Health inspection·June 13, 2024

F 0576 Record review of the facility's, undated, Resident Rights policy reflected: Level of Harm - Minimal harm or potential for actual harm Information and communication: The resident has the right to be informed of his or her rights and of all rules and regulations governing resident conduct and responsibilities during his or her stay in the facility. Residents Affected - Some The resident has the right to send and receive mail, and to receive letters, packages and other materials delivered to the facility for the resident through a means other than a postal service, including the right to: o Privacy of such communications consistent with this section; and o Access to stationary, postage, and writing implements at the residents own expense. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455478 If continuation sheet Page 2 of 14 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 06/13/2024 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure, based on the comprehensive assessment of a resident, that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for 1 of 2 resident (Resident #31) reviewed for quality of care. Residents Affected - Few The facility failed to ensure Resident #31's wound care orders were followed daily. This failure could place residents at risk for worsening of wounds, development of infections, and possible loss of the highest practicable level of functioning. Findings include: Record review of Resident #31's face sheet, dated 06/13/24, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #31 had diagnoses which included Muscle Wasting, Stroke, Chronic Kidney Disease, Gangrene (dead body tissue) and Hypertension (High blood pressure). Record review of Resident #31's Quarterly MDS reflected a BIMS score of 7, indicated the resident's cognition was severely impaired. Record review of Resident #31's Care Plan, reflected a Focus was initiated for open area related to her auto immune disease on her right dorsal shin. This area heals and then reopens at times. The Care Plan Focus was revised on 3/12/24. On 5/1/24 the goal was revised to reflect a goal for her shin to heal without complications. Record review of Resident #31's orders reflected a wound treatment order to be done one time daily with a start date of 6/7/24 at 6:00 pm and a revision date of 6/12/24. Record review of Resident #31's TAR reflected an order beginning on 6/7/24 to provide daily wound care. The order is: Open area to RLE: Cleanse with normal saline, pat dry, apply Silver Alginate, cover with non-adherent dressing daily one time a day for treatment for open area. The TAR reflected no dressing changes were marked as performed for 6/7-6/12/24. The first date charted as wound treatment performed was 6/13/24. Record Review on 6/13/24 at 08:48 a.m. revealed Resident #31's TAR reflected a RLE dressing change charted as completed on 6/13/24 at 5:12 a.m. by agency nurse. On the TAR, the order had a start date on 6/7/24 and a revision date of 6/12/24. The TAR documented 6/13/24 at 05:12 a.m. dressing change was the first dressing change marked as completed and there were no notes which indicated why the dressing changes were not charted for 6/7/24 to 6/12/24. Observation on 06/11/24 at 10:45 a.m. revealed Resident #31 had a dressing on her right lower extremity with no date or initials to indicate when it was last changed. Observation on 06/12/24 at 01:58 p.m. revealed Resident #31 had a dressing on her right lower extremity with no date or initials to indicate when it was last changed. Observation on 6/13/24 at 8:44 a.m. revealed Resident #31 had a dressing on her right lower (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455478 If continuation sheet Page 3 of 14 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 06/13/2024 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few extremity with no date or initials to indicate when it was last changed. The dressing was a clean, flat, approximately 2x2 inch white gauze dressing covered with a clear dressing. The dressing edges were well adhered to skin with no signs of normal deterioration to the dressing. Skin redness extended past the dressing on the resident's right side and above the dressing edges. Unable to determine if redness was small amount of dried blood or scraped skin abrasion only. No drainage or signs of infection were observed on or around the dressing. Record Review on 6/13/24 at 08:48 a.m. revealed Resident #31's TAR reflected a RLE dressing change charted as completed on 6/13/24 at 5:12 a.m. by agency nurse. On the TAR, the order had a start date on 6/7/24 and a revision date of 6/12/24. The TAR documented 6/13/24 at 05:12 a.m. dressing change was the first dressing change marked as completed and there were no notes which indicated why the dressing changes were not charted for 6/7/24 to 6/12/24. Observation