Health inspection·April 29, 2023

F 0600 Monitor resident for tail gaiting when visitor and staff exiting facility Level of Harm - Immediate jeopardy to resident health or safety Reassess elopement risk at least quarterly Residents Affected - Few Use diversion activities when exit seeking behavior occurs Refer to social services as needed Use verbal and if necessary physical cues for redirection to persuade exit-Convey acceptance during periods of inappropriate behavior Talk to resident during entire procedure of care seeking behaviors. Use wander guard system to alert staff of exit seeking behavior Record Review of hospital records dated [DATE]for Resident #1 reflected, Resident #1 was admitted to the hospital on [DATE]. The records reflected Resident # 1 was diagnosed with a Subdural Hematoma (a type of bleeding in which a collection of blood usually associated with a traumatic brain injury). The records reflected that Resident # 1 clinically decompensated and a repeat CT showed a worsening (SDH) Subdural Hematoma (a type of bleeding in which a collection of blood usually associated with a traumatic brain injury) and a (SAH) Seperatical Subarachroid Hemorrhage bleeding that is spreading to other parts of the body). The medical records further reflected that on [DATE] Resident # 1 had a decompressive craniotomy (used to treat intercranial pressure that is unresponsive to conventional treatment for SDH/SAH). Review of Resident #4 face sheet reflected he was a [AGE] year-old man admitted to the facility on [DATE]. Resident # 4 was admitted with a diagnosis of Generalized Epilepsy ( a form of epilepsy characterized by general seizures with no apparent cause), Cerebral Palsy (a group of disorders that affect a person's ability to move and maintain balance and posture), Congenital deformity of spine (the vertebrae don't form properly very early in fetal development), Contracture right elbow(an injury that causes pain and limits bending of the elbow), Unspecified Dementia(a Mental disorder in which a person loses the ability to think, remember, learn, and make decisions), Unspecified Psychosis (when there is inadequate information to make the diagnosis of a specific psychotic disorder), Moderate intellectual disabilities (intellectual and adaptive functioning that are approximately three to four standard deviations below the mean), and Schizoaffective Disorder(a combination of symptoms of schizophrenia and mood disorder, such as depression or bipolar disorder). Record review of Resident # 4 MDS dated [DATE] reflected a BIMS score of 00 (which indicated the resident does not have the cognitive ability for the assessment to be completed). The MDS reflected Resident # 4 is ambulatory no assistance walking or with transfers. Resident #4 has a contracted arm, so he only has the use of one arm. Requires assistance dressing, some ADL's. Record review of Resident #4 care plan dated [DATE], reflected a behavior to be physically aggressive. The plan reflected that Resident # 4 is very protective of his belongings and has become aggressive with staff and recently with another resident. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455478 If continuation sheet Page 2 of 12 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 455478 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ivy Creek Wellness & Rehabilitation 2501 Maple Ave Waco, TX 76707 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 Interventions included: Level of Harm - Immediate jeopardy to resident health or safety Administer medications as ordered, Residents Affected - Few Monitor Q shift (every shift) and document observed behavior and attempted interventions analyze time of day, places, circumstances, triggers, and what de-escalates behavior and document. Monitor/document any signs /symptoms that resident is posing a danger to self or others Staff to provide Q 15minute (every shift) or Q 1-hour (every shift) checks as directed Staff will encourage resident to keep distance from other residents that provoke agitation Record review of facility progress notes dated [DATE] - [DATE] of Resident # 4 aggressive behaviors towards others, the incidents are as follows: Incident [DATE], Resident # 4 assaulted Resident # 1 causing death. Incident [DATE], Resident # 4 assaulted another resident. Incident [DATE], Resident # 4 assaulted another resident Incident [DATE], Resident # 4 assaulted staff member LVN D Observation of facility video dated [DATE], reflected Resident #1 going into Resident # 4's room earlier that day with several staff on the hall never redirected. The video showed there were two staff observed in the hall prior to Resident # 1 entering Resident # 4's room. The video showed LVN B on the hall, and another unknown staff no redirection was provided. Resident #1 sustained were a busted lip that was bleeding, busted nose, one tooth was knocked out, and swelling to the left side on her forehead. Resident # 1 died from the injuries she sustained. Observation on [DATE] at 12:30pm, revealed an unidentified resident wandering on the East end of the hall near the Pharmacy supply room, which was observed to be open at the time. No staff observed in the area to resident this resident. Observation on [DATE] at 4:00, revealed