Health inspection·December 29, 2023

F 0610 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Nurse called ER to get updated, [Resident #1] is being admitted d/t / opioid overdose, [Resident #1] tested positive for opioids and Fentanyl. [Resident #1] has current orders for opioids however does not have an order for Fentanyl. Review of Resident #1's hospital discharge paperwork, dated 12/25/23, reflected the following: Chief Complaint: [Resident #1] presets with Altered Mental Status HPI: .who presented to ED for evaluation of acute encephalopathy (a group of disorders that affect the brain and cause confusion, memory loss, or other mental changes) which began last night. Per chart review this afternoon nursing staff noticed [Resident #1] was not acting like himself and was more lethargic. Reportedly [nursing staff] are worried [Resident #1]'s family was giving him extra medications or narcotics . In ER [Resident #1] was medicated with multiple doses of Narcan (a drug used to treat known or possible opioid overdose), woke up had GCS 15 (The highest possible GCS score is 15, and the lowest is 3. A score of 15 means you were fully awake, responsive and have no problems with thinking ability or memory). Now requiring Narcan drip. Further workup revealing: UA consistent with infection, UDS + opiates and Fentanyl. Mental status: obtunded (dazed, desensitized), withdraws to pain. Principal Diagnosis: Opioid overdose Review of Resident #1's physician orders in his EMR, on 12/28/23, reflected no order for Fentanyl or any other opioids, besides Tylenol with Hydrocodeine. Review of Resident #1's EMR, on 12/28/23, reflected no admission paperwork, documents from his previous SNF , history and physical, or nurse practitioner notes. During an interview on 12/29/23 at 2:37 PM, Resident #1 stated he did not ask anyone for fentanyl or any illegal drugs, and no one, not facility staff or family member, gave him anything he did not recognize. He stated he started feeling off before his family arrived for a visit. He stated at lunch, his food was going everywhere but into his mouth. He stated after his family arrived, he felt the highest he had ever felt in his life. He stated when he went to the hospital back at the beginning of December, he did not feel high like he had this most recent incident. He stated no one brings him drugs and staff do not offer him drugs. During a telephone interview on 12/28/23 at 10:11 AM, Resident #1's FM A state he and two other family members came to pick up Resident #1 on 12/25/23 around 5:00 PM. He stated RN C showed them to his room where he immediately noticed something was off with Resident #1. He stated he seemed to be heavily medicated, had a blank stare, and was mumbling. He stated this was unlike him as he was normally very communicative. He stated he asked RN C, You all had not noticed he was like this? He stated RN C said no and left the room. He stated it was very unnerving no one had noticed Resident #1's change in condition as it was obvious something was wrong with him. He stated it looked like someone had given him drugs as he was acting high. He stated Resident #1 was sent to the hospital earlier in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455478 If continuation sheet Page 2 of 22 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 12/29/2023 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 0610 the month for similar symptoms and wondered if someone had drugged him then, too. Level of Harm - Immediate jeopardy to resident health or safety During an interview on 12/28/23 at 10:59 AM, the ADM stated he was notified of Resident #1's Fentanyl overdose on the morning of 12/26/23. He stated he was told by RN C that family members came to visit him on 12/25/23 and spent some time in his room and then stated they were going to take him out for Christmas dinner. RN C told him the family pushed him down the hallway to leave and she (RN C) asked them to sign him out first. RN C told him that an aide noticed Resident #1 did not look right. RN C told him the aide got RN C and she determined he needed to be sent to the hospital. When asked if he believed this should have been self-reported to HHSC he stated he did not because Resident #1 had a history of drug use. He stated he got kicked out of his previous facility for smoking marijuana. He stated he did not believe drugs were pushed on him, rather that he asked for them. When asked if there was any kind of investigation conducted, he stated he was waiting until he could interview Resident #1 once he returned from the hospital because that would be the main source of his investigation. He stated he had seen Resident #1 a few times on 12/25/23 during the day and he was his normal self. He stated he was not sure if he had any other visitors that day but did regularly have friends that visited him in the facility. He stated he had noticed that not all visitors signed in the visitor log when they entered the facility. He stated he planned on banning the three family members that visited him that day. He stated there was nothing in his care plan regarding his history of drug use because they had not had any incidents with Resident #1 and drugs while he had been at the facility. A request was made at this time for any admitting documents or documentation from his previous facility. Residents Affected - Few During an observation and interview on 12/28/23 at 11:41 AM, the Receptionist stated she worked Monday - Friday from 8:00 AM - 5:00 PM. She stated there was not a receptionist that worked on weekends and she did not work on Christmas Day. She stated visitors were to sign-in in their Visitor Logbook, and she pointed across the lobby to a binder. Record Review of the Visitor Logbook in the lobby, from 12/01/23 - 12/28/23, reflected no documented visitors for Resident #1. During an interview on 12/28/23 at 11:49 AM, LVN D stated she did not work on Christmas Day, but is almost always Resident #1's nurse on days she was working at the facility. She stated he often had visitors such as friends and family that would come by. She stated she had never heard of him requesting illegal substances of any kind. During a telephone interview on 12/28/23 at 1:31 PM, Resident #1's FM B stated that the current hospitalization was the second mysterious incident that has happened to Resident #1 at this facility. He stated on 12/08/23 he was sent to the hospital with the same symptoms, but a drug test was not performed. He stated the family members that visited him on 12/25/23 were family members from the other side of the family. He stated an incident like these two had not happened before at any other facility and Resident #1 had been residing in nursing facilities for over 20 years. He stated at most nursing facilities, you had to sign in when you entered, and this facility did not do that. He stated there is a book but no one enforced the rule. He stated he had never signed in and no one had ever asked who he was. He stated Resident #1 did have a history of drug abuse which is what led to him needing nursing facility care. He stated he asked Resident #1 at the hospital if he requested drugs and he responded, Why would I request something that could kill me? During a telephone interview on 12/28/23 at 2:11 PM, RN C stated she was working on 12/25/23 when Resident #1 had to be sent to the hospital. She