Health inspection·August 31, 2023

F 0697 Level of Harm - Actual harm Residents Affected - Few Observation and interview on 08/30/2023 at 10:52 AM revealed LVN A prepared wound care supplies for Resident #49's cancerous open lesion to the left side of her face. The dressing was noted to cover most of the residents left side of her face. LVN A removed the dressing after squirting NS to loosen the dressing and tugging as it was stuck to the wound on the left side of the resident's face. The dressing was pulled off and the resident grimaced, made some sounds of distress, and tried to pull her face away from the painful stimuli. Her wound was dripping blood and it dripped down her chin onto her chest. LVN A pressed the 4 X 4 gauze to the wound and the resident continued to flinch and make noises. When asked if the resident had been pre-medicated for pain LVN A stated she had not but she had Morphine available as she was on hospice. CA Alginate was then placed on the wound and a silicone dressing. In an Interview on 08/30/2023 at 11:10 AM LVN A stated Resident #49 winced and yes, she was in pain. She stated she could have consoled her, maybe she could have stopped the wound care and medicated her. She stated she does respond in an appropriate manner, and she could have asked if she was in pain. In an interview on 08/31/2023 at 10:11 AM the ADON stated pain meds should be given a ½ hour to 1 hour prior to the wound care procedures and a verbal and non-verbal assessment for pain should be conducted. He stated LVN A should have stopped the procedure to see if there were orders for pian medication. He stated, We can treat the pain. Interview on 08/31/2023 at 11:01 AM the DON stated prior to wound care Resident #49 should have been pre-medicated, or the nurse should have stopped the procedure and called the Doctor. She stated the nurse should be observant for signs of pain. She stated not pre-medicating for pain could cause the resident an increased pain level, emotional distress, and an increased stress level. Review of a facility policy and Procedure titled Pain Assessment and Management dated 2001 and revised October 2010 reflected Purpose: The purposes of this procedure are to help the staff identify pain in the resident, and to develop interventions that are consistent with the residents' goals and needs that address the underlying causes of pain. General Guidelines: 1. The pain management program is based on a facility-wide commitment to resident comfort. 2. Pain management is defined as the process of alleviating the resident's pain to a level that is acceptable to the resident and is based on his or her clinical condition and established treatment goals. 3. Pain management is a multidisciplinary process that includes the following: A. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676290 If continuation sheet Page 2 of 15 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 676290 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Spjst Rest Home 1 1810 Old Granger Road Taylor, TX 76574 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 0697 Assessing the potential for pain Level of Harm - Actual harm B. Residents Affected - Few Effectively recognizing the presence of pain C. Identifying the characteristics of pain D. Addressing the underlying causes of pain E. Developing and implementing approaches to pain management F. Identifying and using specific strategies for different levels and sources of pain; G. Monitoring for effectiveness of interventions; and H. Modifying approaches as necessary. Recognizing pain: 1. Observe the resident (during rest and movement) for physiologic and behavioral (non-verbal) signs of pain. Possible behavioral signs of pain: A. Verbal expressions such as groaning, crying, or screaming. B. Facial expressions such as grimacing, frowning, clenching of the jaw, etc; C. Changes in gait, skin color, and vital signs. D. Behavior such as resisting care, irritability, depression, decreased participation in usual activities. 2. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676290 If continuation sheet Page 3 of 15 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 676290 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Spjst Rest Home 1 1810 Old Granger Road Taylor, TX 76574 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 0697 Ask the resident is he/she is experiencing pain. Be aware that the resident may avoid the term pain and use other descriptors such a throbbing, aching, hurting, cramping, numbness, or tingling. Level of Harm - Actual harm Residents Affected - Few Review of a facility policy and procedure titled Pain - Clinical Protocol dated 2005 and revised April 2023, reflected Assessment and recognition: 1. The physician and staff will identify individuals who have pain or are at risk for having pain. 2. The nursing staff will assess each individual for pain upon admission to the facility, at the quarterly review, whenever there is a significant change in condition, and when there is onset of new pain or worsening of existing pain. 3. The staff and physician will identify the nature (characteristics such as location, intensity, frequency, pattern, etc. and severity of pain) A. Staff will assess pain using a consistent approach and a standardized pain assessment instrument appropriate to the resident's cognitive level. B. The staff will observe the resident (during rest and movement) for evidence of pain; for example, grimacing while being repositioned or having a wound dressing changed. 