Health inspection·September 19, 2024

F 0552 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few consent for other medications. The DON stated that the facility obtained a consent on 12/04/2024, but the consent referenced was not the correct consent for Zyprexa Oral Tablet 15 mg. Medication Administration and Antipsychotic Medication Use/Consent Policy was requested. Interview on 09/18/2024 at 3:30 PM, Resident #36 stated that she received antipsychotic medication but did not know what medications dosage and side effects associated with medications. Resident #36 denied receiving and services and support related to coping with bipolar disorder. Resident denied being sad at the time of the interview but stated that she feelings sad frequently and she could benefit from supportive. In an interview on 09/19/2024 at 11:00AM, the Administrator stated that the facility did not have Antipsychotic Medication Use/Consent Policy. Record review of the facility's admission Packet, Psychoactive Medication Informed Consent Page 12 of the admission Packet If a psychoactive medication is prescribed for a resident either before admission or after, you will be contacted regarding completing the consent form. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676298 If continuation sheet Page 2 of 8 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 09/19/2024 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to coordinate assessments with the Preadmission Screening and Resident Review (PASARR) program to the maximum extent practicable for 1 of 5 residents (Resident #36) reviewed for PASARR. -The facility failed to update the PASARR Level 1 forms for Resident #36 to indicate mental health illness. This failure could place residents requiring PASARR services at risk of not having their special needs assessed and met by the facility. Findings included: Record review of Resident # 36's face sheet provided by the facility on 09/18/2024 revealed that Resident # 36 was a 67 -year-old female who admitted to the facility on [DATE] and had an active diagnosis of Bipolar Disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration) with an onset documented as of 12/04/2023. Record review of the comprehensive MDS assessment revealed Resident # 36 Brief Interview for Mental Status (BIMS) score of 15, indicating the resident's cognition was intact. The MDS assessment for Resident #36 revealed had an active Psychotic Disorder of Bipolar Disorder and had received an antipsychotic 7 days in the 7-day -look -back -period. Record review of Resident #36's care plan dated 08/19/2024 read in part Resident #36 uses psychotropic medications antipsychotic medication, Zyprexa. Record review of Resident #36 physician's order summary report revealed the following order: Zyprexa Oral Tablet 15 mg give one tablet by mouth at bedtime for Bipolar disorder, with a start date of 12/04/2024. Record review of the PASARR Level 1 Screening for Resident #36 dated for 12/04/2023 indicated no mental health illness. It was determined that resident was not eligible for PASARR specialized services because serious mental (Bipolar Disorder) illness was not indicated on initial PASARR Level 1 Screening. Interview and record review on 09/18/2024 at 11:00 AM with the MDS Coordinator revealed that she completed an updated PASARR Level 1 screening on 09/18/2024 after surveyors asked for the PASARR for Resident #36. She said she would wait to see what the recommendations were after the referral was processed. She stated that she did not know why the PASARR referral had not been completed on 12/04/2023. She stated that it would be important for a resident to receive PASARR services if they qualified. The MDS Coordinator stated that by not coordinating PASARR services it placed residents at risk for not receiving the necessary mental health services that the residents may have qualified for. Interview on 09/18/2024 at 3:30 PM, Resident #36 stated that she received antipsychotic medication but did not know what medications dosage and side effects associated with medications. Resident #36 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676298 If continuation sheet Page 3 of 8 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 09/19/2024 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete denied receiving and services and support related to coping with bipolar disorder. Resident denied being sad at the time of the interview but stated that she feelings sad frequently and she could benefit from supportive. Record review of the facility's Resident Assessment-Coordination with PASARR Program policy dated implemented 06/2023 and Date Revised: 06/2023 revealed 9. Any resident who exhibits a newly evident or possible serious mental disorder, intellectual disability, or a related condition will be referred promptly to the state mental health or intellectual disability authority for a level II resident review .b. A resident whose intellectual disability or related was not previously identified and evaluated through PASARR. Event ID: Facility ID: 676298 If continuation sheet Page 4 of 8 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 09/19/2024 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 0695 Provide safe and appropriate respiratory care for a resident when needed. 