unidentified resident on far East end of the building, near back exit door. Resident came in conference where surveyor was working asking to be changed, no staff observed on hall, resident not redirected. During a phone interview on [DATE] at 5:21pm with LVN A, revealed she was working the day of the incident. She stated she provided one on one care and supervision for another resident. LVN A stated she saw Resident # 4 pushing something aggressively in his door, but could not see what, she stated when she walked down the hall, she saw Resident # 1 in the doorway of the Resident #4's room. LVN A described Resident #1 as laid with her head back and legs stretched out in her wheelchair. LVN A stated she pulled Resident # 1 out the room and called for help. LVNA stated Resident # 1 was conscience but seemed to be confused. In an interview on [DATE] at 2:22pm with LVN D, revealed one time when she tried to assist Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455478 If continuation sheet Page 3 of 12 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 455478 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ivy Creek Wellness & Rehabilitation 2501 Maple Ave Waco, TX 76707 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 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few # 2 with pouring the sugar, he got upset and grabbed her wrist. She stated Resident # 2 grabbed her wrist really hard and started to twist it, she stated it hurt and she yelled out in pain. LVN D stated when she yelled out Resident # 2 let her wrist go, stated her arm was red and it hurt. LVN D stated Resident # 1 was a wanderer and stated she had taken the Resident # 1 out of Resident # 2's room before maybe a week before and stated Resident # 1 was in his room while he was asleep watching him sleep. LVN D stated they would try to keep an eye on Resident # 1 throughout the day and redirect her if she went into someone's room. During a phone interview on [DATE] at 2:47pm with LVN B, revealed Resident # 1 was known to be a wanderer and had been known to wander into other resident's rooms. She stated on the day of the incident [DATE] early that day she pushed Resident # 1 off the 1 [NAME] Hall, back to the common area. She stated later she talked to Resident # 1 on the 1 [NAME] Hall but could not remember what she spoke to her about. She stated she did not remember what happened after she had spoken with Resident # 1. She stated she did not redirect Resident # 1 at that time because she was just sitting in the hall, she stated she was not bothering anyone she was just in her chair. LVN B stated she had been trained on abuse/neglect and stated the administrator is the abuse/neglect coordinator. She stated she had never seen or suspected abuse/neglect. In an interview on [DATE] at 3:10pm the ADM. stated Resident # 1 was a wanderer. He stated staff would redirect Resident # 1 when she would go into resident's rooms. The ADM. stated staff tried to keep Resident # 1 in their sight. He stated staff did not redirect Resident # 1 when she was assaulted because it was during dinner time and all staff assisted with dinner service for the other residents. In an interview on [DATE] at 4:21PM the DON stated Resident # 1 was a wanderer. She stated the resident wore a wander guard, they redirected Resident # 1, and tried to keep her in their sight the best they could. The DON stated the staff would make rounds every two hours to check on all the residents. In an interview on [DATE] at 5:00pm the ADON revealed, Resident #1 was a wanderer. She stated they often removed and redirected Resident # 1 from going into other resident's rooms and messing with their things. The ADON stated Resident # 1 wears a wander guard and stated they tried to keep an eye on her the best they could by redirecting, she stated the door alarm would go off if she got close to any of the doors. In a phone interview on [DATE] at 11:30am LE, revealed the facility contacted EMS at 5:55PM on [DATE] and they were dispatched to the facility. LE reported that Resident # 1 was assaulted by Resident #4 at the facility and was transported to the hospital for further treatment. The LE reported the resident that assaulted Resident # 1 was not arrested at the time of the incident due to his diagnosis. LE stated the case was sent to the District Attorney's office to see if charges would be filed. In a phone interview on [DATE] at 1:30PM MD, revealed that Resident # 1 died from the injuries sustained from being assaulted by another resident. He reported that Resident # 1 continued to hemorrhage (bleed) worsened and spread through other parts of Resident # 1 body, he stated Resident # 1 expired on [DATE]. Review of QAPI - (Quality Assurance and Performance Improvement) dated Nov. 2022- [DATE]. ADM. reported the incident was discussed in the meeting along with the other incidents and accidents. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455478 If continuation sheet Page 4 of 12 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 455478 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ivy Creek Wellness & Rehabilitation 2501 Maple Ave Waco, TX 76707 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 Record review of in-service completed [DATE], reflected staff in-serviced on Abuse/Neglect. Level of Harm - Immediate jeopardy to resident health or safety Record review of facility Abuse /Neglect policy dated [DATE] which reflected: Residents Affected - Few Protect our residents from neglect by anyone including but not necessarily limited to facility staff other residents, consultants, and volunteer staff from other agencies. Our resident has the right to be free from abuse/neglect An Immediate Jeopardy was identified on [DATE]. The ADM. was informed of the IJ on [DATE] and provided with the IJ template on [DATE] at 4:20pm. Record review on [DATE] reflects staff in-serviced on Dementia / Behavioral issues 73 staff have been in-serviced. Record review on [DATE] reflected the DON/ADON, and DON completed a training on governance and Leadership on [DATE]. Records review on [DATE] reflected staff were in-serviced on Dementia care 73 staff have been trained and 17 more staff still need to be trained. Review of records reflect 19 staff have been trained on the mealtime monitoring services. Review of records on [DATE] reflected residents identified as wander risk had been reassessed on [DATE], which indicated they were no longer a wander risk. Review of care plans on [DATE], reflected the care plans for residents identified as wander risk had been updated to reflect any new interventions. Record review on [DATE] reflected, the MD (Medical Director) was made aware of the IJ, consulted regarding the plan of removal and agreed with the plan presented. Record review on [DATE] reflected, a QAPI meeting was held on [DATE] the IJ was discussed and plan of correction. An IJ was identified on [DATE]. The IJ began on [DATE] and removed on [DATE]. The facility took action to remove the IJ before the survey began. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of actual harm that was not immediate Jeopardy and a severity level of isolated because (e.g.) all staff had not been trained on abuse/neglect, supervision, wandering/ elopement signs. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455478 If continuation sheet Page 5 of 12 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 455478 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ivy Creek Wellness & Rehabilitation 2501 Maple Ave Waco, TX 76707 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 - Immediate jeopardy to resident health or safety Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide adequate supervision and devices to prevent accidents for 2 of 8 (Resident #1, Resident # 4) residents reviewed for accidents and supervision. Residents Affected - Few The facility failed to supervise and redirect Resident # 1 from entering Resident # 4's room resulting in Resident # 1 being assaulted by Resident # 4 on [DATE]. Resident # 1 died from the injuries sustained on [DATE]. Resident # 1 had a history of wandering behavior and would often wander into other residents rooms. Resident # 4 had a history of aggressive behaviors towards staff and residents. An IJ was identified on [DATE]. The IJ began on [DATE] and removed on [DATE]. The facility took action to remove the IJ before the survey began. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of actual harm that was not immediate Jeopardy and a severity level of isolated because (e.g.) all staff had not been trained on abuse/neglect, supervision, wandering/ elopement signs. This failure placed all residents at risk of accidents, hazards, hospitalization, and /or death. Findings included: Record review of Resident # 1 and Resident # 4 records are closed records review. Resident # 1 discharged to the hospital on [DATE] where she later died on [DATE]. Resident # 4 discharged from the facility on [DATE] return not expected. Record review of Resident #1's face sheet reflected she was a [AGE] year-old woman admitted to the facility on [DATE]. Resident # 1 was admitted with diagnoses of Dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), Alzheimer's (a type of Dementia that affects memory, thinking and behavior), Cirrhosis of the Liver (severe scaring of the liver). Record review of Quarterly MDS dated [DATE], reflected Resident #1 had a BIMS score of 99 which indicated unable to complete assessment. Review of a Care Plan dated [DATE] reflected Resident # 1 had exit seeking behaviors and had the following interventions: Check for proper functioning of the wander guard system every shift Monitor resident for tail gaiting when visitor and staff exiting facility Reassess elopement risk at least quarterly Refer to social services as needed Use diversion activities when exit seeking behavior occurs Use verbal and if necessary physical cues for redirection to persuade exit-Convey acceptance during (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455478 If continuation sheet Page 6 of 12 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 455478 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ivy Creek Wellness & Rehabilitation 2501 Maple Ave Waco, TX 76707 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 periods of Level of Harm - Immediate jeopardy to resident health or safety inappropriate behavior Residents Affected - Few seeking behaviors. Talk to resident during entire procedure of care Use wander guard