stated during the day he was acting normal and there (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455478 If continuation sheet Page 3 of 22 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 12/29/2023 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 0610 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few was nothing out of the usual. She stated in the evening, three family members that she had never seen before came to see him and stated they were going to take him home for Christmas. As they made their way down the hall, she yelled for someone to sign him out first. She stated an aide, who she could not remember who it was, told her that Resident #1 did not look right. She stated she went and assessed him and he was slumped in his wheelchair, was ashy white, eyes were dilated, and he could not talk - which was out of the norm for him. She stated his oxygen level was 81% and she told the family she was calling 911. She stated since the symptoms were very similar to the symptoms he experienced in early December, she requested that a drug test be conducted in the ER. During an interview on 12/28/23 at 2:24 PM, the ADM stated he could not find any admission documents or documents from Resident #1's previous facility. He stated he was an Interim ADM and was not working at the facility when Resident #1 was admitted . He stated the Admissions Coordinator that worked at the facility at that time no longer worked there. Review of the facility's Illegal Drug Use Policy, dated 09/01/23, reflected the following: This facility is an illegal drug-free facility. Illegal drugs are defined for the purpose of this policy as the use, possession, or distribution of any substances which is unlawful under the Controlled Substances Act. The facility reserves the right to inspect staff only areas, conduct staff alcohol and drug testing, and terminate staff employment for violation of this policy. 1. No one is allowed to possess, be under the influence of, or use any of said illegal drugs on the premises of this facility. The ADM was notified on 12/28/23 at 2:47 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 12/29/23 at 11:31 AM:

F 689 - The facility failed to ensure resident environment remains as free of accident hazards as possible On 12/28/2023 an abbreviated survey was initiated at (facility). On 12/28/2023 the surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate jeopardy to resident health and safety. The notification of Immediate Jeopardy states as follows: Per the ADM, Resident #1 has a history of drug use and was kicked out of his old facility for smoking marijuana. He stated they did not investigate the incident because it was his belief that the family brought in the drugs, due to the resident being fine during the day until the family arrived. During an interview with Resident #1's FM revealed that there is no way of knowing who gave the resident his drugs. However, there is no way for the resident to get the drugs himself, regardless of if he asks for them or not. He stated they have no visitation process, and no one has ever asked him to sign in and anyone could just walk into the facility whenever. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455478 If continuation sheet Page 4 of 22 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 12/29/2023 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 0610 Level of Harm - Immediate jeopardy to resident health or safety Interviews with staff revealed Resident #1 has family and friends visiting him often. Review of the Visitor Log at the entrance of the facility reflected no visitors had signed in for this resident for the month of December. There is nothing in Resident #1's CP regarding a history of drug use/addiction, so no interventions were in place. Residents Affected - Few Immediate Action: 1. Action: Resident returned from the hospital and assessed by licensed nurse and care plan updated by MDS Nurse. Current interventions include scheduling a care conference with resident and responsible party to discuss current interventions put into place to prevent reoccurrence. Resident is receiving (psychiatry care services). Referral for face-to-face visit requested. Start Date: 12/28/2023 Completion Date: 12/28/2023 at 5:35 p.m. Responsible: MDS Nurse and Charge Nurse 2. Action: Incident report completed by Interim DON of alleged incident occurring on 12/25/2023 Start Date: 12/28/2023 Completion Date: 12/28/2023 @ 4:42 p.m. Responsible: Interim DON 3. Action: Ad Hoc QAPI Notified Medical Director of IJ template and action items to lower the immediacy. Start Date: 12/28/2023 Completion Date: 12/28/2023 @ 6:34 p.m. Responsible: Administrator, Medical Director, [NAME] President of Clinical Operations Identification of Resident(s) Affected or Likely to be Affected: 1. Action: Review of all residents ICD-10 codes completed by MDS nurse for identification of other residents with illicit drug history to ensure care plans are in place. No other residents identified. Start Date: 12/28/2023 Completion Date: 12/29/2023 at 5:00 p.m. Responsible: MDS Nurse (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455478 If continuation sheet Page 5 of 22 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 12/29/2023 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 0610 Actions to Prevent Occurrence/Recurrence: Level of Harm - Immediate jeopardy to resident health or safety 1. Action: Education provided to Administrator and Interim DON on investigating allegations of residents under the facility's care being on illegal drugs and contacting the proper authorities. Start Date: 12/28/2023 Residents Affected - Few Completion Date: 12/28/2023 at 5:35 p.m. Responsible: [NAME] President of Clinical Operations 2. Action: Signage posted at all facility entrances on no illicit drugs are to be brought in by visitors and/or staff. All facility staff educated on signage posted at all entrances indicating no illicit drugs are to be brought in by visitors and/or staff prior to working their next shift. All new hires will be educated prior to working their first shift. Administrator will designate Department Managers and/or designee to visualize signage remains in place every 8 hours x 7 days a week x 4 weeks. Start Date: 12/28/2023 Completion Date: 12/28/2023 at 6:30 p.m. Responsible: Administrator, Department Managers, [NAME] President of Clinical Operations, and/or designee 3. Action: Visitor log placed at nursing station for facility staff to write name of who is visiting and which resident they are visiting. All facility staff educated on new visitor log and how to complete prior to working their next shift. All new hires will be educated prior to working their first shift. Start Date: 12/28/2023 Completion Date: 12/28/2023 7 p.m. Responsible: Administrator, Interim DON, [NAME] President of Clinical Operations, and/or designee 4. Action: All facility staff educated on Illegal Drug Use Policy and immediately reporting any illegal drugs found in a residents room or on the facility grounds to the Administrator immediately. Start date: 12/29/2023 Completion: 12/29/2023 Responsible: Administrator, Interim DON, [NAME] President of Clinical Operations, and/or designee Action Item: Monitoring for compliance Vice President of Clinical Operations will review all Incident and Accident reports 5 days a week (Monday to encompass Friday-Sunday) x 4 weeks to ensure thorough investigations were completed and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455478 If continuation sheet Page 6 of 22 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 12/29/2023 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 0610 interventions care planned. Level of Harm - Immediate jeopardy to resident health or safety MDS nurse to complete weekly audits of residents ICD-10 codes for current illicit drug use and/or history and such is care planned. Residents Affected - Few Interim DON to audit visitor list at nurses station 5 days a week (Monday to encompass Friday-Sunday) x 4 weeks to ensure visitors are appropriately logged and log indicates which resident they were visiting. Interim DON and/or ADON to validate all staff education completed weekly x 4 weeks. Administrator to validate completion of the above weekly x 4 weeks. Vice President of Clinical Operations to validate completion of the above weekly x 4 weeks. Start Date: 12/28/2023 Completion Date: 2/1/2023 Responsible: [NAME] President of Clinical Operations, MDS nurse, Interim DON, Administrator and/or designee The Surveyor monitored the POR on 12/29/23 as followed: Observation on 12/29/23 at 2:24 PM revealed a sign on the entrance door that read ATTENTION ALL STAFF AND VISITORS: ILLICIT DRUGS ARE NOT PERMITTED TO BE BROUGHT INTO THE FACILITY OR GIVEN TO ANYONE AT THE FACILITY. During interviews on 12/29/23 from 2:58 PM - 5:55 PM with one HSKA, three LVNs, one MA, and two CNAs revealed they were all in-serviced before their shifts on illegal drugs not be allowed in the facility, on the facility's Illegal Drug Use Policy and immediately reporting any illegal drugs found in a residents room or on the facility grounds to the Administrator immediately, the signage posted on all entrance/exit doors regarding no illegal drugs were to be brought in, and the new visitor sign-in process. Observation on 12/29/23 at 3:32 PM revealed a visitor logbook at the nurses' station that was highly visible. There was a large sign that read ALL VISITORS MUST SIGN IN AT THE NURSES STATION. Review of an in-service entitled Illegal Drug Signage conducted by the MDSC, dated 12/28/23, reflected staff were educated on the following: There is a sign posted at the entrance for all staff and visitors that illicit drugs are not permitted to be brought into the facility or given to anyone in the facility. Review of an in-service conducted by the VPCO , dated 12/28/23, reflected staff were educated on the following: Anytime we receive information from outside entities or facility staff and/or visitors regarding illegal drug use the investigation must be started immediately and reported to the Police Department (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455478 If continuation sheet Page 7 of 22 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 12/29/2023 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 0610 and HHSC if warranted. Level of Harm - Immediate jeopardy to resident health or safety Review of the facility's Ad Hoc QAPI meeting, dated 12/28/23, reflected the following were in attendance: ADM, VPCO, RDO, and MD. Residents Affected - Few While the IJ was removed on 12/29/23 at 6:15 PM, the facility remained out of compliance at a severity of actual harm 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) Previous Versions Obsolete Event ID: Facility ID: 455478 If continuation sheet Page 8 of 22 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 12/29/2023 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 0656 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs for one (Resident #1) of five residents reviewed for care plans, in that: The facility failed to care plan Resident #1's history of illegal drug abuse. On 12/25/23, Resident #1 went unresponsive and was diagnosed with a Fentanyl overdose in the hospital. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 12/28/23 at 2:47 PM. While the IJ was removed on 12/29/23 at 6:15 PM, the facility remained out of compliance at a severity of actual harm at a scope of isolated that is not Immediate Jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This failure placed residents at risk of a drug overdose, hospitalization, or death. Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including inhalant abuse (a broad range of household and industrial chemicals whose volatile vapors or pressurized gases can be concentrated and breathed in via the nose or mouth to produce intoxication), nicotine dependence, personal history of traumatic brain injury, major depressive disorder, and other psychoactive substance dependence. Review of Resident #1's admission MDS assessment, dated 09/15/23, reflected a BIMS of 12, indicating a moderate cognitive impairment. Section G (Functional Status) reflected he was completely dependent for ADLs. Review of Resident #1's quarterly care plan, dated 09/28/23, reflected he presented with primary diagnosis of depression and bipolar with an intervention of ensuring all needs were met. There was nothing in the care plan reflected he had a history of drug abuse. Review of Resident #1's admission summary, dated [DATE], reflected the following: Lifestyle: Resident/family member report currently uses or HX of alcohol use. [Resident #1] has a history of smoking in past. Smoked, drank, abused drugs at an early age in life. Review of Resident #1's progress notes in his EMR, dated 12/25/23 at 11:36 PM and documented by RN C, reflected the following: Nurse called ER to get updated, [Resident #1] is being admitted d/t / opioid overdose, [Resident #1] tested positive for opioids and Fentanyl. [Resident #1] has current orders for opioids however does not have an order for Fentanyl. Review of Resident #1's hospital discharge paperwork, dated 12/25/23, reflected 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 22 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 12/29/2023 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 0656 Chief Complaint: [Resident #1] presets with Altered Mental Status Level of Harm - Immediate jeopardy to resident health or safety HPI: .who presented to ED for evaluation of acute encephalopathy (a group of disorders that affect the brain and cause confusion, memory loss, or other mental changes) which began last night. Residents Affected - Few Per chart review this afternoon nursing staff noticed [Resident #1] was not acting like himself and was more lethargic. Reportedly [nursing staff] are worried [Resident #1]'s family was giving him extra medications or narcotics . In ER [Resident #1] was medicated with multiple doses of Narcan (a drug used to treat known or possible opioid overdose), woke up had GCS 15 . Now requiring Narcan drip. Further workup revealing: UA consistent with infection, UDS + opiates and Fentanyl. Mental status: obtunded (dazed, desensitized), withdraws to pain. Principal Diagnosis: Opioid overdose Review of Resident #1's EMR, on 12/28/23, reflected no admission paperwork, documents from his previous SNF , history and physical, or nurse practitioner notes. During an interview on 12/29/23 at 2:37 PM, Resident #1 stated he did not ask anyone for fentanyl or any illegal drugs, and no one, not facility staff or family member, gave him anything he did not recognize. He stated he started feeling off before