Health inspection·February 29, 2024

F 0689 be at risk for falling related to increased weakness. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #1's Nurses Note dated 02/11/2024 at 1:19 PM, reflected Resident #1 required two-person assist with transfers. Signed by LVN T Residents Affected - Few Record review of Resident #1's Nurses Note dated 02/13/2024 at 10:12 PM, reflected Resident #1 was being transferred from a wheelchair to the bed by CNA. Resident #1's legs became weak, and CNA assisted Resident #1 to the floor. No injuries noted. A Sara lift was used to transfer Resident #1 from the floor to the bed. Resident #1 stated her knee was twisted and was sore for a few minutes but was no longer in pain since she was lying in bed. Signed by LVN A ( LVN A stated the CNA was CNA C) Record review of Resident #1's Nurses Notes dated 02/14/2024 at 12:08 PM, reflected a CNA C entered Resident #1's room when Resident #1 began to complain about severe pain (yelling) when the CNA attempted to roll the resident to assist her out of bed. LVN B palpated her left leg and Resident #1 yelled out in pain. Resident #1 appeared visibly abnormal. There was a divot above the knee and swelling to the knee. LVN B called the Nurse Practitioner and received an order for an x-ray. LVN B called the mobile x-ray company and ordered an x-ray. Signed by LVN B Record review of Resident #1's Nurses Notes dated 02/15/2024 at 7:51 PM, reflected Resident #1 requested to remain in bed during this shift (3 PM - 11:00 PM) related to complaint of pain in her left knee. Resident # 1 had an x-ray of her left knee. The x-ray was negative (no injuries were found on the x-ray). Resident #1 had edema (swelling related to excessive fluid) noted to the knee. She had an ice pack order BID (twice a day). Medications taken as ordered without issue, resting quietly in bed watching television at this time, call light in reach, ice pack in place at this time, no needs voiced. Signed by LVN U Record review of Resident #1's Physician Orders dated 02/29/204, reflected Resident #1 was ordered Gabapentin (helps manage the effects of severe knee pain) capsule 400 mg one tablet at 7:30 AM and Gabapentin 400 mg one tablet once a morning at 9:30 AM. Resident #1 also had an order for extra strength Tylenol tablet (help treat mild to moderate pain such as arthritic pain) 500 mg two tablets twice a day between meals 9:30 AM and 7:30 PM. Ice pack to left knee BID (twice a day) 11:30 AM and 7:30 PM. Record review of Resident #1's MAR on 02/28/2024, dated 02/01/2024 thru 02/29/2024, reflected Resident #1 received her pain medication as scheduled, and ice pack as scheduled. Record review of Resident #1's non-emergency communication form on 02/28/2024, dated 02/13/2024 at 9:36 PM, Resident #1's Physician was contacted of the incident with Resident #1. LVN A reported to the Physician, Resident #1 was assisted to the floor. Resident #1's Physician response was noted. Record review of Resident #1's X-Ray report dated 02/15/2024 reflected multiple views of the left knee show a knee arthroplasty (surgical reconstruction or replacement of a joint), in normal alignment without acute fractures or dislocation. Diffuse osteopenia (low bone density- compactness of a substance- is present). The x-ray also reflected the following: 1. There were not joint bodies. 2. There were no knee region soft tissue swelling. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676290 If continuation sheet Page 2 of 14 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 02/29/2024 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 0689 3. There were no joint effusion (excessive accumulation of fluid in the knee joint). Level of Harm - Minimal harm or potential for actual harm 4. There were no radiopaque foreign bodies (any object that enters the body and is visible on an x-ray). Impression: No acute fracture or dislocation of the left knee. Residents Affected - Few Record review of CNA C's written statement of the incident on 02/13/2024 with a transfer of Resident #1, dated 02/14/2024, reflected CNA C was preparing Resident #1 for a shower. Resident #1 was sitting in her wheelchair when CNA C positioned the wheelchair outside of the bathroom door. CNA C documented she had the stand-up lift in front of the bathroom door and the shower chair was turned right at the edge of the shower. CNA C strapped Resident #1 with the lift pads around her. She lifted CNA C from the wheelchair and was moving Resident #1 inside the bathroom. Resident #1 began stating she thought she was going down. CNA C moved around to Resident #1's backside and grabbed the remote and lowered Resident #1 to the floor. CNA C was behind Resident #1's shoulders and neck to prevent Resident #1 from hitting her head. Resident #1 stated her left leg needed to be straightened due to her knee was stuck. CNA C gathered a pillow and placed it behind her head. CNA C exited the room and went to find a nurse. CNA C did not see a nurse and walked to another hall and asked CNA D to assist her with Resident #1. CNA D asked Resident #1 if she was hurt anywhere and Resident #1 stated no, she needed her knee straightened. CNA C and CNA D straightened Resident #1's legs out across the lift and CNA C and CNA D were on both sides of the lift pad located around Resident #1. CNA C and CNA D lifted her into Resident #1's wheelchair. CNA C and CNA D transferred Resident #1 to her bed. (doesn't state how they transferred Resident #1). Resident #1 agreed to a bed bath and before CNA C began