Health inspection·May 10, 2023

F 0645 Level of Harm - Minimal harm or potential for actual harm Record review of Resident # 3's PASARR Level I screening dated 01/26/22 completed by SS revealed Resident # 3 did not have a mental illness. Record review of Resident # 3's clinical record revealed there was no PASRR Level II Screening found after 01/26/22. Residents Affected - Few Record review of Resident # 3's care plan, last revised on 03/10/23, revealed a care plan for Resident # 3 has a diagnosis of Schizophrenia. She exhibits behaviors of verbal and physical aggression towards staff. She also has episodes of care and medication refusals. Goal: No report of injury to self or other due to behaviors through next review date. Interventions: If resident becomes agitated/combative, provide for safety, back away, seek assistance, reproach when calm, provide medication as ordered and indicated for PRN, Refer to psychological services as indicated. In an interview on 05/10/23 at 2:15 PM with LVN A, she stated in regard to Resident # 3, that she had contacted the LIDDA for residents with MI earlier that day, and they told her there had been an error with Resident # 3's PASARR. LVN A stated the other facility that Resident # 3 had been at was responsible for doing the PASARR. She stated Resident # 3 had never had a diagnosis of Dementia. She stated she did not do Resident # 3's PASARR upon Resident # 3 re-admitting and that it had been done by a previous staff member, but she had seen the first PASARR upon residents initial admission. She stated Resident # 3 had gotten COVID-19 and was transferred to another facility and then returned to this facility. She stated she is responsible for checking the accuracy of PASARR's for new admissions after they admit now. She stated she had worked here before and left for a while and then came back. She stated when she worked here before, her and another staff member split the alphabet to determine who did the PASARR's and MDS's. She stated she always corrected any PASARR that she may have found that was wrong She stated the LIDDA for ID/DD normally informed her when it was close to time to have a meeting for residents with ID/DD, but the previous social worker had tried keeping up with residents with MI. She stated if a resident had a PASARR completed incorrectly it could cause them to not receive the services available to them. In an interview on 05/10/23 at 12:24 PM with ADM, he stated the MDS nurse was usually responsible for ensuring the accuracy and completion of PASARR's for residents and sometimes the Social worker ensured the accuracy as well. He stated he was not aware Resident # 3's PASARR was completed incorrectly until LVN A told him about it and LVN A then submitted a form 1012 (mental illness/dementia resident review) and a new PASARR Level I must be submitted. He stated if a PASARR screening was done incorrectly a resident may be identified incorrectly and the resident may miss care needed or not be taken care of correctly, or the resident could miss services that could be offered to them. In an interview on 05/10/23 at 12:32 PM with DON, she stated LVN A was responsible for ensuring accuracy of PASARR screenings. She stated she was not aware that Resident # 3's PASARR was inaccurately completed, and that resident had already resided in facility when she began working there. She stated if a resident's PASARR was not completed correctly, the resident may not get the extra services that may be needed, and Resident # 3 could have missed some counseling or something else that Resident # 3 may have wanted. Record Review of facility policy admission Criteria dated 2001 (revised March 2019) revealed under (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455478 If continuation sheet Page 2 of 3 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 05/10/2023 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 0645 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Policy Statement: Policy Interpretation and Implementation: 9. All new admissions and re-admissions are screened for mental disorders (MD), intellectual disabilities (ID), or related disorders (DR) per the Medical Pre-admission Screening and Resident Review (PASARR) process; a. The facility conducts a level I PASARR screen for all potential admissions, regardless of payor source, to determine if the individual meets the criteria for MD, ID or RD, b. If the level I screen indicates that the individual may meet the criteria for a MD, ID, or RD, he or she is referred to the state PASARR representative for the Level II (evaluation and determination) screening process; (1) The admitting nurse notifies the social services department when a resident is identified as having a possible (or evident) MD, ID, or RD. (2) The social worker is responsible for making referrals to the appropriate state-designated authority. c. Upon completion of the Level II evaluation, the state PASARR representative determines if the individual has a physical or mental condition, what specialized or rehabilitative services he or she needs, and whether placement in the facility is appropriate. d. The state PASARR representative provides a copy of the report to the facility. e. The interdisciplinary team determines whether the facility is capable of meeting the needs and services of the potential resident that are outlined in the evaluation. f. Once a decision is made, the State PASARR representative, the potential resident and his or her representative are notified . 12. Our admission policies apply to all resident s admitted to the facility regardless of race, color, creed, national origin, age, sex, religion, handicap, ancestry, marital or veteran status, and/or payment source. 13. The Administrator, through the Admissions Department, ensures that the resident and the facility follow applicable admission policies. Event ID: Facility ID: 455478 If continuation sheet Page 3 of 3