4. The nursing staff will identify any situations or interventions where and increase in the resident's pain may be anticipated; for example, wound care, ambulation or repositioning. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676290 If continuation sheet Page 4 of 15 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 676290 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Spjst Rest Home 1 1810 Old Granger Road Taylor, TX 76574 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 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 6 residents reviewed for pharmaceutical services. (Resident #49) The facility failed to provide Resident #49 pain medication, Morphine Concentrate Schedule Solution II; 100mg/5ml (20 mg/mL); amt 1ml oral, 15 minutes prior to wound care as ordered. This failure placed the resident at risk of increased pain, poor sleep patterns, increased anxiety and depression, and decreased sense of wellbeing. Findings included: Review of the undated face sheet for Resident #49 reflected she was an [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of Parkinson's Disease (a disorder of the central nervous system that affects movement, often including tremors) exacerbation, Vascular Dementia (brain damage caused by multiple strokes, causes memory loss in older adults), Cognitive Communication Disorder (difficulty communicating because of injury to the brain that control ability to think) and Malignant Neoplasm (cancerous growth) of unspecified site of unspecified female breast. Resident # 49 was noted to be on hospice services (a type of health care that focuses on the palliation [to reduce the intensity or severity] of a terminally ill patients' pain and symptoms) and had a DNR - Do Not Resuscitate - order on file. Review of the quarterly MDS assessment dated [DATE] for Resident #49 reflected a BIMS score of 99 as the resident was unable to complete the interview. Review of the Care Plan dated 08/16/2023 for Resident #49 reflected Problem: I am being seen by wound care for a malignant area on my left side of face. Current measurements as of 10/03/2023 5.0 X 5.0 X 1.5 cm. Goal: Wound to heal without complications, Approach: Wound care to be performed according to orders. Problem: 02/17/2023 I have impaired cognitive function r/t BIMS score less than 13 and my dx of Vascular Dementia. Approach: Ask yes/no questions in order to determine the resident's needs. Review of Physician's orders dated 09/23/2023 for Resident #49 reflected Morphine Concentrate Schedule Solution II; 100mg/5ml (20 mg/mL); amt: 1ml; oral. Special Instructions: give morphine 15 minutes prior to wound care as ordered. Review of Physician's orders dated 09/29/2023 for Resident #49 reflected Cleanse wound to check with NS [Normal Saline], Pat dry, apply calcium alg [alginate] and cover with silicone dressing every other day. Special Instructions: give morphine 15 minutes prior to wound care as ordered. Record review of the September 2023 and October 2023 MAR for Resident #49 reflected Wound care was provided to the resident on 09/29/23 by LVN A and 10/01/23 by LVN B. Record review of the September and October 2023 MAR for Resident #49 reflected blanks (no (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676290 If continuation sheet Page 5 of 15 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 676290 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Spjst Rest Home 1 1810 Old Granger Road Taylor, TX 76574 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 documentation) on the following medication on 09/29/23 and 10/01/23 Morphine Concentrate Schedule Solution II; 100mg/5ml (20 mg/mL); amt: 1ml; oral. Special Instructions: give morphine 15 minutes prior to wound care as ordered. Record review of the Resident Narcotic Count sheet for Resident#49 dated 06/05/23 for Morphine reflected there was no documentation for 09/29/23 and 10/01/23. During an interview on 10/06/23 at 11:45 AM, the DON stated Morphine was not given to Resident #49 prior to wound care on 9/29/23 and 10/01/23. She stated one of the nurses was an agency nurse and added she would call and provide an In Service to the nurse. During an interview on 10/06/23 at 1:47 PM, LVN A stated she provided wound care every other day to Resident #49. She stated Resident #49 had a specific order to receive Morphine 15 minutes prior to wound care. She stated she noticed Morphine relieved the pain of Resident #49 during wound care. She stated she provided wound care