the bed bath, she exited the room, and asked LVN A to come to Resident #1's room. CNA C and CNA D explained to LVN A what occurred with Resident #1. CNA C also explained to LVN A that Resident #1 requested Tylenol. can C stated Resident #1 had explained she had a rough session with therapy that day. Resident #1 later refused a bed bath and wanted a shower. CNA C used the stand-up lift on Resident #1 to give her a shower after the incident. CNA C stated this was not the first time she had used the stand up lift on Resident #1. Record review of CNA D's written statement of the incident on 02/13/2024 with transfer of Resident #1. CNA D was asked by staff (CNA C) who was assigned to unit 1 (100 hall) if CNA D would help her with Resident #1. CNA D entered Resident #1's room and Resident #1 was on the floor. CNA D saw a mechanical lift and CNA D and CNA C attempted to use the lift to assist Resident #1 from the floor onto Resident #1's wheelchair. Resident #1 began to complain about her knee hurting and CNA C and CNA D lowered Resident #1 to the floor and removed the lift. Resident #1 continued to complain and stated get me up. CNA D placed the lift belt around Resident #1. CNA C and CNA D used the lift to assist Resident #1 in her wheelchair and later into her bed. CNA C and CNA D exited the room to find the nurse. CNA D did not witness anything prior to CNA D entering Resident #1's room. Record review of the Facility's In-service Record reflected on 01/05/2024 CNAs and Nurses were in-serviced on the Hoyer Lift Demonstration. (There was no attendance record attached with the in-service). Record review of Facility's In-service related to sling demonstration (green with Hoyer lift on 02/16/2024, reflected CNA E gave a demonstration on use of a green sling. Cross under the legs. How to transfer from W/C. Employee demonstration. In-service attendance: CNA E, CNA F, and CNA G. Staff encouraged to educate other CNAs. There was not a signature of the person completing the in-service training report. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676290 If continuation sheet Page 3 of 14 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 02/29/2024 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 0689 Record review of the Facility's In-service related to How to safely transfer residents dated 02/16/2024, reflected Nursing, CNAs, and CMAs were in- serviced on the following: Level of Harm - Minimal harm or potential for actual harm 1. What is a patent transfer device? Residents Affected - Few 2. Consider the level of assistance required. 3. Assisted Transfer. 4. Dependent Transfer 5. Best transfer aides for extra assistance: a. sit to stand lift, b. Sara Steady patient transfer aide, c. heavy-duty floor patient lift, ceiling lift, 6. Best transfer aids for beds: a. transfer sheet b. bed rail c. pole, grab bar, and assist handle. d. bed ladder 7. Best transfer aides for the bathroom a. bathroom grab bar. b. bathtubs grab bar. c. bathtub transfer bench. Observation on 02/28/2024 at 10:07 AM CNA H transferred Resident #2 with sliding board from bed to wheelchair. CNA H explained the transfer procedure with Resident #2 prior to transfer. Did not observe any concerns with transfer using sliding board. Observation on 02/28/2024 at 1:10 PM CNA I and Hospitality Aide J transferred Resident #3 from the bed to an electric wheelchair with the Hoyer lift. CNA I explained the transfer process to Resident #3 prior to transferring her with the Hoyer lift. The Hospitality aide stood behind the lift and maneuvered the electronic device to assist resident up from the bed and down onto her electric wheelchair. She widened the legs of the Hoyer lift and did not touch the resident. CNA I did the portion of the transfer where she attached the strap to the Hoyer lift and touched the resident and assisted the resident. Did not observe any concerns with the transfer or Resident #3. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676290 If continuation sheet Page 4 of 14 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 02/29/2024 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 0689 Observation on 02/28/2024 at 2:15 PM sign in Resident #1's room reflected Assist x 2. Level of Harm - Minimal harm or potential for actual harm Observation on 02/28/2024 at 3:30 PM CNA H and CNA K transferred Resident #3 with sit to stand/ Sara lift from wheelchair to her bed. CNA H explained the transfer process prior to the transfer with Resident #3. Did not observe any issues with the transfer. Residents Affected - Few Observation on 02/28/2024 at 4:45 PM CNA L transferred Resident # 4 from his wheelchair to bed using a gait belt. CNA L explained the transfer using the gait belt to Resident #4 prior to the transfer. There were no concerns with the gait belt transfer. Observation on 02/28/2024 at 5:00 PM CNA M used stand by assistance when Resident #5 was being transferred from his wheelchair to bed. CNA M explained to Resident #5 how she was going to stand by him and ensure he would not fall when transferring from his wheelchair to his bed. Resident #5 stated ok. Did not observe any concerns with the transfer. In an interview on 02/28/2024 at 10:15 AM CNA N stated Resident # 1 was a two-person transfer. She stated there was a sign in Resident #1's room reflecting Resident #1 required two staff members to transfer her. CNA N stated the sign had been in her room approximately the first week of January 2024 or the end of December 2023. She stated when she was assigned to Resident #1 there were always two people that transferred her with the sit to stand lift. She stated if one person transferred Resident #1 this was an improper transfer. CNA N stated this had been changed in the past few weeks to the Hoyer Lift since the incident in February 2024. She stated all mechanical lifts including the sit to stand lift required two people to lift the residents. CNA N stated she had been in-serviced on the Hoyer lift, sit to stand lift, and she thought the Sara lift was the same thing as the sit to stand lift beginning the year of 2023. She stated the administration staff usually had an in-service on how to use all lifts once a year and it was usually January, February, or March of every year. She stated they had not had the in-service where the therapy department demonstrated how to use lifts in 2024. She also stated she used the electronic medical records to determine how a resident required to be transferred. CNA N stated the nurses sometimes would give report at beginning of shift, but this did not occur very often. In an interview on 02/28/2024 at 12:05 PM the Director of Nurses stated the lifting machine, using a portable policy was the facilities policy for all the mechanical lifts including: [NAME]/sit to stand lift and the Hoyer lift. She stated the [NAME]/sit to stand lift was the same mechanical lift. The Director of Nurses stated this lift had two different names. She also stated when using any type of lift it was expected that two staff assist to transfer residents using any type of lift. If one staff transferred Resident #1 this would not be a correct transfer. In an interview on 02/28/2024 at 12:55 PM LVN B stated she was the nurse supervisor on the 100 hall, the same hall where Resident #1 resided. She stated Resident #1 has been a 2 person assist at least six months. She stated there was a sign in Resident #1's room stating she required 2 staff to assist her with transfers. LVN B stated all residents had signs in their rooms stating how many staff were required to transfer each resident. LVN B stated the signs were placed in the residents' room at the end of December 2023 or first of January 2024. She also stated if any of the staff used a different way to transfer a resident than what was in their room it would not be a proper transfer for that resident including Resident #1. She stated Resident #1 preferred the sit to stand lift instead of the Hoyer lift. She stated since the incident in February 2024 with the lift, Resident #1 had agreed to use the Hoyer lift instead of the [NAME]/ sit to stand lift. She stated all mechanical lifts required two people to use them including the [NAME]/sit to stand lift. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676290 If continuation sheet Page 5 of 14 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 02/29/2024 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few In an interview on 02/28/2024 at 1:30 PM CNA I stated she had given care to Resident #1. She stated Resident #1 was a two person assist and had always been a two person assist (approximately 6 months or more). She stated there was a sign in Resident #1's room stating she was a two person assist. CNA I stated there were signs in all the residents' rooms explaining what type of transfer the resident required, one person or two people to assist, during transfers. She stated the signs were placed in residents' rooms approximately the first week of January 2024. She stated the staff also reviewed the residents' records in the electronic medical record of all the care each resident needed including transfers. CNA I stated Resident #1 was transferred with the sit to stand lift until recently and she is now a Hoyer lift transfer. CNA I stated she knew Resident #1 was a two person assist. She stated she always had someone with her when she transferred Resident #1 with the sit to stand/Sara lift but she always thought sit to stand/Sara lift only required one person to transfer and the Hoyer lift required two people. In an interview on 02/28/2024 at 1:40 PM Hospitality Aide J stated she had assisted with transferring Resident #1 with two different types of lifts. She stated one was the Hoyer lift and she did not know the name of the other lift. She stated she did not touch the resident during transfers. She would use the knob on the lift to move the resident up or down. She stated Resident #1 had a sign in her room stating she was a two person assist. She stated she had been a hospitality aide since August 2023. She stated she had been assisting since August 2023 with transfers of Resident #1 several times per month. Hospitality Aide J stated Resident #2 always was a two person assist when transferring her from bed to chair, chair to bed, or chair to shower chair. She stated the Hoyer lift was the only lift required for a two person assist with transfers. In an interview on 02/28/2024 at 2:15 PM Resident #1 stated sometimes only one staff assisted me when they were moving me from one bed to chair or moving me anywhere with the lift they used. She stated there were times two staff assisted her during transfers. Resident #1 stated the sign in her room that says two people transfer had been there since the first of January 2024. She stated it was on the wall when the staff transfer her by herself and had the accident in February of this year (2024). Resident #1 stated she preferred a certain type of lift, and this was the lift they used when transferring her in February, the day before Valentine's Day. She stated