Spjst Rest Home 1

F-F600

The facility failed to ensure that the resident was free from Abuse.

CNA C attempted to transfer Resident #1 from her bed by pulling her by her arms and hands causing bruising to the resident.

The facility failed to assess and document the injuries of Resident #1 after advising staff her hand was tender to touch.

The facility failed to immediately assess Resident #1 after the allegation of physical abuse was made to LVN A.

Action:

On 6/04/2024, the DON designated an LVN to make a referral to Psychological Care, and Resident #1 was evaluated by their psychologist. The psychologist reported to the DON on 06/04/2024 that resident was doing great. The psychologist will continue to visit with the resident until she discharges her from psychological services. On 06/04/2024, the DON assessed the resident's hands where injuries occurred

during transfer. DON stated that the resident has no more pain and that the injuries are in the final stages of healing. No follow-up will be needed for the bruises on the resident's hands.

Starting 06/04/2024, The DON or designee will in-service and retrain nursing staff on policy and procedures of transfers. Safe transfers must be performed by all staff who work in patient care areas. All CNA's and nurses are required to follow transfer procedures. Education will include stand by, one person assists, 2 person assist, sliding board, sit to stand (Sara lift), Hoyer lift, and the stand and pivot. Return demonstration will be provided by the trainee to confirm understanding. The ADON or designee will monitor 4-5 transfers per week for 3 months to verify company policies and procedures are followed thoroughly and report findings to the DON and/or administrator weekly.

Starting 06/04/2024, The DON or designee will in-service and re-educate all nursing staff on when resident physical assessments should be completed, and appropriate documentation made. If a resident makes any type of physical abuse allegation, then a complete head-to-toe physical assessment must be completed by

the charge nurse. If injuries are found on assessment, appropriate documentation in observations and progress notes should be made as well as documentation of provider informed. Progress notes should be made on each shift by the charge nurse stating a detailed update on the injury site. Staff will be educated on when families should be informed of injuries or findings in a timely manner.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 17 676290 Department of Health & Human Services Printed: 09/24/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 676290 B. Wing 06/06/2024

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 0600 The DON and administrator will be reeducated on pain and skin assessments and following proper policies & procedures by outside DON on 06/05/2024. Starting 06/04/2024, The Director of Nursing (DON) or designee Level of Harm - Immediate will reeducate all nursing staff on triggers to notice when a resident is in pain and what steps need to be jeopardy to resident health or taken. If a C.N.A. observes a resident grimacing in pain, then he/she must notify the charge nurse safety immediately. The charge nurse should evaluate the resident for pain and take appropriate measures. If the resident has orders in place for pain management, then the charge nurse is to follow orders and follow-up an Residents Affected - Few hour after treatment is provided to determine if treatment was successful. If current orders do not seem to be effective, then the charge nurse is to call the attending physician for further treatment/recommendations. If a resident makes an allegation of physical abuse, then the charge nurse is to immediately complete a head-to-toe assessment on the resident and document his/her findings on the resident's skin.

The ADON or designee will monitor all reported pain assessments, via the 24-hour reports 4-5 days per week, to ensure that policies and procedures are being followed appropriately by the nursing staff. The ADON will report her findings to the DON and/or administrator weekly unless she finds noncompliance. If noncompliance is found, she will report immediately to the DON and/or administrator.

Start Date: 06/04/2024.

Completion Date: The above will be completed by 06/07/2024.

Responsible: Administrator, DON and ADON

Monitoring:

Record review on 06/06/2024 of the in-service on abuse/neglect reflected the Administrator and the Director of Nurses was in serviced by Administrator M and DON/RN K from a facility owned by the same company.

They were in serviced on the following:

1. Types of Abuse and Neglect such as verbal, physical, mental, emotional, sexual, exploitation, and neglect.

2. Procedure for suspected abuse and/or neglect.

3. Signs of abuse and /or neglect

4. Training, reporting, response, investigation [TRUNCATED]

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 17 676290 Department of Health & Human Services Printed: 09/24/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 676290 B. Wing 06/06/2024

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 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Level of Harm - Immediate **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 40884 jeopardy to resident health or safety Based on interview, and record review, the facility failed to implement their written policies and procedures that prohibit and prevent the abuse of residents for one (Resident #1) of three residents reviewed for abuse. Residents Affected - Few

The facility did not implement the Abuse and Neglect Policy when CNA C abused Resident #1 and CNA C was not immediately relieved of duty.