to Resident #49 on Friday 09/29/23 and added she did not remember if Resident #49 was in pain during wound care. She stated she did not remember why she did not administer the Morphine prior wound care. She stated maybe an aide wanted to bring the resident out of her room and she noticed the dressing was saturated and proceeded to perform wound care without administering the Morphine. She stated the expectation was to provide Resident #49 with morphine prior wound care. She stated if Morphine was not administered to the resident prior wound care, the resident could have discomfort during wound care. During a phone interview on 10/06/23 at 2:21 PM, LVN B stated she did not remember if she worked on 10/01/23 with Resident #49 or at the facility. She stated since she was an agency nurse she worked at several facilities. She stated that doctors' orders must be followed all the time unless the resident refuses to take the medications and they are supposed to document this. She stated if a resident did not receive the pain medication prior wound care they could be in pain during wound care. During an interview on 10/06/23 at 5:35 PM, the DON stated she expected for the staff to follow physician orders and document it on the MAR. She stated if a resident did not get pain medication prior wound care, the resident could experience excruciating pain during wound care, which could result in emotional and physical stress for the resident. During an interview on 10/06/23 at 5:44 PM, the ADM stated the expectation was for the staff to follow doctors' orders. He stated if the staff had any questions regarding the medication administration, they should call the doctor. He stated staff should document if the resident received the medication and if the resident refuses. There should be documentation since it would look as if it was not given or if the staff forgot to give the medication. He stated if a resident did not receive pain medication prior to wound care, it could be painful. And the purpose of the pain medication was to have minimum pain. Review of the in-service titled Administration of pain medication prior wound care dated 09/05/23 reflected the facility conducted an in service on the following: Wound care nurse or floor nurse will verify each resident receiving wound care has scheduled or PRN order for pain medications prior to wound care. Nurse to administer pain medication appropriately as ordered. If no orders for PRN pain medication, Nurse to obtain order if resident has verbal or nonverbal sign of pain. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676290 If continuation sheet Page 6 of 15 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 676290 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Spjst Rest Home 1 1810 Old Granger Road Taylor, TX 76574 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 Review of the facility policy titled Administering Medication revised December 2012 reflected the following: Level of Harm - Minimal harm or potential for actual harm 4. Medication must be administered in accordance with orders, including any required time frame. Residents Affected - Few 18. If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall initial and circle the MAR space provided for that drug and dose. 19. The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next ones. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676290 If continuation sheet Page 7 of 15 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 676290 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Spjst Rest Home 1 1810 Old Granger Road Taylor, TX 76574 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 - Some 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure drugs and biologicals were stored and labeled in accordance with currently accepted professional principles for 1 of 1 medication storage rooms and 1 of 1 nurse treatment carts. A) The facility failed to ensure 4 boxes containing 2 bottles each of expired glucose control solutions were removed from the medication storage room for Halls 5 and 6. B) The facility failed to ensure the wound treatment cart was locked while unattended by LVN A. C) The facility failed to ensure a container of disinfectant wipes was not left unattended on top of the nurse wound treatment cart in the memory care unit. These failures could place residents at risk of inaccurate blood glucose readings resulting in adverse health consequences, risk of injury from access to disinfectant wipes and medications. Findings included: A. Observation on [DATE] at 3:35 PM of the medication storage room for Halls 5 and 6 with the DON in attendance revealed 4 boxes containing 2 bottles each of expired glucose control solutions with the expiration date of [DATE]. In an interview on [DATE] at 3:43 PM the DON stated the expired glucometer controls could have accidentally been used and would have given a false reading when checking for a resident's blood glucose levels. She stated checking the dates on the