9/13/2023 at 5:27 p.m., CNA B said around 9 p.m. (on 09/10/23), she was in Resident #1's room providing care to the resident's roommate. She said she heard when Resident #1 was refusing her medications, yelling at the nurse to get the hell out, and saying she wanted (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676008 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 676008 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Silsbee Oaks Health Care LLP 920 E Ave L Silsbee, TX 77656 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few to die. CNA B said LVN A told her to keep an eye on Resident #1 as she (the nurse) left the room for assistance. CNA B said she did not stay in the room with Resident #1 once she finished providing care to the roommate, she left the room. She said LVN A did not direct her to provide 1:1 care to Resident #1, and she was not assigned to provide care for Resident #1. CNA B said you could hear Resident #1 hollering and screaming from the hallway. During a telephone interview on 9/13/2023 at 5:35 p.m., CNA C said on 09/10/2023, she was assigned to care for Resident #1 and when she provided care for the resident around 7:30 p.m., the resident was not as talkative as usual but did not make any statements about wanting to die. CNA C said LVN A went to her and asked her to go to Resident #1's room to help calm her down so she would take her nighttime medications and get ready for bed. CNA C said her and LVN A walked into the resident's room around 9:15 p.m. She said LVN A asked the resident, What is that around your neck? She said when LVN A reached for the shoestrings around the resident's neck, she slapped at LVN A's hands. CNA C said LVN A told her to go get scissors from the nurses' station. She said when she returned to the resident's room with the scissors, LVN A was trying to release tension on the shoestrings. She said LVN A cut the shoestrings from around the resident's neck and asked the resident, Did you do that to kill yourself? CNA C said Resident #1 screamed out, I sure did! She said Resident #1 was placed on 1-on-1 supervision at that time. CNA C said it was a very scary incident and said she would never thought Resident #1 would have done anything like that. CNA C did not recall seeing any other staff in the room prior to them entering. Record review of Resident #1's hospital records, dated 9/11/2023, indicated she was transferred from the facility to the acute care hospital and later seen by the associated behavioral unit. During a telephone interview on 9/14/2023 at 12:19 p.m., NP D said he was a psych service NP and visited with Resident #1 two to three times a month for a year or more. He said he was seeing the resident for delusions, depression/sadness, sleep disturbances, and for management of psychotropic medications and side effects, and to monitor the effects of medications and for dose adjustments. He said he was surprised to hear the resident made suicidal ideations or expressed any desire or plan to commit suicide because she denied risk of self-harm during visits. NP D said Resident #1 could be moody at times and depending on her mood, she might not speak with anyone or allow anyone to assess her. NP D said the facility notified him of Resident #1's suicide attempt and her being sent out for evaluation. He said he would visit with her when she returned to the facility. NP D denied knowledge of the resident having occasional episodes of crying and hollering out and saying she wanted to die. Record review of progress note on 9/14/2023 at 12:30 p.m. indicated Resident #1 returned to facility on 9/13/2023 at 11:00 pm. During an observation and interview on 9/14/2023 at 1:30 p.m., Resident #1 was sitting up in her wheelchair in her room. She had slurred speech but was able to answer questions and made her needs known. Resident #1 answered questions, but when asked about the 09/10/2023 suicide attempt incident, she would not respond. Resident #1's room was clean, and no hazardous materials were noted (shoes with no shoestrings or elastic shoes with strings sewn in, no sharp objects). During an interview on 9/14/2023 at 3:00 p.m., the DON said Resident #1 had been a resident at the facility for several years and had a history of making statements about wanting to die when she was mad. The DON said she was aware of Resident #1 making the statements of wanting to die at times. She said the resident would do this at times when her family would leave after visiting or it seemed to happen when she was mad or seeking attention. The DON said the facility care planned those (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676008 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 676008 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Silsbee Oaks Health Care LLP 920 E Ave L Silsbee, TX 77656 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few behaviors with interventions to include staff talking with her and see why she was upset or mad. She said usually the staff could resolve the issue and Resident #1's behavior. She said prior to Resident #1's suicide attempt, if a resident made a suicide threat or expressed they wanted to die, the expectations of staff's response to the resident depended on who the resident was and if this was a previously identified behavior. The DON said (on 09/11/2023) after Resident #1's suicide attempt, the facility implemented a new suicidal prevention policy to include if any resident expressed or voiced thoughts of suicide/wanting to die, the resident would not be left alone and 1-on-1 care would be provided until arrangements could be made for the resident to receive emergency psychiatric care or until the resident's physician determined when the resident was no longer a suicide risk. She said all staff prior to working their next shift were in-serviced on the new suicidal precautions and expectations. She said Resident #1's care plan was updated to include interventions of: provide counseling with psych services, keep family involved, provide one to one care if a resident expressed wanting to die and consult psych services, psych would continue to follow the resident and treat her for depression. She said when Resident #1 returned the facility on 09/13/23, the facility implemented every 15-minute observations for 72 hours following recent behavioral hospital stay for suicide attempt, provide calming atmosphere, engage resident in activities, provide care, and alert MD of any negative changes. The DON said her expectations were all residents with suicidal ideations were not to be left alone, and staff to monitor 1:1 until the resident was sent out for evaluation or when the resident received a psych emergency evaluation. The DON said no other residents in the facility have been identified as a suicide risk. Record review of an undated care plan dated indicated Resident #1 was placed on every 15 minute frequent monitoring by staff observations related to a recent behavioral hospital stay for a suicide atempt for the next 72 hours with a target date of 09/17/23. Record review of an undated care plan indicated Resident #1 had a psychosocial well-being problems, often making statements of wanting to die. The resident was sent out to the emergency room on [DATE] for an attempted suicide and returned to the facility on [DATE]. The interventions included: counseling would be provided with psych services, provide 1:1 care when resident was having episodes of stating she wanted to die and consult psych services, and psych would continue to follow residents and treat for depression. The target date was 11/05/23. Record review of the facility policy, implemented date of 9/11/2023, titled Suicide Prevention Policy: it is the policy of the facility to act quickly and appropriately if a resident expresses thoughts of suicide. Definitions: 'Suicide' is defined as a death from injury, poisoning or suffocation where there is evidence that the death was self-inflicted. 'Suicidal Ideation' is defined as self-reported thoughts about engaging in suicide-related behaviors .1. All staff members will immediately report any suicidal ideation to the resident's charge nurse and facility social worker .2. Immediately notify the resident's physician if the resident presents with suicidal ideation even if he or she isn't specific about a plan or intent .3. If applicable, notify the resident's responsible party of the resident's suicidal ideations and any orders received from the residence physician .4. The resident will not be left alone. One-on-one care will be provided until arrangements can be made for the resident to receive emergency psychiatric care, or until the residence physician determines that the risk of suicide is no longer present .5. Objectively and thoroughly document the resident's mood and behaviors, as well as all actions taken, in the medical record .6. If the resident requires inpatient psychiatric service state specific guidelines and requirements will be followed. Record review of in-service sign in sheet for new policy on Suicidal Prevention, dated 9/11/2023, indicated 69 staff members signed the in-service record which included LVN A, CNA B, and CNA C. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676008 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 676008 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Silsbee Oaks Health Care LLP 920 E Ave L Silsbee, TX 77656 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few During interviews on 9/13/2023 from 1:30 p.m. - 9/14/2023 4:30 p.m., 6 LVNs (2 from each shift- LVN A, LVN L, LVN I, LVN K, LVN G, LVN N), were able to identify suicidal expressions, all were knowledgeable of the new suicide policy implemented 09/11/2023, all were aware of the new expectations to not leave any resident who alone if suicidal expressions/ideations occurred, and said residents would need 1:1 care at that time, and to notify the DON/ADON and the Administrator immediately. During interviews on 9/13/2023 from 1:30 p.m. - 9/14/2023 4:30 p.m., 6 CNAs (2 from each shift- CNA B, CNA C, CNA M, CNA H, CNA E, CNA O, CNA P) were able to identify suicidal expressions, all were knowledgeable of the new suicide policy implemented 09/11/2023, all were aware of the new expectations to not leave any resident alone if suicidal expressions/ideations occurred, and said residents would need 1:1 care at that time, and to notify the charge nurse/DON/ADON and the Administrator immediately. During interviews on 9/13/2023 from 1:30 p.m. - 9/14/2023 4:30 p.m., 2 MAs (one from each shift- MA F and MA J) were able to identify suicidal expressions, both were knowledgeable of the new suicide policy implemented 09/11/2023, both were aware of the new expectations to not leave any resident who alone if suicidal expressions/ideations occurred, and said residents would need 1:1 care at that time, and to notify the charge nurse/DON/ADON and the Administrator immediately. Record review of in-service sign in sheet for new policy on Suicidal Prevention, dated 9/11/2023, indicated 69 staff members signed the in-service record which included LVN A, CNA B, and CNA C. Record review of a QAPI Committee Report, dated 9/11/2023 & 9/15/2023, indicated there was a meeting held on 9/11/2023and 9/15/2023 at 8:00 a.m. consisting of the Administrator, the assistant Administrator, the DON, the ADON, the AD, the wound care nurse, the MDS nurse, the social worker, the wound care nurse, the psych services NP, and the MD. The following interventions were put in place: New Policy: Suicide prevention In-service: Suicide Prevention Care planning for suicidal ideations and attempts The non-compliance was identified as past non-compliance (PNC). The Immediate Jeopardy began on 9/10/2023 and ended on 9/11/2023. The facility had corrected the noncompliance before the survey began. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676008 If continuation sheet Page 5 of 5