his family arrived for a visit. He stated at lunch, his food was going everywhere but into his mouth. He stated after his family arrived, he felt the highest he had ever felt in his life. He stated when he went to the hospital back at the beginning of December, he did not feel high like he had this most recent incident. He stated no one brings him drugs and staff do not offer him drugs. During a telephone interview on 12/28/23 at 10:11 AM, Resident #1's FM A state he and two other family members came to pick up Resident #1 on 12/25/23 around 5:00 PM. He stated RN C showed them to his room where he immediately noticed something was off with Resident #1. He stated he seemed to be heavily medicated, had a blank stare, and was mumbling. He stated this was unlike him as he was normally very communicative. He stated he asked RN C, You all had not noticed he was like this? He stated RN C said no and left the room. He stated it was very unnerving no one had noticed Resident #1's change in condition as it was obvious something was wrong with him. He stated it looked like someone had given him drugs as he was acting high. He stated Resident #1 was sent to the hospital earlier in the month for similar symptoms and wondered if someone had drugged him then, too. During an interview on 12/28/23 at 10:59 AM, the ADM stated he was notified of Resident #1's Fentanyl overdose on the morning of 12/26/23. He stated he was told by RN C that family members came to visit him on 12/25/23 and spent some time in his room and then stated they were going to take him out for Christmas dinner. RN C told him the family pushed him down the hallway to leave and she (RN C) asked them to sign him out first. RN C told him that an aide noticed Resident #1 did not look right. RN C told him the aide got RN C and she determined he needed to be sent to the hospital. He stated he got kicked out of his previous facility for smoking marijuana. He stated he did not believe drugs (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455478 If continuation sheet Page 10 of 22 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 12/29/2023 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 0656 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few were pushed on him, rather that he asked for them. When asked if there was any kind of investigation conducted, he stated he was waiting until he could interview Resident #1 once he returned from the hospital because that would be the main source of his investigation. He stated he had seen Resident #1 a few times on 12/25/23 during the day and he was his normal self. He stated he was not sure if he had any other visitors that day but did regularly have friends that visited him in the facility. He stated he had noticed that not all visitors signed in the visitor log when they entered the facility. He stated he planned on banning the three family members that visited him that day. The ADM stated the MDSC was primarily responsible for ensuring the accuracy of care plans. He stated it was important to individualize the care plans to each resident to ensure the highest quality of care to avoid any potential minor or major harm. He stated he would assume Resident #1's drug history was not in his care plan due to it not having happened while he had been residing at the facility. During an observation and interview on 12/28/23 at 11:41 AM, the Receptionist stated she worked Monday - Friday from 8:00 AM - 5:00 PM. She stated there was not a receptionist that worked on weekends and she did not work on Christmas Day. She stated visitors were to sign-in in their Visitor Logbook, and she pointed across the lobby to a binder. Record Review of the Visitor Logbook in the lobby, from 12/01/23 - 12/28/23, reflected no documented visitors for Resident #1. During an interview on 12/28/23 at 11:49 AM, LVN D stated she did not work on Christmas Day, but is almost always Resident #1's nurse on days she was working at the facility. She stated he often had visitors such as friends and family that would come by. She stated she had never heard of him requesting illegal substances of any kind. During a telephone interview on 12/28/23 at 1:31 PM, Resident #1's FM B stated that the current hospitalization was the second mysterious incident that has happened to Resident #1 at this facility. He stated on 12/08/23 he was sent to the hospital with the same symptoms, but a drug test was not performed. He stated the family members that visited him on 12/25/23 were family members from the other side of the family. He stated an incident like these two had not happened before at any other facility and Resident #1 had been residing in nursing facilities for over 20 years. He stated at most nursing facilities, you had to sign in when you entered, and this facility did not do that. He stated there is a book but no one enforced the rule. He stated he had never signed in and no one had ever asked who he was. He stated Resident #1 did have a history of drug abuse which is what led to him needing nursing facility care. He stated he asked Resident #1 at the hospital if he requested drugs and he responded, Why would I request something that could kill me? During a telephone interview on 12/28/23 at 2:11 PM, RN C stated she was working on 12/25/23 when Resident #1 had to be sent to the hospital. She stated during the day he was acting normal and there was nothing out of the usual. She stated in the evening, three family members that she had never seen before came to see him and stated they were going to take him home for Christmas. As they made their way down the hall, she yelled for someone to sign him out first. She stated an aide, who she could not remember who it was, told her that Resident #1 did not look right. She stated she went and assessed him and he was slumped in his wheelchair, was ashy white, eyes were dilated, and he could not talk - which was out of the norm for him. She stated his oxygen level was 81% and she told the family she was calling 911. She stated since the symptoms were very similar to the symptoms he experienced in early December , she requested that a drug test be conducted in the ER. During an interview on 12/28/23 at 2:24 PM, the ADM stated he could not find any admission (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455478 If continuation sheet Page 11 of 22 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 12/29/2023 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 0656 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few documents or documents from Resident #1's previous facility. He stated he was an Interim ADM and was not working at the facility when Resident #1 was admitted . He stated the Admissions Coordinator that worked at the facility at that time no longer worked there. During an interview on 12/29/23 at 4:25 PM, the MDSC stated she was responsible for all resident care plans. She stated she looked at what was triggering from the MDS, medications that needed monitoring, diagnoses, and behaviors. She stated not having any interventions for Resident #1 regarding his history of drug abuse was an over-sight and was missed. Review of the facility's Comprehensive Care Plans Policy, dated 01/01/23, reflected the following: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. The ADM was notified on 12/28/23 at 2:47 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 12/29/23 at 11:31 AM:

F656 - The facility must develop and implement a comprehensive person-centered care plan for each resident. On 12/28/2023 an abbreviated survey was initiated at (facility). On 12/29/2023 the surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate jeopardy to resident health and safety. The notification of Immediate Jeopardy states as follows: Resident #1 is a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including TBI, cocaine dependence (in remission), and bipolar disorder. Interview with the ADM revealed that on 12/25/23 around 5:00 PM, three of Resident #1's family members came to visit. Approximately 20 minutes later the family was pushing him down the hallway towards the exit to take him to dinner when a CNA noticed that he did not look like himself. The CNA went and got the nurse who observed him to be sedated, have low O2 sats, and was unresponsive. Resident #1 was immediately sent to the hospital. Due to him having a similar episode earlier in the month, the nurse requested that a drug test be conducted at the ER. The results showed fentanyl and THC in the resident's system. Per the ADM, Resident #1 has a history of drug use and was kicked out of his old facility for smoking marijuana. He stated they did not investigate the incident because it was his belief that the family brought in the drugs, due to the resident being fine during the day until the family arrived. Interviews with staff revealed Resident #1 has family and friends visiting him often. Review of the Visitor Log at the entrance of the facility reflected no visitors had signed in for this resident for the month of December. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455478 If continuation sheet Page 12 of 22 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 12/29/2023 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 0656 There is nothing in Resident #1's CP regarding a history of drug use/addiction, so no interventions were in place. Level of Harm - Immediate jeopardy to resident health or safety Review of the facility's ANE Policy reflects that the facility will implement policies and procedures to prevent neglect. Residents Affected - Few Facility Response: Immediate Action 1. Action: Resident returned from the hospital and assessed by licensed nurse and care plan updated by MDS Nurse. Current interventions include scheduling a care conference, scheduled for 12/29/2023 at 3:00 pm with resident and responsible party to discuss current interventions put into place to prevent reoccurrence (1) Observe resident(s) for signs and symptoms of drug use, change in level of consciousness, excessive sedation, speech impairment. Any findings to be reported to administrator/designee, medical director, and responsible party and (2) Educate resident(s) on the adverse effects that illegal drugs could have on their overall health condition. Resident is receiving Psychiatry Services. Referral for face-to-face visit requested by MDS nurse. Start Date: 12/28/2023 Completion Date: 12/28/2023 at 5:35 p.m. Responsible: MDS Nurse and Charge Nurse Identification of Resident(s) Affected or Likely to be Affected: Action: Review of all residents ICD-10 codes completed by MDS nurse for identification of other residents with illicit drug history to ensure care plans are in place. 1 other resident identified and care plan updated by MDS nurse. Start Date: 12/28/2023 Completion Date: 12/29/2023 at 12:00 p.m. Responsible: MDS Nurse Action to Prevent Occurrence/Recurrence: Action 1: Interim Director of Nursing and MDS Nurse educated to ensure care plans are in place and interventions are present for all current residents with a history of drug addiction (through audit only 2 residents identified with a history of drug addiction) and all future admissions with a history/current drug abuse will have a history of drug abuse care plan initiated, with interventions, per regulation. New admissions with a history of drug abuse will be identified through their referral paperwork or upon admission assessment. State Date: 12/29/2023 Completion: 12/29/2023 at 2 p.m. Responsible: [NAME] President of Clinical Operations (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455478 If continuation sheet Page 13 of 22 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 12/29/2023 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 0656 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Action 2: All facility staff educated on Illegal Drug Use Policy and immediately reporting any illegal drugs found in a resident's room or on the facility grounds to the administrator/designee immediately. The administrator/designee will call the proper authorities, initiate an investigation, report to HHSC if warranted, and will notify the DON/MDS to ensure a care plan is initiated/updated and interventions are in place. The Administrator, Interim DON, VP of Clinical Operations, and the MDS nurse will educated all facility staff prior to working their next scheduled shift. The Administrator, Interim DON, and/or the MDS nurse will educate all new staff prior to working their first shift. Start date: 12/29/2023 Completion: 12/29/2023 by 12 p.m. Responsible: Administrator, Interim DON, [NAME] President of Clinical Operations, MDS nurse and/or designee Action for Monitoring for Compliance: Action: MDS nurse to complete weekly audits of residents ICD-10 codes for current illicit drug use and/or history and ensure it is care planned weekly x 4 weeks. Administrator/designee will document on the morning stand up form, any residents with a new diagnosis of illicit drug use 5 days a week x 4 weeks (Monday to encompass Friday - Sunday). The VP of clinical operations will validate daily stand-up forms weekly x 4 weeks. All new admissions identified as having a history of drug addiction, the MDS Coordinator will initiate a care plan and ensure interventions are in place. VP of Clinical Operations will audit weekly all new admission for illegal drug use and validate care plan includes drug use history. At a minimum the QAPI committee will review all education and all audits surrounding deficient practice. Start Date: 12/28/2023 Completion: 12/29/2023 by 12 p.m. Responsible: Administrator, Interim DON, MDS nurse, and or/designee Action: Ad Hoc QAPI Notified Medical Director of IJ template and action items to lower the immediacy. Start Date: 12/29/2023 Completion Date: 12/29/2023 @ 12 p.m. Responsible: Administrator, Medical Director, [NAME] President of Clinical Operations The Surveyor monitored the POR on 12/29/23 as followed: Observation on 12/29/23 at 2:24 PM revealed a sign on the entrance door that read ATTENTION ALL STAFF AND VISITORS: ILLICIT DRUGS ARE NOT PERMITTED TO BE BROUGHT INTO THE FACILITY OR GIVEN TO ANYONE AT THE FACILITY. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455478 If continuation sheet Page 14 of 22 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 12/29/2023 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 0656 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few During interviews on 12/29/23 from 2:58 PM - 5:55 PM with one HSKA, three LVNs, one MA, and two CNAs revealed they were all in-serviced before their shifts on illegal drugs not be allowed in the facility, on the facility's Illegal Drug Use Policy and immediately reporting any illegal drugs found in a residents room or on the facility grounds to the Administrator immediately, the signage posted on all entrance/exit doors regarding no illegal drugs were to be brought in, and the new visitor sign-in process. Observation on 12/29/23 at 3:32 PM revealed a visitor logbook at the nurses' station that was highly visible. There was a large sign that read ALL VISITORS MUST SIGN IN AT THE NURSES STATION. Review of an in-service entitled Illegal Drug Signage conducted by the MDSC, dated 12/28/23, reflected staff were educated on the following: There is a sign posted at the entrance for all staff and visitors that illicit drugs are not permitted to be brought into the facility or given to anyone in the facility. Review of an in-service conducted by the VPCO , dated 12/28/23, reflected staff were educated on the following: Anytime we receive information from outside entities or facility staff and/or visitors regarding illegal drug use the investigation must be started immediately and reported to the Police Department and HHSC if warranted. Review of the facility's Ad Hoc QAPI meeting, dated 12/28/23, reflected the following were in attendance: ADM, VPCO, RDO, and MD. Review of an in-service conducted by the VPCO, dated 12/29/23, reflected the MDSC was educated on the following: All residents diagnoses are part of the care plan and should be included with interventions. In morning meeting review of all new diagnosis of illicit drug use are to be care planned immediately. You must let the ADM know in morning meeting of any residents with a new diagnosis of illicit drug use. Review of Resident #1's updated care plan, dated 12/29/23, reflected he had a history of illicit drug use with interventions of notifying the NP if there is a change in condition and to set up appointment with psychiatric services. While the IJ was removed on 12/29/23 at 6:15 PM, the facility remained out of compliance at a severity of actual harm 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) Previous Versions Obsolete Event ID: Facility ID: 455478 If continuation sheet Page 15 of 22 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 12/29/2023 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 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 ensure each resident recived adequate supervision to prevent accidents for one (Resident #1) of five residents reviewed for accidents and hazards, in that: The facility failed to supervise or prevent access to illegal drugs for Resident #1, knowing he had a history of drug use. On 12/25/23, Resident #1 went unresponsive and was diagnosed with a Fentanyl overdose in the hospital. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 12/28/23 at 2:47 PM. While the IJ was removed on 12/29/23 at 6:15 PM, the facility remained out of compliance at a severity of actual harm at a scope of isolated that is not Immediate Jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This failure placed residents at risk of a drug overdose, hospitalization, or death. Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including inhalant abuse (a broad range of household and industrial chemicals whose volatile vapors or pressurized gases can be concentrated and breathed in via the nose or mouth to produce intoxication), nicotine dependence, personal history of traumatic brain injury, major depressive disorder, and other psychoactive substance dependence. Review of Resident #1's admission MDS assessment, dated 09/15/23, reflected a BIMS of 12, indicating a moderate cognitive impairment. Section G (Functional Status) reflected he was completely dependent with ADLs. Review of Resident #1's quarterly care plan, dated 09/28/23, reflected he presented with primary diagnosis of depression and bipolar with an intervention of ensuring all needs were met. Review of Resident #1's admission summary, dated [DATE], reflected the following: Lifestyle: Resident/family member report currently uses or HX of alcohol use. [Resident #1] has a history of smoking in past. Smoked, drank, abused drugs at an early age in life. Review of Resident #1's progress notes in his EMR, dated 12/25/23 at 11:36 PM and documented by RN C, reflected the following: Nurse called ER to get updated, [Resident #1] is being admitted d/t / opioid overdose, [Resident #1] tested positive for opioids and Fentanyl. [Resident #1] has current orders for opioids however does not have an order for Fentanyl. Review of Resident #1's hospital discharge paperwork, dated 12/25/23, reflected the following: Chief Complaint: [Resident #1] presets with Altered Mental Status (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455478 If continuation sheet Page 16 of 22 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 12/29/2023 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 HPI: Level of Harm - Immediate jeopardy to resident health or safety .who presented to ED for evaluation of acute encephalopathy (a group of disorders that affect the brain and cause confusion, memory loss, or other mental changes) which began last night. Residents Affected - Few Per chart review this afternoon nursing staff noticed [Resident #1] was not acting like himself and was more lethargic. Reportedly [nursing staff] are worried [Resident #1]'s family was giving him extra medications or narcotics . In ER [Resident #1] was medicated with multiple doses of Narcan (a drug used to treat known or possible opioid overdose), woke up had GCS 15 (The highest possible GCS score is 15, and the lowest is 3. A score of 15 means you were fully awake, responsive and have no problems with thinking ability or memory). Now requiring Narcan drip. Further workup revealing: UA consistent with infection, UDS + opiates and Fentanyl. Mental status: obtunded (dazed, desensitized), withdraws to pain. Principal Diagnosis: Opioid overdose Review of Resident #1's physician orders in his EMR, on 12/28/23, reflected no order for Fentanyl or any other opioids, besides Tylenol with Hydrocodeine. Review of Resident #1's EMR, on 12/28/23, reflected no admission paperwork, documents from his previous SNF , history and physical, or nurse practitioner notes. During an interview on 12/29/23 at 2:37 PM, Resident #1 stated he did not ask anyone for fentanyl or any illegal drugs, and no one, not facility staff or family member, gave him anything he did not recognize. He stated he started feeling off before his family arrived for a visit. He stated at lunch, his food was going everywhere but into his mouth. He stated after his family arrived, he felt the highest he had ever felt in his life. He stated when he went to the hospital back at the beginning of December, he did not feel high like he had this most recent incident. He stated no one brings him drugs and staff do not offer him drugs. During a telephone interview on 12/28/23 at 10:11 AM, Resident #1's FM A state he and two other family members came to pick up Resident #1 on 12/25/23 around 5:00 PM. He stated RN C showed them to his room where he immediately noticed something was off with Resident #1. He stated he seemed to be heavily medicated, had a blank stare, and was mumbling. He stated this was unlike him as he was normally very communicative. He stated he asked RN C, You all had not noticed he was like this? He stated RN C said no and left the room. He stated it was very unnerving no one had noticed Resident #1's change in condition as it was obvious something was wrong with him. He stated it looked like someone had given him drugs as he was acting high. He stated Resident #1 was sent to the hospital earlier in the month for similar symptoms and wondered if someone had drugged him then, too. During an interview on 12/28/23 at 10:59 AM, the ADM stated he was notified of Resident #1's Fentanyl overdose on the morning of 12/26/23. He stated he was told by RN C that family members came to visit him on 12/25/23 and spent some time in his room and then stated they were going to take him out for Christmas dinner. RN C told him the family pushed him down the hallway to leave and she (RN C) asked them to sign him out first. RN C told him that an aide noticed Resident #1 did not look right. RN C told him the aide got RN C and she determined he needed to be sent to the hospital. When asked (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455478 If continuation sheet Page 17 of 22 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 12/29/2023 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 if he believed this should have been self-reported to HHSC he stated he did not because Resident #1 had a history of drug use. He stated he got kicked out of his previous facility for smoking marijuana. He stated he did not believe drugs were pushed on him, rather that he asked for them. When asked if there was any kind of investigation conducted, he stated he was waiting until he could interview Resident #1 once he returned from the hospital because that would be the main source of his investigation. He stated he had seen Resident #1 a few times on 12/25/23 during the day and he was his normal self. He stated he was not sure if he had any other visitors that day but did regularly have friends that visited him in the facility. He stated he had noticed that not all visitors signed in the visitor log when they entered the facility. He stated he planned on banning the three family members that visited him that day. He stated there was nothing in his care plan regarding his history of drug use because they had not had any incidents with Resident #1 and drugs while he had been at the facility. A request was made at this time for any admitting documents or documentation from his previous facility. During an observation and interview on 12/28/23 at 11:41 AM, the Receptionist stated she worked Monday - Friday from 8:00 AM - 5:00 PM. She stated there was not a receptionist that worked on weekends and she did not work on Christmas Day. She stated visitors were to sign-in in their Visitor Logbook, and she pointed across the lobby to a binder. Record Review of the Visitor Logbook in the lobby, from 12/01/23 - 12/28/23, reflected no documented visitors for Resident #1. During an interview on 12/28/23 at 11:49 AM, LVN D stated she did not work on Christmas Day, but is almost always Resident #1's nurse on days she was working at the facility. She stated he often had visitors such as friends and family that would come by. She stated she had never heard of him requesting illegal substances of any kind. During a telephone interview on 12/28/23 at 1:31 PM, Resident #1's FM B stated that the current hospitalization was the second mysterious incident that has happened to Resident #1 at this facility. He stated on 12/08/23 he was sent to the hospital with the same symptoms, but a drug test was not performed. He stated the family members that visited him on 12/25/23 were family members from the other side of the family. He stated an incident like these two had not happened before at any other facility and Resident #1 had been residing in nursing facilities for over 20 years. He stated at most nursing facilities, you had to sign in when you entered, and this facility did not do that. He stated there is a book but no one enforced the rule. He stated he had never signed in and no one had ever asked who he was. He stated Resident #1 did have a history of drug abuse which is what led to him needing nursing facility care. He stated he asked Resident #1 at the hospital if he requested drugs and he responded, Why would I request something that could kill me? During a telephone interview on 12/28/23 at 2:11 PM, RN C stated she was working on 12/25/23 when Resident #1 had to be sent to the hospital. She stated during the day he was acting normal and there was nothing out of the usual. She stated in the evening, three family members that she had never seen before came to see him and stated they were going to take him home for Christmas. As they made their way down the hall, she yelled for someone to sign him out first. She stated an aide, who she could not remember who it was, told her that Resident #1 did not look right. She stated she went and assessed him and he was slumped in his wheelchair, was ashy white, eyes were dilated, and he could not talk - which was out of the norm for him. She stated his oxygen level was 81% and she told the family she was calling 911. She stated since the symptoms were very similar to the symptoms he experienced in early December, she requested that a drug test be conducted in the ER. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455478 If continuation sheet Page 18 of 22 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 12/29/2023 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 During an interview on 12/28/23 at 2:24 PM, the ADM stated he could not find any admission documents or documents from Resident #1's previous facility. He stated he was an Interim ADM and was not working at the facility when Resident #1 was admitted . He stated the Admissions Coordinator that worked at the facility at that time no longer worked there. Review of the facility's Illegal Drug Use Policy, dated 09/01/23, reflected the following: Residents Affected - Few This facility is an illegal drug-free facility. Illegal drugs are defined for the purpose of this policy as the use, possession, or distribution of any substances which is unlawful under the Controlled Substances Act. The facility reserves the right to inspect staff only areas, conduct staff alcohol and drug testing, and terminate staff employment for violation of this policy. 1. No one is allowed to possess, be under the influence of, or use any of said illegal drugs on the premises of this facility. The ADM was notified on 12/28/23 at 2:47 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 12/29/23 at 11:31 AM:

F 689 - The facility failed to ensure resident environment remains as free of accident hazards as possible On 12/28/2023 an abbreviated survey was initiated at (facility). On 12/28/2023 the surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate jeopardy to resident health and safety. The notification of Immediate Jeopardy states as follows: Per the ADM, Resident #1 has a history of drug use and was kicked out of his old facility for smoking marijuana. He stated they did not investigate the incident because it was his belief that the family brought in the drugs, due to the resident being fine during the day until the family arrived. During an interview with Resident #1's FM revealed that there is no way of knowing who gave the resident his drugs. However, there is no way for the resident to get the drugs himself, regardless of if he asks for them or not. He stated they have no visitation process, and no one has ever asked him to sign in and anyone could just walk into the facility whenever. Interviews with staff revealed Resident #1 has family and friends visiting him often. Review of the Visitor Log at the entrance of the facility reflected no visitors had signed in for this resident for the month of December. There is nothing in Resident #1's CP regarding a history of drug use/addiction, so no interventions were in place. Immediate Action: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455478 If continuation sheet Page 19 of 22 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 12/29/2023 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 1. Action: Resident returned from the hospital and assessed by licensed nurse and care plan updated by MDS Nurse. Current interventions include scheduling a care conference with resident and responsible party to discuss current interventions put into place to prevent reoccurrence. Resident is receiving (psychiatry care services). Referral for face-to-face visit requested. Start Date: 12/28/2023 Residents Affected - Few Completion Date: 12/28/2023 at 5:35 p.m. Responsible: MDS Nurse and Charge Nurse 2. Action: Incident report completed by Interim DON of alleged incident occurring on 12/25/2023 Start Date: 12/28/2023 Completion Date: 12/28/2023 @ 4:42 p.m. Responsible: Interim DON 3. Action: Ad Hoc QAPI Notified Medical Director of IJ template and action items to lower the immediacy. Start Date: 12/28/2023 Completion Date: 12/28/2023 @ 6:34 p.m. Responsible: Administrator, Medical Director, [NAME] President of Clinical Operations Identification of Resident(s) Affected or Likely to be Affected: 1. Action: Review of all residents ICD-10 codes completed by MDS nurse for identification of other residents with illicit drug history to ensure care plans are in place. No other residents identified. Start Date: 12/28/2023 Completion Date: 12/29/2023 at 5:00 p.m. Responsible: MDS Nurse Actions to Prevent Occurrence/Recurrence: 1. Action: Education provided to Administrator and Interim DON on investigating allegations of residents under the facility's care being on illegal drugs and contacting the proper authorities. Start Date: 12/28/2023 Completion Date: 12/28/2023 at 5:35 p.m. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455478 If continuation sheet Page 20 of 22 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 12/29/2023 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 Responsible: [NAME] President of Clinical Operations Level of Harm - Immediate jeopardy to resident health or safety 2. Action: Signage posted at all facility entrances on no illicit drugs are to be brought in by visitors and/or staff. All facility staff educated on signage posted at all entrances indicating no illicit drugs are to be brought in by visitors and/or staff prior to working their next shift. All new hires will be educated prior to working their first shift. Administrator will designate Department Managers and/or designee to visualize signage remains in place every 8 hours x 7 days a week x 4 weeks. Residents Affected - Few Start Date: 12/28/2023 Completion Date: 12/28/2023 at 6:30 p.m. Responsible: Administrator, Department Managers, [NAME] President of Clinical Operations, and/or designee 3. Action: Visitor log placed at nursing station for facility staff to write name of who is visiting and which resident they are visiting. All facility staff educated on new visitor log and how to complete prior to working their next shift. All new hires will be educated prior to working their first shift. Start Date: 12/28/2023 Completion Date: 12/28/2023 7 p.m. Responsible: Administrator, Interim DON, [NAME] President of Clinical Operations, and/or designee 4. Action: All facility staff educated on Illegal Drug Use Policy and immediately reporting any illegal drugs found in a residents room or on the facility grounds to the Administrator immediately. Start date: 12/29/2023 Completion: 12/29/2023 Responsible: Administrator, Interim DON, [NAME] President of Clinical Operations, and/or designee Action Item: Monitoring for compliance Vice President of Clinical Operations will review all Incident and Accident reports 5 days a week (Monday to encompass Friday-Sunday) x 4 weeks to ensure thorough investigations were completed and interventions care planned. MDS nurse to complete weekly audits of residents ICD-10 codes for current illicit drug use and/or history and such is care planned. Interim DON to audit visitor list at nurses station 5 days a week (Monday to encompass Friday-Sunday) x 4 weeks to ensure visitors are appropriately logged and log indicates which resident they were visiting. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455478 If continuation sheet Page 21 of 22 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 12/29/2023 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 Interim DON and/or ADON to validate all staff education completed weekly x 4 weeks. Level of Harm - Immediate jeopardy to resident health or safety Administrator to validate completion of the above weekly x 4 weeks. Residents Affected - Few Start Date: 12/28/2023 Vice President of Clinical Operations to validate completion of the above weekly x 4 weeks. Completion Date: 2/1/2023 Responsible: [NAME] President of Clinical Operations, MDS nurse, Interim DON, Administrator and/or designee The Surveyor monitored the POR on 12/29/23 as followed: Observation on 12/29/23 at 2:24 PM revealed a sign on the entrance door that read ATTENTION ALL STAFF AND VISITORS: ILLICIT DRUGS ARE NOT PERMITTED TO BE BROUGHT INTO THE FACILITY OR GIVEN TO ANYONE AT THE FACILITY. During interviews on 12/29/23 from 2:58 PM - 5:55 PM with one HSKA, three LVNs, one MA, and two CNAs revealed they were all in-serviced before their shifts on illegal drugs not be allowed in the facility, on the facility's Illegal Drug Use Policy and immediately reporting any illegal drugs found in a residents room or on the facility grounds to the Administrator immediately, the signage posted on all entrance/exit doors regarding no illegal drugs were to be brought in, and the new visitor sign-in process. Observation on 12/29/23 at 3:32 PM revealed a visitor logbook at the nurses' station that was highly visible. There was a large sign that read ALL VISITORS MUST SIGN IN AT THE NURSES STATION. Review of an in-service entitled Illegal Drug Signage conducted by the MDSC, dated 12/28/23, reflected staff were educated on the following: There is a sign posted at the entrance for all staff and visitors that illicit drugs are not permitted to be brought into the facility or given to anyone in the facility. Review of an in-service conducted by the VPCO , dated 12/28/23, reflected staff were educated on the following: Anytime we receive information from outside entities or facility staff and/or visitors regarding illegal drug use the investigation must be started immediately and reported to the Police Department and HHSC if warranted. Review of the facility's Ad Hoc QAPI meeting, dated 12/28/23, reflected the following were in attendance: ADM, VPCO, RDO, and MD. While the IJ was removed on 12/29/23 at 6:15 PM, the facility remained out of compliance at a severity of actual harm 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) Previous Versions Obsolete Event ID: Facility ID: 455478 If continuation sheet Page 22 of 22