This failure could place residents at risk of abuse, neglect, physical harm, pain, mental anguish, emotional distress, and serious harm.

An Immediate Jeopardy (IJ) situation was identified on 06/03/2024 at 8:19 PM. While the IJ was removed on 06/06/2024 at 6:50 PM, the facility remained out of compliance at a scope of isolated with potential for more than minimal harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of

the corrective systems.

Findings included:

Record review of the Facility Policy of Resident Abuse/ Neglect, (not dated), reflected This facility will not tolerate resident abuse and neglect. Any reported of suspected abuse or neglect will be thoroughly investigated by administrative staff. The residents in this facility have the right to be free of verbal, sexual, physical, or mental abuse, corporal punishment, involuntary seclusion, and/ or injury of unknown source. Definitions:

1. Allegations of Abuse/Neglect (Employees): After investigation is completed, and there is reason to believe that abuse, neglect, or mistreatment of a resident has occurred, the administrator or his/her designee will notify the family, attending physician, medical director, ombudsman, and the licensing agency. The administrator will relieve the employee of duty immediately.

2.Abuse- Any act, failure to act, or incitement to act done willingly, knowingly, or recklessly through words or physical action which causes or could cause mental or physical injury or harm or death to a resident.

3. Physical Abuse- Physical action within the definition of abuse including, but not limited to, hitting, slapping, pinching, and kicking. It also includes controlling behavior through corporal punishment.

3. Verbal Abuse- The use of any oral, written, or gesture language that includes disparaging or derogatory terms to the resident or within the resident's hearing distance, regardless of the resident's age, ability to comprehend, or disability.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 17 676290 Department of Health & Human Services Printed: 09/24/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 676290 B. Wing 06/06/2024

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 0607 Record review of Resident #1's face sheet, dated 06/03/2024, reflected Resident #1 was a [AGE] year-old female admitted to the facility on [DATE REDACTED] with diagnoses of rheumatoid arthritis with rheumatoid factor, Level of Harm - Immediate unspecified (a chronic inflammatory disorder that affect more than just your joints), polyosteoarthritis, jeopardy to resident health or unspecified (have arthritis in five or more joints at the same time), and scoliosis, unspecified (spine safety deformity).

Residents Affected - Few Record review of Resident #1's BIMS assessment, dated 05/16/2024, reflected Resident #1 had a BIMS score of 15 which indicated her cognition was intact.

Record review of Resident #1's Admission MDS Assessment, dated 05/22/2024, reflected Resident #1 had a BIMS score of 11 which indicated her cognitive status was moderately impaired. She required assistance with ADLs such as: bathing, dressing, hygiene, bed to chair transfer, sit to stand transfer, toilet transfer and shower transfer. Resident #1 was assessed to need PRN pain medication. She also had diagnosis of arthritis (joint inflammation) and medically complex conditions (usually involve multiple body systems and are often chronic in nature).

Record review of Resident #1's Baseline Care Plan, dated 05/17/2024, reflected Resident #1 was alert and oriented to time, place, and person. She was risk for pain related to scoliosis and other diagnosis. Her bed mobility, dressing, transfers, and toileting required one staff person assist.

Record review of Resident #1's Comprehensive Care Plan, dated 05/22/2024, reflected Resident #1 was at risk for injury from decrease in ADLs. Intervention: Administer medication as ordered per the physician. Assess and document pain level. She had impaired physical mobility related to rheumatoid arthritis, and polyarthritis. Intervention: Encourage participation in range of motion exercises and praise accomplishments. Evaluate and treat underlying causes. PT and OT evaluations as needed. Resident is at risk for falls due to impaired mobility. Interventions: Increased staff supervision with intensity based on resident need. Monitor resident's use of side rails when repositioning and resident's ability to safely enter/exit bed. Monitor resident's use / need of side rails per protocol.

Record review of Resident #1's facility investigation report reflected the incident occurred on 05/16/2024 at 4:00 AM Resident #1 was interviewable and had capacity to make informed decisions. She had diagnosis of rheumatoid arthritis and polyosteoarthritis. CNA C was described as the perpetrator. Description of the allegation CNA C entered Resident #1's room to change her, CNA C was telling her to sit up, he grabbed Resident #1 by her hands and was assisting her up. Resident #1 asked him (CNA C) to stop because he was hurting her. Staff member (CNA C) kept pulling her up.