she asked the staff why she was the only staff transferring her and the staff explained to her, one person could transfer her with this type of lift. Resident #1 stated she did not question the staff any further about the transfer. Resident #1 stated she was being transferred from her wheelchair to the shower chair in her room. She stated when she was lifted in the air her feet were touching the floor, she felt like the back of the lift was going to tip over, and she thought she was falling. Resident #1 stated this was when she began to yell at the staff to get her down, she was falling, and her knee was hurting. She stated the staff got her on the floor and her left knee and leg was bent in an awkward position and it was not straight. Resident #1 stated the staff left the room to get some help to lift her off the floor. She stated a young man that worked at the facility came in the room and both staff lifted her off the floor and into the wheelchair. She stated the young man used the lift to move her from the wheelchair to the bed. She stated later the nurse came in, was asking her questions about her pain, and looked at her body for any bruises or if she was hurt anywhere. Resident #1 also stated she used the other lift and it was a lot better. She stated she did not realize the difference in the lifts they used to transfer. She stated she did not know why the girl (staff CNA) did not have someone with her when she transferred her the night of the incident in February of this year (2024). She stated the staff was having difficulty using the lift and she asked the staff to get someone to help her. She stated she was in pain for a short time the day of the transfer. In an interview on 02/28/2024 at 3:15 PM (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676290 If continuation sheet Page 6 of 14 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 02/29/2024 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few LVN A stated CNA C and CNA D asked her to assess Resident #1. She stated she entered Resident #1's room and she was in bed complaining of her left knee hurting. LVN A stated she noticed some swelling to the left knee. She stated she did a partial head to toe assessment on Resident #1. She was mostly looking at her lower extremities due to this was where Resident #1 complained pain was located. She stated she did not see any mechanical lift in Resident #1's room. She stated CNA C explained Resident #1 felt she was falling during transfer and CNA C lowered her to the floor. LVN A stated after Resident #1 was in bed for a few minutes she no longer complained of pain. She stated she did give the resident her regular pain medication. She stated she did not complete a pain assessment or a head-to-toe assessment on Resident #1. In an interview on 02/28/2024 at 3:35 PM CNA K stated she had assisted with transferring Resident #1. She stated Resident #1 did use the sit to stand/Sara lift transfer prior to mid-February after the incident. She stated Resident #1 has been a two person assist for several months. CNA K also stated signs were in every resident's room that indicated if a Resident was a one person or two person assist. She stated the signs have been in the residents' room since the end of December 2023 or first week of January of 2024. CNA K also stated Resident #1's sign in her room showed Resident #1 was required 2 person assist with transfers. She stated if you needed to know more information about each resident ADL care the CNAs referred to the electronic medical records. In an interview on 02/28/2024 at 3:46 PM CNA F stated he did not know until 02/28/2024 that the Sara lift/sit to stand lift required two person assist. He stated the Hoyer lift required two person to assist transferring residents from one surface to another surface. CNA F stated Resident #1 had a sign in her room stating she was a two person assist with transfers. He stated all residents had signs in their rooms that indicated how many staff were required to transfer the resident. CNA F stated when he transferred Resident #1, he would have someone assist him because she was not always stable during transfer. CNA F stated Resident #1 was difficult to transfer by one person. In an interview on 02/28/2024 at 4:45 PM CNA L stated she had been assigned to give care to Resident #1. She stated Resident #1 did require to be transferred with sit to stand lift. She stated the Hoyer lift was a two person assist. CNA L stated sit to stand/Sara lift required only one person to transfer with that lift. CNA L stated Resident #1 was a two person assist. She stated Resident needed more than one person to transfer due to her size and not being very mobile during transfer. She stated there was a sign in her room and all residents' rooms that stated how many staff to transfer a resident. She stated the signs had been in the residents' rooms since the beginning of January 2024. CNA L stated the sign in Resident #1's room always stated 2 person assist. In an interview on 02/28/2024 at 5:00 PM CNA M stated Resident #1 was a two person assist with transfers. She stated there was a sign in all residents' rooms alerting staff of what type of transfer the residents required. CNA M stated Resident #1 sign stated two person assist. She stated the signs had been in residents' room approximately the first week of January of 2024 and had always stated she was a two person assist. CNA M stated two staff were expected to transfer using the Hoyer lift and the sit to stand/Sara lift required one