Health inspection·July 28, 2023

F 0760 assist from one person for bed mobility, transfers, locomotion, dressing, toilet use, and personal hygiene. Level of Harm - Immediate jeopardy to resident health or safety Record review of CR #84's Care Plan dated 05/01/2023 read in part there was potential for complications related to diabetes mellitus. The 'goal' was for the resident to have blood glucose levels within acceptable limits and absence of signs of hypoglycemia or hyperglycemia (high blood sugar). One approach was to administer medications as ordered by MD and evaluate/record/report effectiveness and any adverse side effects. Residents Affected - Few Record review of CR #84's admission Prescription Order dated 04/26/2023 at 6:10 p.m. read in part the resident was to receive 6 units of Lantus Solostar (long-acting) insulin every night at bedtime (8:00 p.m.). It was ordered by Physician A and transcribed by LVN B. Record review of CR #84's Patient Medication Profile dated April 2023 read in part the resident was to be administered Humulog U-100 (fast-acting) insulin on a sliding scale (the amount of insulin to be administered based on the fsbs reading). If the fsbs was greater than 401 mg/dl, administer 12 units of Humulog U-100 and re-check the fsbs in 15 minutes. If the fsbs was still greater than 401 mg/dl at that time, notify Physician. Record review of CR #84's NN dated 04/26/2023 at 8:37 p.m. (late entry) read in part Resident #84's had a fsbs of 412 mg/dl. Sliding scale insulin was administered. The fsbs after 15 minutes was 409 mg/dl. The Physician was notified. A new order for 60 units of insulin was noted. The type of insulin was not specified. The NN was signed by LVN C. Record review of CR #84's Prescription Order dated 04/26/2023 at 8:19 p.m. read 60 units of Lantus Solostar insulin administer at bedtime (8:00 p.m.). The Order reflected a start date of 04/26/2023. Record review of the NN dated 04/27/2023 at 12:28 p.m. revealed LVN C conducted a fsbs for Resident #84 at 7:15 a.m. The resident had a blood glucose level of 26 mg/dl. LVN C rechecked, and got a reading of 21 mg/dl. The NN reflected another nurse (LVN D) brought a different glucometer and obtained a fsbs. The reading reflected 26 mg/dl. LVN C called NP E and NP E ordered Glucagon (a hormone that acts to increase blood sugar) 1 mg and to recheck the fsbs at 7:35 a.m. The Glucagon was administered into the left deltoid (muscle around the shoulder). The fsbs recheck after 15 minutes yielded 44 mg/dl. A fsbs at 8:35 a.m. was 85 mg/dl, followed by a 49 mg/dl reading at 10:30 a.m. Physician A was notified, and he ordered Glucagon 1 mg to be administered, and the resident was to be sent to the ER for further evaluation. The Glucagon was administered, and the resident was transported to the hospital via 911. Record review of the Provider Investigation Report dated 05/05/2023 revealed Resident #84 required hospitalization for four days. Interview on 07/11/2023 at 11:37 a.m. with LVN C revealed she said she worked the 6:00 a.m. to 6:00 p.m. shift on 04/27/2023. She said she was checking blood sugars in the morning, and Resident #84's was 26 mg/dl. She had not received any report regarding insulin for Resident #84. She said she went and got the other nurse (LVN D). LVN D's glucometer reflected a reading of 21 mg/dl. The NP was called, and an order for Glucagon was received. The Glucagon was administered. She said she believed the blood glucose level went up to 89 mg/dl. When the next fsbs reflected 49 mg/dl, Physician A was called. The resident was administered another dose of Glucagon and was sent to the hospital. LVN C said Resident #84 was at the hospital for '3 or 4 days.' (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676298 If continuation sheet Page 2 of 4 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 676298 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Spjst Rest Home No 2 8611 Main St Needville, TX 77461 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Interview on 07/11/2023 at 11:45 a.m. with LVN D revealed she said LVN C approached her and said Resident #84 had a low blood sugar that was in the 20's (mg/dl). She said they called and received the order for the Glucagon. The Glucagon was administered, and the blood glucose level began to rise. She said at that time she went back to her nursing station in another part of the facility. She said the resident was then sent to the hospital. Interview via telephone on 07/13/2023 at 11:00 a.m. with LVN B revealed she said Resident #84 was admitted to the facility on [DATE]. She said she verified the admission orders with Physician A. She said the order for insulin (Lantus) was 6 units. She said she checked Resident #84's blood sugar, and it was between 412-419 mg/dl. She said she had already given the 6 units per the admission order. She said she called the doctor and he said to give 60 units of Lantus. She said she repeated '60?' and it was confirmed. She said LVN F was present when she spoke with Physician A. She said she was not sure if Physician A was on the speaker on the phone, but she repeated it to LVN F, and LVN F entered the order into the computer. She said she gave the 