Assessment of Resident #1 completed by the Director of Nurses reflected there were purple discoloration to

the top of right hand between the thumb and index finger. The size of the bruise on Resident #1 right hand was 5.5 cm x 3.0 cm and was tender to touch. There was not treatment provided. The investigation reflected

the investigation findings was confirmed. NP, DON, and Administrator was notified. CNA C received one-on-one counseling (date counseling was completed not indicated on the facility investigation report) and was to return to facility and reassigned to work on another hall where Resident #1 was not residing. CNA C was reeducated on resident rights, abuse, and neglect. Resident wanted to notify her family. Investigation was completed by the Administrator and Director of Nurses.

Record review of CNA C's time sheet reflected he was allowed to return to work the night of 05/16/2024.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 17 676290 Department of Health & Human Services Printed: 09/24/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 676290 B. Wing 06/06/2024

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 0607 Record review of CNA C's disciplinary action dated 05/22/2024 reflected CNA C had a final written warning for performance and policy violation. Details of the incident: see self-report (gave the intake number of this Level of Harm - Immediate investigation). Methods by which the employee can correct the unsatisfactory behavior: No further C/O jeopardy to resident health or abuse by residents. Consequences: Termination. Time frame for improvement: Remaining Employment. safety Employee Signature: Via Phone date: -5/22/2024. Preparer's signature: Director of Nurses date: 05/22/2024.

Residents Affected - Few In an interview on 06/03/2024 at 2:00 PM Resident #1 stated she was happy someone was here to investigate what happened to her when she was admitted to this facility. She stated she had not seen CNA C and she hoped she never saw him for the rest of her life. Resident #1 stated if she saw him she did not know what she would do but try to get away from him. She also stated she was afraid that morning when he was pulling her hands and she kept asking him to stop. She stated her hand did hurt and she asked for a pain pill for her hand. She stated the nurse worked the same time as CNA C did not ask her anything what happened. She stated she wanted to look at her skin and did not understand what she was wanting to look at. She did not ask to look at her hands. Resident #1 stated if the nurse (LVN D) asked her to look at her hands she would have let her. Resident #1 stated she did not understand why the CNA C did not stop when

she told him to stop he was hurting her hands. She stated she interviewed staff and asked them questions

before she allows anyone to touch her. Resident #1 stated she was lying in bed asleep when CNA C came in

the room and kept on wanting her to sit up on the bed and be changed. She stated she did not trust him by

the way he talked to her in a loud tone and was not treating her like a human. Resident #1 stated he kept pulling on her hands and then told me he rather for me to hurt than from him to get hurt. She stated no one had ever treated me so bad like he did early that morning. She stated she had only been in the facility less than 24 hours. Resident #1 also stated when CNA C said to her he rather for her to hurt than for him to get hurt, she stated she felt he was the meanest person to say something like that to an elderly lady who could not care for herself. She stated it made her mad and she became more afraid of CNA C after he said he did not care if she hurt as long as he did not hurt. Resident #1 stated she did not see him again after that night

he pulled on her hands.

In an interview on 06/03/2024 at 3:10 PM the Director of Nurses stated she completed the investigation of

the incident with Resident #1 and CNA G. She stated abuse was confirmed during the investigation. The Director of Nurses stated Resident #1 did have difficulty trusting staff and would talk to the staff before she agreed for any type of care given to her. She also stated LVN A reported the incident to her after LVN A assessed Resident #1. She stated she completed investigation on 05/16/2024 and determined abuse did occur with Resident #1 from CNA C. She stated Resident #1 was afraid CNA C was going to harm her such as: break her hand or pull her shoulder out of socket. Director of Nurses stated Resident #1 did not come out of her room approximately 1-2 weeks after the incident 05/16/2024. She stated she would speak to each staff who entered her room and would not allow them to give her care until she felt safe and the staff reassured her they would not hurt her. The Director of Nurses stated CNA C was counseled via phone on 05/22/2024.