person and sometimes two people to assist according to the resident. She stated if she transferred Resident #1 with sit to stand/Sara lift she would have someone to assist her with using this lift on Resident #1. CNA M stated it would be difficult to maneuver Resident #1 and the lift at the same time. In a telephone interview on 02/28/2024 at 5:15 PM CNA C stated she was in Resident #1's room and was organizing to give Resident #1 a shower. She stated she assisted Resident #1 in her wheelchair near the bathroom door. CNA C stated she had the shower chair at the edge of the shower in Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676290 If continuation sheet Page 7 of 14 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 02/29/2024 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few #1's bathroom. She stated she used the sit to stand lift and had Resident #1 strapped in with the lift pads around Resident #1. She stated as she began to lift Resident #1 her backside was in the bathroom and this was when Resident #1 began to yell, she thought she was falling. CNA C stated Resident #1's feet were on the floor. She had to move from where she was standing in front of Resident #1 to behind the sit to stand lift to lower Resident to the floor. She had to move back to where Resident #1 was and hold her head to prevent her from hitting it on anything. She stated she grabbed a pillow and placed it underneath Resident #1's head. She stated, Resident #1 stated her left knee was hurting and was not straight. CNA C stated it was difficult to describe the position her left leg was in. It was somewhat bent sideways to the left of Resident #1's body. She stated she knew she needed assistance and needed to report the incident to the nurse. CNA C stated she was not able to locate the nurse and she went to another hall and asked CNA D to assist her with Resident #1. She stated when CNA D entered Resident #1's room he asked Resident #1 if she was hurt. CNA C stated Resident #1 explained her left knee was hurting and her leg was sideways. CNA C stated she and CNA D straightened out Resident #1's left leg. She also stated CNA D assisted her in transferring Resident #1 from the floor to the wheelchair with the sit to stand lift. She stated once Resident #1 was in the wheelchair she continued to complain of pain in her left knee. She stated CNA D transferred Resident #1 without assistance from the wheelchair to the bed using the sit to stand lift. CNA C stated she lifted her with the sit to stand lift and assisted her to the shower in her room. She stated she did not ask for assistance when she transferred her the second time to the shower. CNA C stated there was a sign in the resident's room stating how many staff the resident required for transfer, but she did not recall what was on the sign. She stated she thought the sign had one person assist. CNA C stated the sign about transfers had only been in Resident #1's room about two weeks. She stated this was not the first time she had been assigned to care for Resident #1 and she had used the sit to stand lift by herself when transferring Resident #1. She stated if she had any questions about the residents care she would ask the charge nurse. CNA C stated after the incident she did not feel Resident #1 would be unsafe transferring her with one person using the sit to stand lift. She stated she had not been trained at this facility on how to use mechanical lifts. CNA C also stated the Hoyer lift was the only lift required two staff to transfer residents. In an interview on 02/29/2024 at 8:50 PM the Assistant Director of Nurses stated when it was the first day for agency staff to work at this facility the staff coordinator walks with the agency staff and explained the care each resident required on the hall the agency staff was assigned to for that day. The Assistant Director of Nurses stated if the staff coordinator was not in the facility the nurse supervisor would give report to the agency staff. He also stated that there was paper signage in each resident's room with information on how to transfer the resident. He stated at this time we do not have a program where agency staff would be trained on how to use all lifts in the facility including: Hoyer and sit to stand/Sara lifts. The Assistant Director of Nurses stated a CNA that worked at this facility for at least a year or more was assigned with the agency staff for the first and second time the agency staff was working in the facility. The Director of Nurses designates someone to place signs in each resident room. If there was a change of how a resident was transferred, she would designate someone to make changes to the sign in that resident's room. He stated that he was not aware of a system in place to monitor the transfer signs in each resident's room. The staff has access to electronic medical records for transfer information for the resident. He stated all mechanical lifts were two person assist. He stated the policy on the mechanical lifts applied to all lifts in the facility including the [NAME]/sit to stand lift and the Hoyer lift. The Assistant Director of Nurses stated the signs were placed in each (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676290 If continuation sheet Page 8 of 14 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 02/29/2024 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few resident's room referring to if a resident was a one person or two person assist beginning of January 2024. He stated Resident #1 was a