system to alert staff of exit seeking behavior Review of Resident #4 face sheet reflected he was a [AGE] year-old man admitted to the facility on [DATE]. Resident # 4 was admitted with a diagnosis of Generalized Epilepsy ( a form of epilepsy characterized by general seizures with no apparent cause), Cerebral Palsy (a group of disorders that affect a person's ability to move and maintain balance and posture), Congenital deformity of spine (the vertebrae don't form properly very early in fetal development), Contracture right elbow(an injury that causes pain and limits bending of the elbow), Unspecified Dementia(a Mental disorder in which a person loses the ability to think, remember, learn, and make decisions), Unspecified Psychosis (when there is inadequate information to make the diagnosis of a specific psychotic disorder), Moderate intellectual disabilities (intellectual and adaptive functioning that are approximately three to four standard deviations below the mean), and Schizoaffective Disorder(a combination of symptoms of schizophrenia and mood disorder, such as depression or bipolar disorder). Record review of Resident # 4 MDS dated [DATE] reflected a BIMS score of 00 (which indicated the resident does not have the cognitive ability for the assessment to be completed). Resident # 4 was ambulatory no assistance walking or with transfers. Resident #4 has a contracted arm, so he only has the use of one arm. Requires assistance dressing, some ADL's Record review of Resident #4 care plan dated [DATE], reflected a behavior to be physically aggressive. The plan reflected that Resident # 4 is very protective of his belongings and has become aggressive with staff and recently with another resident. Interventions included: Administer medications as ordered, analyze time of day, places, circumstances, triggers, and what de-escalates behavior and document. Monitor Q shift (every shift) and document observed behavior and attempted interventions Monitor/document any signs /symptoms that resident is posing a danger to self or others Staff to provide Q 15minute (every shift) or Q 1-hour (every shift) checks as directed Staff will encourage resident to keep distance from other residents that provoke agitation Record review of facility progress notes dated [DATE] - [DATE] of Resident # 4 aggressive behaviors towards others, the incidents are as follows: Incident [DATE], Resident # 4 assaulted Resident # 1 causing death. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455478 If continuation sheet Page 7 of 12 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 455478 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ivy Creek Wellness & Rehabilitation 2501 Maple Ave Waco, TX 76707 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 Incident [DATE], Resident # 4 assaulted another resident. Level of Harm - Immediate jeopardy to resident health or safety Incident [DATE], Resident # 4 assaulted another resident Residents Affected - Few In an interview on [DATE] at 4:00pm LVN C, stated Resident # 1, was a wanderer. She statedshe wore a wander guard, so this would alert them if the resident went near the exit doors. She stated they monitored by redirecting the resident and checking on her every two hours. Incident [DATE], Resident # 4 assaulted staff member LVN D During a phone interview on [DATE] at 5:21pm LVN A, revealed that Resident # 1, was a wanderer and they monitored as best as they could. LVN A stated they monitored by redirecting, tried to keep her close to the nurse's station, and when they completed their two- hour checks on all residents. LVN A described Resident # 4 as being pleasant when around others, stated she had heard that he was aggressive with others but stated she had never seen Resident # 4 be aggressive. During a phone interview on [DATE] at 2:47pm LVN B, revealed Resident # 1, was a wander stated they monitored by redirecting the resident and she wore a wander guard so if she went close to the doors the alarm would sound. LVN B stated Resident # 4 had been aggresive with other residents in the past, and stated also a staff member. LVN B stated Resident # 4 is usually a happy person who likes to speak to everyone when walking down the halls. In an interview on [DATE] at 2:22pm with LVN D, revealed one time when she tried to assist Resident # 4 with pouring the sugar, he got upset and grabbed her wrist. She stated Resident # 2 grabbed her wrist really hard and started to twist it, she stated it hurt and she yelled out in pain. LVN D stated when she yelled out Resident # 4 let her wrist go, stated her arm was red and it hurt. LVN D stated Resident # 1 was a wanderer and stated she had taken the Resident # 1 out of Resident #4's room before maybe a week before and stated Resident # 1 was in his room while he was asleep watching him sleep. LVN D stated they would try to keep an eye on Resident # 1 throughout the day and redirect her if she went into someone's room In an interview on [DATE] at 2:00pm with CNA A, B, and C, revealed Resident # 1, was identified as a wanderer. They reported that they monitored the resident movements by keeping her close to the nurse's station throughout the day. They reported the resident also wore a wander guard and she went close to the