She stated the investigation was completed on 05/16/2024 and she did not counsel with him and give him a written disciplinary action until 05/22/2024 via phone. She stated she should have spoken to him face to face when she gave him the disciplinary action. The Director of Nurses stated she did not recall the reason the disciplinary action was not completed on 05/16/2024 after the investigation. She stated according to the facility policy he should have been terminated immediately and the abuse was violation of their abuse and neglect policy.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 17 676290 Department of Health & Human Services Printed: 09/24/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 676290 B. Wing 06/06/2024

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 0607 In an interview on 06/03/2024 at 3:45 PM The Administrator stated he did sign the investigation report and it was confirmed Resident #1 was abused by CNA C. He stated CNA C had not been accused of abusing Level of Harm - Immediate anyone in the facility until now. The Administrator also stated he believed CNA C had only been confirmed jeopardy to resident health or abuse one time and the Administrator did not agree with terminating him at that particular time. He stated safety according to the policy the facility was required to terminate CNA C immediately.

Residents Affected - Few The Administrator was notified on 06/03/2024 at 8:19 PM, that an Immediate Jeopardy had been identified due to the above failures and an IJ template was provided.

The following POR was accepted on 06/05/2024 at 06:01 PM:

On 06/03/2024, an abbreviated survey was initiated at the facility. On 06/03/2024, the surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate threat to resident health and safety.

The notification of Immediate Jeopardy states as follows:

F-F607 The facility failed to develop and implement written policies and procedures that prohibit and prevent abuse, neglect and exploitation of residents.

CNA A- attempted to transfer Resident #1 from her bed by pulling her by her arms and hands causing bruising to the resident.

The facility failed to follow their policy when physical abuse was confirmed.

Action:

On 6/04/2024, the DON designated an LVN to make a referral to Psychological Care, and Resident #1 was evaluated by their psychologist. The psychologist reported to the DON on 6/04/2024 that resident was doing great. The psychologist will continue to visit with resident until she discharges her from psychological services. On 6/04/2024, the DON assessed the resident's hands where injuries occurred during transfer. DON stated that the resident has no more pain and that the injuries are in the final stages of healing. No follow-up will be needed for the bruises on the resident's hands.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 17 676290 Department of Health & Human Services Printed: 09/24/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 676290 B. Wing 06/06/2024

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 0607 The DON and administrator will be reeducated on pain and skin assessments and following proper policies & procedures by outside DON on 6/05/2024. Starting 6/04/2024, The Director of Nursing (DON) or designee Level of Harm - Immediate will reeducate all nursing staff on triggers to notice when a resident is in pain and what steps need to be jeopardy to resident health or taken. C.N.A.'s will be trained by the DON or designee on how to observe a resident that is grimacing in safety pain. The C.N.A. must notify the charge nurse immediately. The charge nurse should evaluate the resident for pain and take appropriate measures including documenting under pain assessment. If the resident has Residents Affected - Few orders in place for pain management, then the charge nurse is to follow orders and follow-up an hour after treatment is provided to determine if treatment was successful. If current orders do not seem to be effective, then the charge nurse is to call the attending physician for further treatment/recommendations. All of this will be documented in the resident's progress notes and chart reports. The ADON or designee will monitor all reported pain assessments, via the 24-hour reports 4-5 days per week, to ensure that policies and procedures are being followed appropriately by the nursing staff. The ADON will report her findings to the DON and/or administrator weekly unless she finds noncompliance. If noncompliance is found, she will report immediately to the DON and/or administrator.

Starting 6/04/2024, The DON or designee will in-service all nursing staff on when providing a thorough skin assessment is necessary and expected, such as upon admission, if a bruise or skin tear is noticed for the first time on a resident, if resident complains of roughness or states they were abused. The charge nurse will be responsible for completing and documenting a thorough skin assessment, incident report and calling the physician for orders, if necessary. Along with a skin assessment, a pain assessment must always be performed to determine the pain level of the resident. If it is determined that the resident is in pain, then the procedures for pain treatment must be followed by the charge nurse. The ADON or designee will monitor all reported bruises / skin tears to ensure company policies and procedures are followed thoroughly. Findings will be reported weekly to the DON and/or administrator unless she discovers violation of policy. If violation of company policy is found, then she will report immediately to the DON and/or administrator.

Starting 06/04/2024, The DON or designee will in-service and retrain staff on policy and procedures of transfers. Safe transfers must be performed by all staff who work in patient care areas. All CNA's and nurses are required to follow transfer procedures. Education will include stand by, one person assists, 2 person assist, sliding board, sit to stand (Sara lift), Hoyer lift, and the stand and pivot. Return demonstration will be provided by the trainee to confirm understanding.