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 ensure that a resident who needed respiratory care was provided such care consistent with professional standards of practice, physicians orders, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 42 (Resident #34) residents reviewed for quality of care Residents Affected - Few The facility failed to ensure Resident #34's oxygen tubing was labeled and dated. This failure places the resident at an increased risk of infection leading to a decline in health. The findings included: Record review of Resident #34's face sheet dated 07/02/2024 reflected a [AGE] year-old female with admission date of 03/17/2023 and re-admission date 06/20/2024. Pertinent diagnoses included Pneumonia, unspecified organism, Allergic rhinitis (also called hay fever, is an allergic reaction that causes sneezing, congestion, itchy nose and watery eyes), unspecified, Cough, unspecified, and acute respiratory disease. Record review of Resident #34's MDS assessment , dated 08/13/2024 reflected Resident #34 had a BIMS score of 8 (severe cognitive impairment) and indicated she used Oxygen. Record review of Resident #34's Care Plan last updated 07/02/2024 read in part . Administer oxygen therapy as ordered . Record review of Resident #34's Treatment Administrative Record dated 09/06- 09/19/2024 read in part . Order: Change tubing on O2 concentrator Weekly. Frequency: Once A Day on Tue. Record review of the facility Oxygen Administration policy dated October 2010 did not mention labeling and or dating the oxygen tubing or hydration bottle. Interview and observation on 09/17/2024 at 9:08 AM with Resident #34 revealed she had an O2 concentrator, and there was no date on the tubing. Interview and observation on 09/18/2024 at 9:55 AM with Resident #34 revealed the oxygen tubing was still unlabeled. Resident #34 said staff had not changed the tubing since this surveyor was there yesterday. Interview on 09/18/2024 at 9:51 AM with CNA A revealed she recently started back the previous week. She stated before, she worked 2 years at the facility. She said she was familiar with Resident #34 and knew the resident was on O2. She said routinely, she helped toilet and bathe the resident, and looked over the O2 machine to make sure things were connected and labeled for the resident. She observed the oxygen tubing was not labeled. She said normally the nurse changed the O2 tubing and said it was supposed to be labeled. She said she did not know why the O2 tube was unlabeled. She said she should have had training on O2 tubing to be aware of how things looked but did not recall the last time she had training on O2 tubing. She said the charge nurse for the wing was responsible for oversight to ensure staff followed protocol regarding the Oxygen care. She said the risk to the resident if policy/ procedure was not followed was bacteria could or germs could transfer to the resident if (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676298 If continuation sheet Page 5 of 8 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 09/19/2024 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the tubing touched the floor or was not changed and the worst thing that can happen to the resident when proper protocols are not practiced was it could cause the resident to become ill. Interview on 09/18/2024 at 9:58 AM with LVN A revealed she had worked at the facility for 13 years as an LVN. She said she was acting medication aide. She said she gave medications, performed wound care, documented her work and, tried to make the residents happy. She said she normally worked from 6am2pm, Monday through Friday. She said she was familiar with and routinely would do things like positioning the resident. She said regarding the resident's oxygen, the O2 was set on 2ml and generally the tubing and water was replaced on the night shift. She said the policy or procedure was the O2 tubing was changed weekly on night shift unless the water in the hydration bottle ran out sooner than weekly. She observed there was no date on the O2 tubing on the resident. LVN A replaced the tubing and added a hydration bottle. She said there was a failure to date the tubing . She said there was a new night nurse who have had 2 days training. She said in-services on Oxygen care and tubing was reinforced all the time. She said they were all aware that dating the tubing was supposed to be done. She said she was responsible for ensuring the tubing was dated. She said the risk to the resident if policy/procedure was not followed was bacteria could get in side the tubing and in the resident, and the resident and or their roommate could get sick. Interview on 09/18/2024 at 12:11 PM with DON revealed O2 tubing was changed weekly and as needed. She said nursing was responsible for changing the O2 tubing. She said the night nurse was scheduled to change the O2 tubing. She said nurses were responsible for checking that the O2 tubing were dated and CNAs, if aware, could bring it to the nurse's attention. She said the policy or procedure was that the O2 tubing was changed out every 7 days and was dated for when it was changed. When not in use, it was bagged up. She said she was not aware of the O2 tubing not being dated. She said the last trained staff on O2 tubing on 2/08/2024. She said she and the Administrator were responsible for ensuring protocol was followed. She said the risk to the resident if policy/protocol was not followed could be infection. Interview on 09/18/2024 at 12:52PM with the Administrator revealed the policy or procedure for Oxygen tubing was it was supposed to be changed out every 7 days, and when not in use it was bagged up. She said it was labeled with the date of when the tubing was changed. She said she was familiar with Resident #34. She said she did not know why the O2 tubing was not labeled, and it was supposed to happen every 7 days and it looked like the night nurse should have looked at the oxygen tubing. She said every nurse was responsible, but especially the night nurse was responsible for the oxygen tubing because the night nurse was supposed to change and label for O2 tubing. She said she last was in-serviced on residents with oxygen recently, within last 2 months. She said she was responsible for ensuring policy was followed. She said the risk to the resident if policy or proper protocols was not followed, was there was the potential for respiratory infection , and it could lead to hospitalization. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676298 If continuation sheet Page 6 of 8 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 09/19/2024 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 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for the kitchen in that: Residents Affected - Some 1. The facility failed to ensure unlabeled foods were not stored in the refrigerator. 2. The facility failed to ensure unsealed foods were not stored in the dry good storage. This failure had the potential to place residents at risk of serious complications from foodborne illness as a result of their compromised health status. Findings include: Interviews and observation s on 09/17/2024 at 8:15 AM with the [NAME] revealed while in the dry food storage there was a bag cereal that was opened which the [NAME] identified as corn flakes. There was also a bag of potato chips unsealed. Observation in the refrigerator was made of a bag of frozen meat that the cook identified as breaded pork chops were unlabeled/dated. She said the date was supposed to be on there. Also observed were bags of frozen steak fries that were not labeled/dated. There was another unlabeled bag of frozen meat that the Dietary Manager identified as catfish nuggets. Interview on 09/18/2024 at 9:27 AM with the [NAME] revealed she had worked at the facility for 2.5 months as a Cook. She said the policy or procedure for storing food was it needed to be labeled and dated. She said the reason for labeling the food was to make sure it was still good /not expired. She said the older food was used first. She said she did not know why the food was left opened and undated. She said the last time she was in-serviced for food storage was when working at the hospital where she came from. She said the supervisor/Dietary Manager was responsible for ensuring foods were labeled and closed and was responsible for oversight to ensure staff followed protocol. She said the risk to the residents when policy/protocol was not followed was the residents may get sick. Interview on 09/18/2024 at 9:35 AM with the Dietary Manager revealed she had worked at the facility for 4 years that upcoming March. She said the policy or procedure for storing food was to label and date them and make sure it was closed. If the food was in its own box, the box was labeled. If the food was outside its box, then the food was individually labeled. She said the date on the food was the date it was received and use-by date. She did not know what happened and why the food was no labeled or closed properly. She said the foods were not labeled because the staff might have been distracted and didn't know why it was not done. She said the last time she was trained on food storage was around July of that year. She said she was responsible for ensuring policy/protocol was followed. She said the worst thing that can happen to the residents if staff did not follow policy/protocol was residents could get sick. Record review of Labeling and Dating Foods (Date Marking) policy dated 2020 read in part . 2. Date marking for refrigerated storage food items- Unopened cases of refrigerated food items will be dated with the date the item was received into the facility and will be stored using the first in -first out method of rotation. Once a case is opened, the individual, refrigerated food items are dated with the date the item was received into the facility and placed in/on the proper storage location utilizing the first in -first out method of rotation . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676298 If continuation sheet Page 7 of 8 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 09/19/2024 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of the Food Receiving and Storage policy dated July 2014 read in part . 7. All foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date). Other opened containers must be dated and sealed or covered during storage . Record review of U.S. Food and Drug Administration Food Code dated 2022 reflected in part . 3-305.11 (A) Except as specified in (B) and (C) of this section, FOOD shall be protected from contamination by storing the FOOD: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination . A record review of the August 2021 version of the TFER reflected the following: (b) The department adopts by reference the U.S. Food and Drug Administration (FDA) Food Code 2017 (Food Code) and the Supplement to the 2017 Food Code. A record review of the FDA food code and the code that is relevant to the failure. https://www.fda.gov/media/110822/download FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676298 If continuation sheet Page 8 of 8