on 6/13/24 at 9:49 a.m. revealed LVN-B changed the dressing on Resident #31's right lower extremity according to orders and facility policy. The uncovered wound revealed an approximate wound area at its largest points were 3.5 inches width by 3.0 inches height. The wound appeared as a red abrasion with a small center spot approximately 1.5 mm radius and 1 mm deep (about the size of a pen tip) with a white dry center. Small, scabbed areas appeared across the red area. There was no drainage or signs of infection observed. In an interview on 6/11/24 at 10:45 a.m., Resident #31 stated the last time the dressing was changed on her right lower extremity was 3 days ago after her Saturday shower. In an interview on 6/12/24 at 01:58 p.m., Resident #31 stated the nursing staff had not come in to change the dressing since yesterday. In an interview on 6/13/24 at 08:48 a.m., LVN-B stated the last time a dressing change could be determined by looking at the date on the dressing and by looking in the electronic chart on the TAR. She said the TAR showed the dressing had already been changed on 6/13/24 at 05:12 a.m. by the night nurse. She stated the order was written to start on 6/7/24 and revised on 6/12/24. LVN-B stated the TAR showed the 6/13/24 at 05:12 a.m. dressing change was the first dressing change completed and there were no notes which indicated why the dressing changes were not completed for 6/07/24 to 6/12/24. In an interview on 6/13/24 at 08:54 a.m., Resident #31 stated, I think the dressing was changed the day before yesterday when I showered. The resident stated the dressing was not changed at 5:12 a.m. today. In an interview on 6/13/24 at 08:56 a.m., DON stated she instructed the staff to wait and do the dressing today with the State Surveyor. The DON stated an agency nurse was assigned to Resident #31 and she was sure the dressing was not changed this morning at 5:12 a.m. The DON stated she would research the order and dressing change history charted. In a joint interview on 6/13/24 at 09:43 a.m. with the DON and the ADON they stated they did daily Fail-Safe Risk Rounds to confirm orders were not missed. The DON stated she was responsible for auditing records to ensure wounds were done. She stated the audit was done but this one order was not caught due to a recent computer change. The DON stated a section of the electronic health record called the WAR was inactivated, but the staff nurse inadvertently entered the order into the WAR, so it did not show in the audit nor the treatment record. The DON also stated the staff were in serviced on the computer changes and the correct process to enter orders prior to the change. The ADON stated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455478 If continuation sheet Page 4 of 14 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 06/13/2024 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few she did additional audits, and she caught the problem on 6/12/24 and corrected the order. The DON instructed LVN-B to change the dressing because it was not currently dated, and dressings needed to be dated. In a joint interview on 6/13/24 at 12:05 p.m. with the DON and the ADON, the DON stated an audit was done on all of agency nurse assignment and all task she signed as completed were verified as completed except the dressing change for Resident #31. The ADON stated an audit was done on the WAR tab for all of June and all orders were previously corrected by the ADON with no treatments missed for any residents except Residents #31's dressing change. In an interview on 6/13/24 at 2:38 PM, Resident #31 stated she did not remember if she told anyone about the missed dressing changes. Resident #31 stated the dressings were done on shower days and shower days were Saturday (6/8/24) Tuesday (6/11/24) and Thursday (6/13/24). In an interview on 6/13/24 at 2:36 p.m. the MDR stated the facility notified him some of Resident #31's dressing changes were missed. He stated, they always let me know anytime an order is not done or if there is a problem. The MDR stated the wound had not worsened but the concern if a wound was not treated properly was always a risk of infection. In an interview on 6/13/24 at 03:05 p.m., the DON stated her expectation was wound orders be implemented correctly and placed in the right tab. She stated wound care should be charted in the electronic health record and the dressing should be dated to track when dressing changes were done. The DON stated the potential outcome if wound care was missed was the wound could get worse or develop an infection. The DON stated the computer department was permanently correcting the problem with the WAR so no orders could be entered into that tab. In an interview on 6/13/24 at 03:12 p.m., the ADON stated her expectation was wound orders be completed per physician orders and if questions arose the