two person assist and had been a two person assist for several months. In an interview on 02/29/2024 at 9:45 AM Interim Director of Therapy stated when a resident was required to be transferred using a mechanical lift it was determined by the following: a resident was not safe to transfer with a gait belt and/or stand by assistance. She stated that manual lifting was the safest transfer for the resident. She stated a [NAME] / sit to stand lift and Hoyer lift required two staff to use these lifts. She stated it was not safe to use any type of mechanical lift with one person when transferring any resident. She stated Resident #1 used a mechanical lift. She stated she used the sit to stand lift and now the Hoyer lift. She stated Resident #1 was a two person assist since she used a mechanical lift. The Interim Director of Therapy stated if one person used a lift a resident had a greater risk of having an injury due to improper transfer. In an interview on 02/29/2024 at 10:38 AM reflected CNA D was attempted to be contacted by phone and unable to a leave message. In an interview on 02/29/2024 at 10:48 AM reflected CNA D was sent a text in an attempt to interview him. In an interview on 02/29/2024 at 12:00 PM the ADON attempted to contact CNA D. In an interview on 02/29/2024 at 3:00 PM the Director of Nurses stated the facility did not have anything in place to ensure who oversaw the signs on the walls in each resident's room that stated required number of staff assistance. She stated she oversaw updating the signs and would delegate to someone to place the sign in the resident's room. She stated the mechanical lift policy included all the lifts in the facility: sit to stand/[NAME] and the Hoyer lift. The Director of Nurses stated the sit to stand/ Sara lift and the Hoyer lift required 2 staff to use the lift to transfer residents. She stated that agency staff was given report by the nurse supervisor and the CNA on the previous shift would walk with the agency staff and give report on each resident on the hall the agency staff was assigned to for that shift. She stated there had been in-services throughout the year and the facility had one big in-service with the therapy staff demonstrating how to use all lifts in the facility. She stated this in-service was done the first quarter of the year and the facility had one done in 2023. Record review of the Facility's Policy on Lifting Machines, using a Portable, dated 02/2014, reflected the purpose of this procedure is to help lift residents using a manual lifting device. Two nursing assistants are required to perform this procedure. The following equipment and supplies will be necessary when performing this procedure: 1. Portable lift 2. Sling FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676290 If continuation sheet Page 9 of 14 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 02/29/2024 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents. The facility failed to ensure the safe transfer of residents when hospitality aides were allowed to assist with resident transfers outside of the scope of their job description. This failure could place residents at risk for serious injury, serious harm, serious impairment, or death. Findings included: Record review of Hospitality Aide J personnel record on 02/28/2024 reflected form titled Hospitality Aide was signed by Hospitality Aide J on 08/31/2024. The hospitality Aide form reflected the following: Answer call lights in a timely manner; determine if request does not involve direct care and then carry out request. Examples of non-direct care: a. Helping with TV b. Getting a personal item for a resident. c. Giving them a blanket or pillow. - Be Alert to resident's comfort and needs. Answer their request promptly and report to nurse any need that exceeds your ability. - Uses tactful, appropriate communications in sensitive and emotional situations. - Observe all residents and report anything unusual or abnormal to Charge Nurse. - Offer fluids and encourage residents to drink (check with nurse for a list of residents with fluid restrictions or on thickened liquids). - Pass out meals trays and labeled snacks to residents. - Clean and pick up rooms. - Stock gloves in rooms and notify housekeeping/ maintenance if paper towels running low. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676290 If continuation sheet Page 10 of 14 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 02/29/2024 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 0726 - Pass ice and pick up meal trays from resident rooms. Level of Harm - Minimal harm or potential for actual harm - Empty beside commodes. - Take laundry barrels to laundry room, get linens for beds, make unoccupied beds. Residents Affected - Some - Bring residents to and from daily activities. - Performs other duties as assigned. - Treat all residents, visitors, and staff with courtesy. What you cannot do: You cannot help feed residents (unless you have received training to be a feeding assistant). No direct care (include changing, showering, transfers, shaving). Cannot cut nails. Cannot do vitals. Record review on 02/28/2024 of personnel record reflected Hospitality Aide O did not sign job description of a hospitality aide. She was hired on 06/07/2023. The personnel record also reflected there was no training on transfers in her employee file. Record review on 02/28/2024 of personnel record reflected Hospitality Aide Q did not have a hospitality aide job description in her personnel file. She was hired