doors the alarm would sound and alert them. CNA A, B, and C stated they monitored Resident # 1, the best that they could. CNA A, B, and C stated Resident # 4 was usuaully happy, he liked to interact with others and wave when he walked down the halls. CNA A, B, and C stated Resident # 4 had been aggressive with other residents and with another staff member. They stated Resident # 4 was protective of his things and didn't like people messing with this things such as his hats and sun glasses that he always wore. In an interview on [DATE] at 4:45pm with DON revealed, Resident # 1, was a wanderer and staff must redirect resident. She stated they monitor the resident every two hours and check the wander guard daily to ensure that it is working. The DON described Resident # 4 as pleasant, happy guy and stated this was the first aggressive behavior she had seen by Resident # 4 since she started at the facility. In an interview on [DATE] with ADM. revealed all staff were aware that Resident # 1, was a wanderer. He stated the resident wore a wander guard that would alarm if she went near the doors. He stated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455478 If continuation sheet Page 8 of 12 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 455478 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ivy Creek Wellness & Rehabilitation 2501 Maple Ave Waco, TX 76707 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 - Immediate jeopardy to resident health or safety Residents Affected - Few Resident # 1was injured by Resident # 4 during dinner time service and the staff were passing trays to the other residents. The administrator stated they had their QAPI meeting on [DATE] and they discussed their incidents and reportable findings and that the facility had been substantiated but not cited. The administrator did not indicate that there was any discussion regarding monitoring of the other residents, how t the incident occurred and what they needed to do to prevent an incident like this from happening again. He stated they did not talk about the incident in detail. The administrator stated that he was not able to put every resident on one-to-one supervision. Records Review of in-service completed [DATE], revealed staff in-serviced on Abuse/Neglect. Review of facility Abuse /Neglect policy dated [DATE] which reflected: Our resident has the right to be free from abuse/neglect Protect our residents from neglect by anyone including but not necessarily limited to facility staff other residents, consultants, and volunteer staff from other agencies. Record Review of Wander guard Policy dated [DATE] reflected the following: 1. If identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety. Record Review of facility Safety and Supervision of Residents policy dated [DATE] reflected the following: 1. Safety risks and environmental hazards are identified on an ongoing basis through a combination of employee trainings, employee monitoring, and reporting process. 2. Our individualized, resident- centered approach to safety addresses safety and accident hazards for individual residents 3. The are team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices. 4. Monitoring the effectiveness of interventions to include the following: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455478 If continuation sheet Page 9 of 12 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 455478 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ivy Creek Wellness & Rehabilitation 2501 Maple Ave Waco, TX 76707 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 a. Level of Harm - Immediate jeopardy to resident health or safety Evaluating the effectiveness of interventions Residents Affected - Few Modifying and replacing interventions as needed b. c. Ensuring that interventions are implemented correctly and consistently An Immediate Jeopardy was identified on [DATE]. The ADM. was informed of the IJ on [DATE] and provided with the IJ template on [DATE] at 4:20pm. Observation of facility video dated [DATE], reflected Resident #1 going into Resident # 4's room earlier that day with several staff on the hall never redirected. The video showed there were two staff observed in the hall prior to Resident # 1 entering Resident # 4's room. The video showed LVN B on the hall, and another unknown staff no redirection was provided. Resident #1 sustained were a busted lip that was bleeding, busted nose, one tooth was knocked out, and swelling to the left side on her forehead. Resident # 1 died from the injuries she sustained. Observation of facility video dated [DATE], reflected Resident #1 going into Resident # 4's room that day with several staff on the hall with no redirection provided. Observation on [DATE] at 12:30pm, revealed an unidentified resident wandering on the East end of the hall near the Pharmacy supply room, which was observed to be open at the time. No staff observed in the area to resident this resident. Observation on [DATE] at 4:00, revealed unidentified resident on far East end of the building, near back exit door. Resident came in conference where surveyor was working asking to be changed, no staff observed on hall, resident not redirected. In an interview on [DATE] at 3:30pm with CNA D revealed, he