staff should reach out to her for help. She stated wound care should be charted in the electronic health record and the dressing should be dated and initialed. The ADON stated the potential outcome if wound care was missed was infections. In an interview on 6/13/24 at 03:18 p.m., the ADM stated her expectation was wound care orders should be implemented and followed. The ADM stated the care should be recorded in the correct place under the correct tab. She stated the potential outcome if wound care was missed was that wounds could worsen and cause further health issues. In an interview on 6/13/24 at 03:25 p.m., CNA-C stated the CAN's reported wounds to the nurses. She stated that if wound care was missed infections could develop. Record review of the facility's, undated, policy titled; Wound Treatment Management reflected: It is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician orders . Wound treatments will be provided in accordance with physician orders . Treatment will be documented in the Treatment Administration Record or in the electronic health (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455478 If continuation sheet Page 5 of 14 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 06/13/2024 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 0684 record. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455478 If continuation sheet Page 6 of 14 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 06/13/2024 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food and nutrition services. The facility failed to ensure the kitchen staff cleaned and sanitized the blender in between pureed food items. This failure could place residents at risk for food contamination and foodborne illness. Findings include: Observation of the kitchen on 06/11/24 at 10:02 AM revealed [NAME] E pureeing mixed vegetables for lunch. The mixed vegetables were pureed and placed in an appropriate container. Once the puree vegetables were completed, [NAME] E took the blender to the three-compartment sink. [NAME] E rinsed the blender with water and air dried the container. [NAME] E did not wash with soap or sanitize the blender. [NAME] E left the blender lid on the counter where the puree vegetables were. [NAME] E placed cooked beef inside the blender, with the unwashed blender lid that had mixed vegetable residue on the top. [NAME] E placed the beef in an appropriate holding container. [NAME] E took the blender and the lid to the three compartments sink and rinsed the blender and the lid with water. [NAME] E did not sanitize the blender or blender lid. [NAME] E continued with puree mashed potatoes with the non-sanitized blender. In an interview on 06/11/2024 at 10:30AM, [NAME] E stated she was trained to wash and sanitize the blender in between pureed items but said she forgot. [NAME] E stated the proper technique for cleaning and sanitizing the blender was to use the three-compartment sink to wash it and air dry in between pureed items. She stated a potential negative outcome of not properly cleaning and sanitizing the blender was the residents could get sick . In an interview on 06/12/2024 at 11:00 AM, the DM stated, the expectation for washing and sanitizing the blender was to use the three compartments sink in between food items and use a sanitation wipe if the dish could not be washed in water. She stated a potential negative outcome of not using proper washing and sanitizing between pureed food items was there could be cross contamination, the resident could get sick, or it could affect the integrity of the meal. In an interview on 06/13/2024 at 3:02 PM, [NAME] F stated he was trained to wash and sanitize the blender in between pureed items. [NAME] F stated the process for cleaning and sanitizing the blender was to use the three-compartment sink. He stated a potential negative outcome of not properly washing and sanitizing the blender in between puree food items was food poisoning and cross contamination could occur. In an interview on 06/13/2024 at 3:30 PM, the ADM stated the expectation for the blender was that it was properly cleaned and sanitized in between food items. She stated a potential negative outcome would be cross contamination or illness. Record review of the facility's policy Kitchen Sanitation, dated 2023, reflected it is the policy of the facility to ensure kitchen sanitation is completed by the kitchen staff per shift, per day. It (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455478 If continuation sheet Page 7 of 14 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 06/13/2024 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 0812 is up to the facility to ensure facility equipment is cleaned and sanitized. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455478 If continuation sheet Page 8 of 14 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 06/13/2024 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the transmission of communicable diseases and infections for 5 of 5 residents (Residents #27, #11, #20, #38 and #17) reviewed for infection control. Residents Affected - Some 1. The facility failed to ensure CMA performed proper hand hygiene when passing medications. 2. The facility failed to ensure CMA sanitized equipment according to infection control guidelines. This failure could place residents at risk for development of communicable diseases and infections. Findings were: 1. Record review of Resident #27's face sheet, dated 06/12/24, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #27 had diagnoses which included Muscle wasting, Heart disease, Chronic Obstructive Pulmonary Disease (lung disease). Depression and Anxiety Disorder. Record review of Resident #27's quarterly MDS, dated [DATE], reflected a BIMS of 15, which indicated the resident's cognition was intact. Record review of Resident #27's Care Plan reflected on 3/15/20 a Focus was initiated for risk of infection. 2. Record review of Resident #11's face sheet, dated 06/11/24, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #11 had diagnoses which included Schizophrenia, (mental illness) COPD (lung disease), Anemia, Anxiety Disorder, Hypertension (high blood pressure) and Deficiency of Specified B group vitamins. Record review of Resident #11's quarterly MDS, dated [DATE], reflected a BIMS score of 15, which indicated the resident's cognition was intact. Record review of Resident #11's Care Plan reflected on 3/15/20 a Focus was initiated for risk of infection. The Care plan also reflected Resident #11 had a risk for shortness of breath and respiratory distress due to her diagnosis of COPD. 3. Record review Resident #20's face sheet, dated 06/12/24, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #20 had diagnoses which included Alzheimer's Disease (Dementia), Hypertension (high blood pressure), Muscle Wasting, Seizures, Vascular Dementia, Bipolar (mood disorder) and Stroke. Record review Resident #20's quarterly MDS, dated , 05/26/24, reflected a BIMS score of 11, which indicated the resident had moderate cognitive impairment. Record review of Resident #20's Care Plan reflected on 12/20/22 a Care Plan Focus was initiated for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455478 If continuation sheet Page 9 of 14 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 06/13/2024 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 0880 self-care deficit related to stroke, weakness and deconditioning. Level of Harm - Minimal harm or potential for actual harm 4. Record review of Resident #38's face sheet, dated 06/12/24, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #38 had diagnoses which included COPD (lung disease), Pneumonia, Malnutrition, Respiratory (Breathing) Failure, Heart Failure and Dependence on Supplemental Oxygen. Residents Affected - Some Record review of Resident #38's quarterly MDS, dated [DATE], reflected a BIMS score of 07, which indicated the resident had severe cognitive impairment. Record review of Resident #38's Care Plan reflected on 1/31/24 a Focus was initiated for respiratory failure with a goal to remain free from complications of asthma and interventions planned to encourage prompt treatment of any respiratory infections. 5. Record review of Resident #17's face sheet, dated 06/14/24, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #17 had diagnoses which included Heart Disease, COPD (lung disease), Post Traumatic Stress Disorder and Muscle Weakness. Record review of Resident #17' quarterly MDS reflected a BIMS score of 09, which indicated the resident had moderate cognitive impairment. Record review of Resident #17's Care Plan reflected on 9/26/23 a Focus was initiated for asthma with a goal to remain free from complications of asthma and interventions planned to encourage prompt treatment of any respiratory infections. Observation on 6/12/24 at 8:44 a.m. revealed MA went to Resident #27's room with a blood pressure cuff to check his vitals. She returned to the medication cart and placed blood pressure cuff on the top of the medication cart without sanitizing it. The MA proceeded to administer Resident #27's medications, then returned to the medication cart to start the next resident's medications without sanitizing the blood pressure cuff. Her hands were sanitized. Observation on 6/12/24 at 9:00 a.m. revealed MA prepared medications for Resident #11 on top of the medication cart. The blood pressure cuff she had not sanitized was still on the top of the medication cart on which she was working. She then proceeded to take Resident #11's blood pressure. After administering Resident #11's medications, she returned the blood pressure cuff to the top of the medication cart without sanitizing it. MA performed hand hygiene on her hands. Observation