solutions is not specifically delegated to any staff and the nurses who work 11:00 PM -7:00 AM do the controls on the glucometers. In an interview on [DATE] at 10:11 AM the ADON stated he had been employed at the facility for over 4 years. He stated if the glucose control solutions were outdated, the calibration on the machine would not be accurate and the blood glucose values could be inaccurate. He stated the floor nurse is supposed to be checking the expiration dates and the pharmacy comes through to check dates as well. He stated the pharmacy nurse may have missed them. B. Review of Resident #45's undated Face Sheet reflected she was a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of unspecified Dementia (a group of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676290 If continuation sheet Page 8 of 15 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 676290 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Spjst Rest Home 1 1810 Old Granger Road Taylor, TX 76574 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 thinking and social symptoms that interferes with daily functioning), and Pressure Ulcer (injury to skin and underlying tissue resulting from prolonged pressure on the skin) of unspecified site, unstageable. Observation on [DATE] at 10:35 AM LVN A left her treatment cart unlocked and out of her visual contact while she was in Resident #45's room performing wound care. Residents Affected - Some Review of Resident #138's undated Face Sheet reflected she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of Vascular Dementia (brain damage caused by multiple strokes, causes memory loss in older adults) with Anxiety (feeling of dread, fear and uneasiness), unspecified open wound right ankle, Covid-19 (infectious disease caused by the SARS CoV-2 virus) acute Respiratory Disease, age related physical debility (physical weakness) and abnormal weight loss. Observation on [DATE] at 10:44 AM LVN A left her treatment cart unlocked and out of her visual contact while she was in Resident #138's room performing wound care. Observation on [DATE] at 10:50 AM LVN A came out of Resident #138's room and locked her treatment cart. Review of the undated face sheet for Resident #49 reflected she was an [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of Parkinson's Disease (a disorder of the central nervous system that affects movement, often including tremors) exacerbation, Vascular Dementia (brain damage caused by multiple strokes, causes memory loss in older adults), Cognitive Communication Disorder (difficulty communicating because of injury to the brain that control ability to think) and Malignant Neoplasm (cancerous growth) of unspecified site of unspecified female breast. Observation on [DATE] at 10:52 AM LVN A sanitized her hands, unlocked her cart, obtained wound care supplies for Resident #49, left her cart unlocked and walked to the middle of the hall to get a garbage bag. She was not in visual contact of her cart. C. Review of Resident #138's undated Face Sheet reflected she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of Vascular Dementia (brain damage caused by multiple strokes, causes memory loss in older adults) with Anxiety (feeling of dread, fear, and uneasiness), unspecified open wound right ankle, Covid-19 (infectious disease caused by the SARS CoV-2 virus) acute Respiratory Disease, age related physical debility (physical weakness) and abnormal weight loss. Observation on [DATE] at 10:44 AM of a container of disinfectant wipes left on top of the nurse treatment cart while LVN A was in Resident #138's room performing wound care and out of view of the cart. Review of the undated face sheet for Resident #49 reflected she was an [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of Parkinson's Disease (a disorder of the central nervous system that affects movement, often including tremors) exacerbation, Vascular Dementia (brain damage caused by multiple strokes, causes memory loss in older adults), Cognitive Communication Disorder (difficulty communicating because of injury to the brain that control ability to think) and Malignant Neoplasm (cancerous growth) of unspecified site of unspecified female (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676290 If continuation sheet Page 9 of 15 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 676290 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Spjst Rest Home 1 1810 Old Granger Road Taylor, TX 76574 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 breast. Level of Harm - Minimal harm or potential for actual harm Observation on [DATE] at 10:52 AM of a container of disinfectant wipes left on top of the nurse treatment cart while LVN A was in Resident #49's room performing wound care and out of view of the cart. Residents Affected - Some Observation on [DATE] at 11:00 AM of disinfectant wipes left on top of the treatment cart. The product label reflected, Precautionary statements: Hazards to humans and domestic animals, Caution: Causes moderate eye irritation. Avoid contact with eyes or clothing. Wear protective eyewear. Wash thoroughly with soap and water after handling and before eating, drinking, chewing gum, using tobacco, or using the toilet. Have the product container or label with you when calling a poison control center or doctor or going for treatment. In an Interview on [DATE] at 11:10 AM LVN A stated she had worked at the facility for 3 years. She stated technically a resident could grab the disinfectant wipes, eat them, touch them, or put it in their eyes. She stated she was not supposed to leave the wipes on top of the cart or leave the cart unlocked but there weren't any residents in the hallway. In an interview on [DATE] at 10:11 AM the ADON by leaving the treatment cart unlocked, residents could access hazardous products and ingest them. He stated this was a safety concern. He stated by leaving the disinfectant wipes on the top of the cart a resident could injure themselves. Interview on [DATE] at 11:01 AM the DON stated LVN should not have left the treatment cart unlocked if she wasn't in visual contact of the cart. She stated this could affect the safety of the residents as there are medications in the cart they could potentially ingest, could be allergic to and cause harm. She stated the disinfectant wipes could cause cancer, a burning sensation to the skin, or be an irritation to the eyes. Review of a facility policy and procedure titled Storage of Medications dated 2001 and revised in [DATE] reflected, Policy Statement: The facility shall store all drugs and biologicals in a safe, secure and orderly manner. Policy Interpretation and Implementation The nursing staff shall be responsible for maintaining medication storage and preparation areas in a safe, clean, and sanitary manner. The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed. Antiseptics, disinfectants, and germicides used in any aspect of resident care must have legible, distinctive labels that identify the contents and the direction for use and shall be stored separately from regular medication. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or potentially available to others. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676290 If continuation sheet Page 10 of 15 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 676290 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Spjst Rest Home 1 1810 Old Granger Road Taylor, TX 76574 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 0880 Provide and implement an infection prevention and control program. 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 establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections and follow accepted national standards for 3 of 3 residents (Resident's #45, #138 and #49) reviewed for infection control measures. Residents Affected - Some The facility failed to ensure LVN A followed standard precautions during wound care. This failure could place residents who receive wound care at risk for the development of infections. Findings included: Review of Resident #45's undated Face Sheet reflected she was a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of unspecified Dementia (a group of thinking and social symptoms that interferes with daily functioning), and Pressure Ulcer (injury to skin and underlying tissue resulting from prolonged pressure on the skin) of unspecified site, unstageable. Review of Resident #45's Quarterly MDS assessment dated [DATE] reflected she was unable to complete a BIMS interview. Section M Skin Conditions indicated she had one or more unhealed pressure ulcers /injuries. Review of Resident #45's Care Plan dated 07/18/2023 reflected Problem - I have a pressure ulcer to my sacrum. Current measurements as of 08/22/2023: 5.8 X 2.7 X 2.2 cm. Goal: My wound will heal without complication or infection in this review period. Approach start date: 0718/2023 Wound to left buttock, cleanse with betadine daily and leave open to air daily until healed. Review of Resident #45's Physician's Orders dated 07/28/2023 reflected Santyl ointment, small amount; topical. Special instructions: Wound care: Cleanse with NS, pat dry, apply Santyl to wound bed, then calcium alginate and cover with silicone dressing once a day 07:00AM - 03:00 PM. Observation on 08/30/2023 at 10:35 AM LVN A sanitized her hands then placed waxed paper on top of her treatment cart. She placed a border dressing on the wax paper, then retrieved Calcium Alginate (used to provide a moist wound environment and can prevent bacterial contamination) and Santyl (removes dead tissue from wounds so they can start to heal) which she placed in a medication cup and stirred using a wooden spoon. She touched the treatment drawer, opened it and using her unsanitized hands grabbed a stack of 4 X 4 gauze and placed it on the wax paper. She then placed a tube of normal saline on the wax paper with some gloves using her unsanitized hands. She cleaned Resident #45's wound with gauze and NS, removed her gloves, did