on 03/07/2023. Hospitality Aide Q did receive training on 02/20/2024 on how to transfer with the Hoyer lift. There was a comment on her training stated needs to work on knowledge of safety protocols. Observation on 02/28/2024 at 1:10 PM CNA I and Hospitality Aide J transferred Resident #3 from the bed to an electric wheelchair with the Hoyer lift. CNA I explained the transfer process to Resident #3 prior to transferring her with the Hoyer lift. Hospitality aide J stood behind the lift and maneuvered the electronic device to assist the resident up from the bed and down onto her electric wheelchair. She widened the legs of the Hoyer lift and did not touch the resident. CNA I did the portion of the transfer where she attached the strap to the Hoyer lift and touched the resident and assisted the resident. Did not observe any concerns with the transfer of Resident #3. In an interview on 02/28/2024 at 12:50 PM LVN B stated the hospitality aides had always assisted with the CNAs using the Hoyer lift, sit to stand lift, and the Sara lift. She stated the CNAs trained (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676290 If continuation sheet Page 11 of 14 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 02/29/2024 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some the hospitality aides on how to use all the lifts during the transfer of a resident. The CNA would guide the hospitality aide on what to do when using the lift. She stated she never witnessed a hospitality aide touching the resident during the transfer. LVN B also stated she thought it was the job duty of the hospitality aide to assist the CNA in any job duties of caring for a resident. In an interview on 02/28/2024 at 1:30 PM CNA I stated hospitality aides had been assisting with transfers for approximately a year. She stated prior to February 2024 she had not received training on how to use the Hoyer lift. She stated she was trained by other CNAs when they transferred a resident. CNA I stated the hospitality aides did not know how to use the Hoyer lift or the sit to stand lift. She stated she would show the hospitality aides how to use both lifts during a transfer of a resident. In an interview on 02/28/2024 at 1:40 PM Hospitality Aide J stated she did not receive in-services or training from the therapy department or anyone in nursing administration on how to use any type of lifts such as the sit to stand lift or the Hoyer lift. Hospitality Aide J stated she thought the Sara lift and sit to stand lift were the same lift and people used different names for it. She stated she received training from a CNA during a transfer when she began working at the facility. She stated the CNA would explain to her how to use the Hoyer lift during a transfer. She stated she would follow the CNAs directions when using a lift to transfer a resident. The hospitality aide stated she did not remember if she signed a job description or information explaining duties of hospitality aide. She stated she had always assisted with transfers since she began working at the facility in 08/2023. Hospitality Aide J stated when she assisted transferring residents with a lift or a gait belt no injuries occurred with the residents she assisted with transfers. In an interview on 02/29/2024 at 9:20 AM Hospitality Aide O stated she had been an employee at this facility as a hospitality aide since 06/2023. She stated she did not recall the exact date she was hired. Hospitality Aide O stated she was trained on how to use the Hoyer lift, sit to stand lift, and Sara lift by CNAs at this facility. She stated during transfers with any of the lifts the CNAs would guide her during the transfer of a resident. She stated she did not touch the resident only the lift. Hospitality Aide O also stated she would use the electronic part of the lift to lower the resident and raise the resident from the bed or wheelchair. She stated she did not receive any training from the therapy department or from anyone else at the facility except the CNAs. She stated during her transfers of residents there was not any accidents with the residents. Hospitality Aide O stated she had not witnessed any injuries to residents during transfers she was involved in. In an interview on 02/29/2024 at 10 :00 AM CNA P stated the hospitality aides would answer call lights and did assist with transfers using the Hoyer lift and the sit to stand/ Sara lift. She stated the hospitality aides were allowed to transfer residents with the sit to stand/ [NAME] or the Hoyer lift only if a CNA was with the hospitality aide. She stated all mechanical lifts were two person assist. CNA P stated the hospitality aides were trained on how to use the sit to stand/Sara lift and the Hoyer lift by the CNAs during a transfer of a resident. She stated the hospitality aide would maneuver the resident up and down by using the knob on the lifts and would not touch the residents during the transfers. CNA P stated she would guide the hospitality aide what to do during the transfer. She also stated there were 3 hospitality aides in the facility and she had worked with all three hospitality aides with using the mechanical lifts to transfer residents. In a phone interview on 02/29/2024 at 10:20 AM Hospitality Aide Q stated she had been working as a hospitality aide at this facility since March 2023. She stated some of the hospitality aide's duties were the following: give showers, feed residents, transfer residents, and answer call lights. She (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676290 