60 units of Lantus. She said the resident was 'fine, alert' when she left the facility in the morning. Interview on 07/13/2023 at 11:20 a.m. with LVN F revealed she said Resident #84's blood sugar level 'was in the 400s.' She said the physician gave a verbal order to administer additional insulin, but she could not recall the amount. She said she let LVN B use her cell phone, but she did not stand next to her. She said LVN B told her (LVN F) to change the insulin order in the computer to reflect the new order. LVN F said she entered the new order into the computer, even though she had not spoken with Physician A directly. When asked if that was the normal procedure for entering orders, LVN F said typically the nurses enter their own orders, but LVN B was not feeling well so she helped her. Interview on 07/13/2023 at 11:45 a.m. with the DON revealed she said when a nurse calls the doctor for an order, that nurse is the person who would enter the order into the computer. She said if both nurses heard the doctor, either could enter the order. She said it was inappropriate for LVN F to enter the order if LVN B spoke to the doctor and relayed the order. Interview on 07/13/2023 at 1:26 p.m. with Physician A revealed he said he received the call that Resident #84 had a high blood sugar. He said he thought he ordered the insulin to be increased to 14 units. He said he did not know where the '60' came from. He said that was too much of an increase. The above failures were determined to be a past non-compliance Immediate Jeopardy (IJ) on 07/28/23 at 10:38 a.m. The Administrator and the Director of Nursing were notified at that time. The Administrator was provided with the IJ template on 07/28/23 at 10:38 a.m. The facility had addressed the non-compliance prior to entry by the HHS surveyors. The facility actions to correct the non-compliance was accepted in lieu of a Plan of Removal. SPJST Rest Home No. 2 Facility actions to correct the non-compliance included: -The nurse (LVN B) who administered the 60 units of insulin was suspended then resigned on 04/28/2023. -LVN F received written counseling on improper transcription of physician orders and was required to receive CEU education on proper transcription of physician orders . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676298 If continuation sheet Page 3 of 4 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 676298 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Spjst Rest Home No 2 8611 Main St Needville, TX 77461 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few -Eight nurses were in-serviced on insulin administration with return-demonstration on 04/28/23. The signatures of nurses observed during the survey and investigation were on the in-service attendance sheet. The nurses were LVN C, LVN D, LVN E, LVN F, LVN G, LVN H, LVN I, and LVN J. -Eight nurses were in-serviced on receiving physician orders and proper transcription on 04/28/2023. The signatures of nurses observed during the survey and investigation were on the in-service attendance sheet. The nurses were LVN C, LVN D, LVN E, LVN F, LVN G, LVN H, LVN I, and LVN J. In an interview on 07/27/2023 at 11:00 a.m., LVN C said she had been in-serviced regarding insulin and physician orders. In an interview on 07/27/2023 at 11:10 a.m., LVN D said she had received in-services regarding insulin and physician orders . Observation on 07/27/2023 at 11:15 a.m. revealed LVN D performed a fsbs for Resident #90. The resident required sliding scale insulin. LVN D reviewed the order, and then administered the correct insulin and the correct dosage. In an interview on 07/27/2023 at 1:50 p.m., the Administrator said the insulin incident was discussed extensively in the QAPI. She said the Physician was not able to attend, but he did review the notes . In an interview on 07/27/2023 at 4:00 p.m., the DON said there were a total of 16 nurses employed at the facility, including her and the Administrator (RN). She said all nurses who have worked since the incident had had been in -serviced. She said the remainder of the nurses would receive the in-services prior to starting their first shift. Record review of the facility's policy titled Insulin Administration (revised September 2014) read in part .3. The type of insulin, dosage requirements, strength, and method of administration must be verified before administration, to assure it corresponds with the order on the medications sheet and the physician's order. The policy revealed long-acting insulins reached their peak effect (maximum effectiveness) at 'up to 8 hours' and for a duration of up to 24 hours . Add in the MerckManual reference that was included in the original visit and include access date. Record review of MerckManuals.com Professional Version revealed hypoglycemia (low blood sugar) is defined as a glucose level of equal or less than 70 mg/dl. Hypoglycemia could result stroke-like symptoms of aphasia (inability to speak) or hemiparesis (limited ability to move one side of the body, and is likely to precipitate stroke, myocardial infarction (heart problems), and sudden death. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676298 If continuation sheet Page 4 of 4