not wash or sanitize her hands, then applied Santyl, CA Alginate and a border dressing to the wound. Review of Resident #138's undated Face Sheet reflected she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of Vascular Dementia (brain damage caused by multiple strokes, causes memory loss in older adults) with Anxiety (feeling of dread, fear, and uneasiness), unspecified open wound right ankle, Covid-19 (infectious disease caused by the SARS CoV-2 virus) acute (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676290 If continuation sheet Page 11 of 15 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 676290 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Spjst Rest Home 1 1810 Old Granger Road Taylor, TX 76574 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 0880 Respiratory Disease, age related physical debility (physical weakness) and abnormal weight loss. Level of Harm - Minimal harm or potential for actual harm Review of Resident #138's Quarterly MDS assessment dated [DATE] reflected a BIMS score of 3 indicating severe cognitive status. Section M Skin Conditions indicated she had one or more unhealed pressure ulcers /injuries. Residents Affected - Some Review of Resident 138's Care Plan dated 08/23/2023 reflected Problem - I have a pressure ulcer on my Right Lateral Malleolus (outer part of ankle) Goal: Wound to heal without complications. Approach: Wound care to be performed as ordered. Review of Resident #138's physician's orders dated 07/28/2023 reflected Rt lateral malleolus: Cleanse with NS, pat dry, apply Anasept, mixed with collagen and cover with foam border dressing once a day on Mon, Tues, Wed, Thu, Fri 07:00 AM - 03:00 PM. Observation on 08/30/2023 at 10:44 AM LVN A placed waxed paper on top of her treatment cart and opened the drawers and placed a silicon dressing on the wax paper. She retrieved antimicrobial gel and placed it in a medication cup. She opened drawers to obtain collagen sprinkles which she mixed into the gel using a wooden spoon, then she touched a stack of 4 X 4 gauze with unsanitized hands, placed them on the wax paper, and placed several gloves under the 4 X 4 gauze on the wax paper. She sat on the floor in front of Resident #138, removed the soiled dressing from her right ankle with gloved hands and placed the soiled bandages on the bare floor. LVN A did not wash her hands or change gloves and used 4 X 4 gauze with NS to clean the wound, placed the antimicrobial gel on the wound and covered it with silicone dressing. Review of the undated Face Sheet for Resident #49 reflected she was an [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of Parkinson's Disease (a disorder of the central nervous system that affects movement, often including tremors) exacerbation, Vascular Dementia (brain damage caused by multiple strokes, causes memory loss in older adults), Cognitive Communication Disorder (difficulty communicating because of injury to the brain that control ability to think) and Malignant Neoplasm (cancerous growth) of unspecified site of unspecified female breast. Review of the quarterly MDS dated [DATE] for Resident #49 reflected a BIMS score of 99 as the resident was unable to complete the interview. The MDS did not note any wounds. Review of the Care Plan dated 08/16/2023 for Resident #49 reflected Problem: I am being seen by wound care for a malignant area on my left side of face. Current measurements as of 08/22/2023 5.0 X 3.0 X 1.5 cm. Goal: Wound to heal without complications, Approach: Wound care to be performed according to orders. Observation on 08/30/2023 at 10:52 AM LVN A sanitized her hands, unlocked her cart, obtained wound care supplies for Resident #49, placed wax paper on top of her cart, touched drawers and grabbed a silicone dressing, CA Alginate, NS. She did not sanitize her hands and touched a stack of 4 X 4 gauze which she placed on the wax paper along with several gloves. She left her cart to walk down the hall to retrieve a plastic garbage bag. She entered the Resident's room, placed the bag in the garbage can, did not wash her hands and donned gloves. She removed the dressing from the left side of the resident's face after squirting NS to loosen the dressing. CA Alginate was placed on the wound and a silicone dressing. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676290 If continuation sheet Page 12 of 15 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 676290 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Spjst Rest Home 1 1810 Old Granger Road Taylor, TX 76574 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 0880 Level of Harm - Minimal harm or potential for actual harm In an interview on 08/30/2023 at 11:20 AM the DON stated LVN A had not attended a wound care class. She stated she or the ADON would have done rounds with nurses to assess their wound care skills. She stated a clean wound care protocol should be followed during wound care. She stated by placing soiled dressings on the floor that could lead to bacteria contamination being transferred to the floor. She stated it was an infection control issue. Residents Affected - Some Review of a Clean Dressing Application annual skill assessment dated [DATE] for LVN A reflected she had been observed completing wound care by the DON and her level of skill was intermediate. In an interview on 08/31/2023 at 10:11 AM the ADON stated LVN A should have washed her hands prior to donning gloves. He stated by not following hand hygiene and a clean-to-clean procedure, it could cause an infection of a residents wound. He stated the nurse placing dirty bandages on the floor could transfer bacteria to the floor. He stated a resident could roll their wheelchair over it and spread bacteria through the facility and cause cross contamination. Interview on 08/31/2023 at 11:01 AM the DON stated the treatment cart should be cleaned prior to using with disinfectant wipes, the nurse should review the orders, unlock the cart, open the drawers that have needed supplies, clean hands with sanitizer, glove or have clean hands to obtain supplies and put on a clean surface. She stated the nurse should clean hands in between opening drawers and not open sterile items. The nurse should clean a tray table or use disposable under pads and then place the wax paper with supplies on the clean surface. She stated soiled dressings should be placed in a trash receptacle and not on the floor. She stated if soiled dressings are set on the floor, they could be spreading pathogens (bacteria) around and the floor should have been cleaned. She stated by not following the proper clean-to-clean wound care procedures that could cause a resident's wound to get worse, not heal, or get infected. Review of a facility policy and procedure titled Dressings, Dry/Clean and dated 2001 and revised in February 2014 reflected, The purpose of this procedure is to provide guidelines for the application of dry, clean dressings. Steps in the Procedure: 1. Clean bedside table. Establish a clean field. 2. Place the clean equipment on the clean field. Arrange the supplies so they can be easily reached. 3. Tape a biohazard or plastic bag on the bedside stand or use a waste basket below clean field. 4. Position resident and adjust clothing to provide access to affected areas. 5. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676290 If continuation sheet Page 13 of 15 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 676290 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Spjst Rest Home 1 1810 Old Granger Road Taylor, TX 76574 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 0880 Wash and dry your hands thoroughly. Level of Harm - Minimal harm or potential for actual harm 6. Put on clean gloves. Loosen tape and remove soiled dressing. Residents Affected - Some 7. Pull glove over dressing and discard into biohazard or plastic bag. 8. Wash and dry your hands thoroughly. 9. Open dry, clean dressings by pulling corners of the exterior wrapping outward, touching only the exterior surface. 10. Label tape or dressing with date, time, and initials. Place on clean field. 11. Using clean technique open other products (i.e., prescribed dressing, dry clean gauze). 12. Wash and dry your hands thoroughly. 13. Put on clean gloves. 14. Assess the wound and surrounding skin for edema, redness, drainage, tissue healing and wound stage. 15. Cleanse the wound with ordered cleanser. If using gauze, use clean gauze for each cleansing stroke. Clean from the least contaminated area to the most contaminated area (usually, from the center outward) 16. Use dry gauze to pat the wound dry. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676290 If continuation sheet Page 14 of 15 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 676290 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Spjst Rest Home 1 1810 Old Granger Road Taylor, TX 76574 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 0880 17. Level of Harm - Minimal harm or potential for actual harm Apply the ordered dressing and secure with tape or bordered dressing per order. Label and date and initial to top of dressing. Residents Affected - Some 18. Discard disposable items into the designated container. Wash and dry your hands thoroughly. 19. Remove disposable gloves and discard into designated container. Wash and dry your hands thoroughly. Review of a facility policy and procedure titled Dressings, Soiled/Contaminated dated 2001 and revised in April 2019 reflected, All soiled /contaminated dressings must be handled in a safe and sanitary manner and must be incinerated or disposed of following decontamination or containment. Policy Interpretation and implementation 1. Disposable items such as bandages, applicators, gauze pads, etc. that are soiled or contaminated with infective material, blood or body fluids must be placed in a plastic bag and removed from the residents room upon completion of any procedure. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676290 If continuation sheet Page 15 of 15