had been trained on abuse/neglect, wandering and supervision, resident rights. Stated the abuse /neglect protocol is to report if they see or suspect abuse /neglect to the administrator who is the abuse/ neglect coordinator. Stated they have been trained on monitoring during mealtimes, stated residents are being required to dine in their room or in the dining room so they can ensure supervision of the residents. Stated she looked at the [NAME] to see what a resident's care needs were and the nurse updated them when changes were made to the care plan. Stated rounds are made every two hours or as needed when residents use their call lights. In an interview on [DATE] at 3:40 with CNA E revealed, he had been trained on abuse/neglect, wandering and supervision, resident rights. Stated they have been trained on monitoring during mealtimes, stated residents are being required to dine in their room or in the dining room so they can ensure supervision of the residents. Stated he looked at the [NAME] to see what a resident's care needs were and the nurse updated them when changes were made to the care plan. Stated rounds are made every two hours, stated however throughout the day they are walking the halls. Stated the abuse /neglect protocol is to report if they see or suspect abuse /neglect to the administrator who is the abuse/ (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455478 If continuation sheet Page 10 of 12 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 455478 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ivy Creek Wellness & Rehabilitation 2501 Maple Ave Waco, TX 76707 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 neglect coordinator. Level of Harm - Immediate jeopardy to resident health or safety In an interview on [DATE] at 3:50pm with CNA F revealed, she had been trained on abuse/neglect, wandering and supervision, resident rights. Stated she looked at the [NAME] to see what a resident's care needs were and the nurse updated them when changes were made to the care plan. Stated rounds are made every two hours, stated however throughout the day they are walking the halls. Stated they have been trained on monitoring during mealtimes, stated residents are being required to dine in their room or in the dining room so they can ensure supervision of the residents. Stated the abuse /neglect protocol is to report if they see or suspect abuse /neglect to the administrator who is the abuse/ neglect coordinator. Residents Affected - Few In an interview on [DATE] with DON, stated all nursing and CNA staff have been trained on how to review the [NAME] in the PCC (point click care system) and know what the care needs are for the residents. She stated the nurses would continue to train staff on changes with residents on admission and as they occur with the residents. DON stated they would continue to assess the residents for wandering and elopement risk and make changes to interventions as they go. In an interview on [DATE] with ADM. Stated was his expectation that all staff get the needed training, and they follow the care plans of the residents when providing care and supervision. He stated they would continue to monitor and make changes as needed to their facility policies and systems that are in place. Record review on [DATE] reflects staff in-serviced on Dementia / Behavioral issues 73 staff have been in-serviced. Record review on [DATE] reflected the DON/ADON, and DON completed a training on governance and Leadership on [DATE]. Records review on [DATE] reflected staff were in-serviced on Dementia care 73 staff have been trained and 17 more staff still need to be trained. Review of records reflect 19 staff have been trained on the mealtime monitoring services. Record review on [DATE] of wander assessment dated [DATE] reflected, Resident # 1 and Resident # 2 are no longer identified as risk for wandering or elopement from the facility. Records Review of care plans on [DATE], reflected the care plans for Resident # 2 reflected no changes to the current interventions in place. The care plan for Resident # 3 reflected new interventions in place and that Resident # 3 has a wander guard for wandering and elopement. Record review on [DATE] reflected, the MD was made aware of the IJ, consulted regarding the plan of removal and agreed with the plan presented. Record review on [DATE] reflected, a QAPI meeting was held on [DATE] the IJ was discussed and plan of correction. An IJ was identified on [DATE]. The IJ began on [DATE] and removed on [DATE]. The facility took action to remove the IJ before the survey began. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of actual harm that was not immediate Jeopardy and a severity level (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455478 If continuation sheet Page 11 of 12 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 455478 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ivy Creek Wellness & Rehabilitation 2501 Maple Ave Waco, TX 76707 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 of isolated because (e.g.) all staff had not been trained on abuse/neglect, supervision, wandering/ elopement signs. Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455478 If continuation sheet Page 12 of 12