The ADON or designee will monitor 4-5 transfers per week for 3 months to verify company policies and procedures are followed thoroughly. Findings will be reported to the DON and/or administrator weekly unless noncompliance is observed. If noncompliance is observed, then she will report immediately to the DON and/or administrator.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 17 676290 Department of Health & Human Services Printed: 09/24/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 676290 B. Wing 06/06/2024

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 0607 The facility administrator and DON will be reeducated by outside administrator on company policies and procedures regarding resident abuse. The administrator, who is the abuse coordinator, or designee will Level of Harm - Immediate in-service all facility staff on company policies and procedures regarding resident abuse/neglect. jeopardy to resident health or Administrator and DON will thoroughly review company policy and procedures regarding resident abuse and safety neglect for retraining purposes. If an employee witnesses an abuse allegation or if an employee is told that a resident is abused/neglected by a resident/family member or visitor, the employee will be trained by the Residents Affected - Few administrator or designee to report the allegation, immediately to the administrator. If the administrator is unavailable, then the employee is to report the allegation to their immediate supervisor. It is then the supervisor's responsibility to notify the administrator. It is then the administrator's responsibility to ensure that all of the proper steps are completed, and a thorough investigation is completed, after reporting the allegation(s) to HHSC. The administrator or designee are responsible for completing the investigation and sending in the final report to HHSC in accordance with state regulatory requirements.

If any of the staff are unavailable for training sessions by 6/7/2024, then each employee, including agency staff will not be able to work on the floor until they have gone through the appropriate training.

C.N.A. A has been terminated from employment by the administrator, effective 6/04/2024.

Start Date: 06/04/2024.

Completion Date: The above will be completed by 6/7/2024.

Responsible: Administrator, DON and ADON

Record review on 06/06/2024 of the inservice on Resident Abuse/Neglect Policy, dated 06/04/2024, reflected 67 staff was inserviced on the abuse and neglect policy by the Administrator and DON.

Record review on 06/06/2024 of CNA C personnel record reflected he was terminated on 06/04/2024.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 17 676290 Department of Health & Human Services Printed: 09/24/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 676290 B. Wing 06/06/2024

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 0607 Interview on 06/06/2024 at 11:03 am the DON stated she was reeducated on pain and skin assessments and the proper policies and procedures by DON K from a sister facility. She stated she was inserviced when Level of Harm - Immediate pain and skin assessments were to be completed after an incident with a resident. The DON stated a pain jeopardy to resident health or and or skin assessment should be reported when any new skin findings or abnormalities are discovered, or safety resident has new complaints of pain or if resident falls. The DON stated if this occurred, a skin and pain assessment should be completed, and resident should be evaluated head to toe including any report of Residents Affected - Few abuse or neglect. She also stated nurses were to evaluate pain, look at non-verbal grimacing, verbal screaming, the nurses had a scale of 0 - 10 to use on residents who are verbal. She also stated reporting should be completed when there was bruises from an unexplained injury within 2 hours of discovery. The DON also stated the nurses was expected to document in the chart any administration of pain medication as ordered or needed and to notify the physician. She also stated the CNAs was expected to immediately report any abuse/neglect, change of condition or pain to the charge nurse. She stated she was in-serviced on abuse and neglect and read over the policy. She stated she learned the facility had five days to complete investigation and send in the report to HHSC. She stated if anyone reported abuse or neglect to her or the Administrator they had 2 hours to resport it to HHSC. She sated the Administrator was the abuse and neglect coordinator. The DON also stated the staff was expected and had been in serviced to report any signs of abuse or neglect to the Abuse Coordinator, the Administrator.

On 6/6/2024 at 1:57 am the Administrator revealed he was reeducated on pain and skin assessments and

the proper policies and procedures by RN K DON and Administer M at a sister facility. He learned pain and skin assessment should be complete anytime anything is noticed on a resident that has not been seen before. If it is noticed by the CNA, it should be report to the nurse immediately. If the CNA sees something that is red on the resident's body, and it is new it needs to be reported to the charge nurse. The charge nurse should then do a head-to-toe assessment and a pain assessment. He was also in-serviced in abuse and neglect. If someone is dismissed for abuse or neglect, the facility needs to report it to the licensing authority within 5 days. He will report abuse and neglect to HHSC as soon as possible as soon as he can get his computer up and running.

On 06/06/2024 at 6:50 PM, the Administrator was notified the IJ was removed on 06/06/2024 at 6:50 PM, the facility remained at a level of with potential for more than minimal harm that is not immediate jeopardy at a scope of isolated that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 17 676290