If continuation sheet Page 12 of 14 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 02/29/2024 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some stated the CNAs trained her on how to use the Hoyer lift and the sit to stand/Sara lift. Hospitality Aide Q stated if she had any questions on how to use the Hoyer lift or the other two mechanical lifts, she would ask the CNA and the CNA would guide her during the transfer of a resident. She stated she did not recall of any in-services she had with the therapy staff or with a nurse on how to use mechanical lifts. Hospitality Aide Q stated she did not touch the residents during the transfers, she assisted with lifting the residents up and down from the lift. In an interview on 02/29/2024 at 10:40 AM CNA R stated she had not worked with any hospitality aides when she worked as a CNA. She stated she was a CMA and a CNA. CNA R also stated she had witnessed hospitality aides transfer residents with another CNA using the Hoyer lift. She stated she was not aware of any accidents when hospitality aides and a CNA used a mechanical lift to transfer a resident. She stated all mechanical lifts required two staff to use all mechanical lifts in the facility. In an interview on 02/29/2024 at 12:30 PM CNA S stated the hospitality aides were trained on how to use the Hoyer lifts and the sit to stand /Sara lifts by the CNAs. She stated the CNAs would train the hospitality aides on how to use the mechanical lifts when a resident was being transferred by a mechanical lift. CNA R stated the hospitality aides would maneuver the lift when transferring a resident from one surface to another surface, such as bed or wheelchair. She also stated she was not aware of any accidents when she was with the hospitality aide during a transfer using mechanical lift. She stated she had worked at this facility for 13 years. CNA S stated the hospitality aides began working at this facility during the COVID pandemic. She stated after the pandemic was when the hospitality aides began to assist the CNAs with transferring residents with the Hoyer lift and sit to stand/Sara lift. She stated she had been trained on how to use the Hoyer lift and the sit to stand/Sara lift. She stated she did not remember the last time she received in-service on how to use mechanical lifts. In an interview on 02/29/2024 at 3:40 PM the DON stated hospitality aides job duties were not to have any type of transfer duties. She stated if there was a mishap during a transfer with a Hoyer lift the hospitality aide would not have the training to know what to do. The DON stated she was not aware the hospitality aides were transferring residents with mechanical lifts. She also stated this was not in the hospitality aides job description. The DON stated the hospitality aides job description would be considered the facilities policy for hospitality aides. She stated hospitality aides did not have the training the CNAs had on giving proper transfers and without the proper training there was a potential of improper use of mechanical and if there was a malfunction of lifts during transfer the Hospitality Aide would not have the knowledge of how to adjust the resident and possibly the resident may have a injury. In an interview on 02/29/2024 at 3:55 PM the ADON stated the hospitality aides were not to transfer any residents. He stated if a hospitality aide were to transfer a resident and something went wrong with the transfer, the hospitality aide would not have the proper training to correct the issue. He stated it was his responsibility and the DONs responsibility to ensure all staff were trained on their job duties according to their job descriptions. The hospitality aides had a greater risk of not properly transferring residents due to not being trained properly and there was a possibility of a resident endure an injury during a improper transfer. Record Review of the Facility Policy on Hospitality Aide (not dated) reflected the following: 1. Provide customer service support to residents, assist with non-hands-on tasks, and works under the direction of the supervision of a registered nurse or licensed practical nurse. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676290 If continuation sheet Page 13 of 14 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 02/29/2024 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 0726 Level of Harm - Minimal harm or potential for actual harm 2. Assist residents with nutritional needs including service meals, snacks, and providing for proper fluid requirements by passing water/ice and ensuring that water/ice glasses are always within their reach. 3. Respond to resident requests (verbally or call lights) for assistance and attend to those needs which do not require direct care; perform all responsibilities with respect to resident's rights. Residents Affected - Some 4. Relay resident needs to nursing staff. 5. Report to Charge Nurse immediately when observing any unusual or significant changes in a resident's physical or behavioral condition. 6. Wash soiled linen. 7. Clean personal equipment utilized by residents (i.e., wheelchairs, walker, eyeglasses) 8. Ensure resident devices are properly placed within their reach: call light, water /ice pitcher, and/or eyeglasses. 9. Assist wheelchair dependent residents to and from different areas within the facility and activities the resident wished to participate in. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676290 If continuation sheet Page 14 of 14