on 6/12/24 at 9:04 a.m. revealed MA prepared medications for Resident #20 on top of the medication cart. The blood pressure cuff she had not sanitized was still on the top of the medication cart, on which she was working. The MA then proceeded to take Resident #20's blood pressure with the blood pressure cuff. After administering Resident #20's medications, she returned the blood pressure cuff to the top of the medication cart without sanitizing it. The MA did not wash or sanitize her hands after leaving the resident's room. Observation on 6/12/24 at 9:23 a.m. revealed MA entered Resident #38's room without performing hand hygiene to ask if he was ready for his medications. Resident was on his cell phone, so she agreed to come back for his medications. She removed the breakfast tray from his room. MA did not perform hand hygiene after disposing of the tray. The blood pressure cuff she had not sanitized remained on her cart. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455478 If continuation sheet Page 10 of 14 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 06/13/2024 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Observation on 6/12/24 at 9:26 a.m. revealed MA entered Resident #17's room to see if she was ready for medication. The resident was not ready for her medications. MA left the room and washed her hands. The un-sanitized blood pressure cuff remained on her cart. In an interview on 6/12/24 at 09:40 a.m., the MA stated she missed hand hygiene between a couple of rooms. She stated she, wondered if she should be cleaning the blood pressure cuff. She stated infection control was important to prevent the spread of infections between residents and examples of potential spread would be scabies or C. Diff. (Clotridoides Difficile Colitis) infections. In an interview on 6/13/24 at 03:05 p.m., the DON stated the facility knew hand hygiene, and it was expected. The policy was to sanitize hands with alcohol gel if not visibly soiled or wash hands if visibly soiled. The DON stated she gave hand hygiene in-services often and did monthly hand hygiene competencies. She stated the policy was for staff to disinfect equipment between residents and they are expected to do that. The DON stated the potential outcome of not doing hand hygiene and disinfecting equipment was potential outbreak of infections. In an interview on 6/13/24 at 03:12 p.m., the ADON stated the policy was to sanitize hands with alcohol gel if they were not soiled and to use soap and water if hands were soiled. The ADON stated she gave frequent in-services on this and randomly asked staff to demonstrate how to wash hands properly. She stated the policy on disinfecting equipment was to disinfect based on kill time that was indicated on the disinfecting wipes. The ADON said she gave regular in-services on disinfecting equipment. The ADON stated the potential outcome of not doing hand hygiene and disinfecting equipment was possible transfer of infections to residents. In an interview on 6/13/24 at 03:18 p.m. the ADM stated the policy on hand hygiene between residents was to clean hands with soap and water if soiled or use 70% alcohol if not soiled. The ADM stated they gave regular in-services on hand hygiene and disinfecting equipment between residents. She stated equipment should be disinfected between residents every single time. The ADM stated the potential outcome of not doing hand hygiene and disinfecting equipment was germs and disease could be spread to others. In an interview on 6/13/24 at 03:25 p.m., CNA-C stated the policy on hand hygiene between residents was to wash hands. She stated they were regularly in-serviced on hand hygiene and sanitizing equipment. CNA-C stated they had a disinfecting spray they could use on equipment between residents. She stated the potential outcome of not doing hand hygiene and disinfecting equipment was they could get in trouble for not doing it and residents could get infections. CNA-C stated they always had supplies to do hand hygiene and sanitizing the equipment. Record review of the facility's, undated, policy titled, Hand Hygiene reflected All staff will perform proper hand hygiene procedures to prevent the spread of infections to other personnel, residents, and visitors .Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to, the attached hand hygiene table . either hand washing, or Alcohol Based Hand Rub is indicated in the following circumstances: Between resident contacts After handling contaminated objects Before preparing or handling medications (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455478 If continuation sheet Page 11 of 14 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 06/13/2024 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 0880 Level of Harm - Minimal harm or potential for actual harm Record review of the facility's policy titled, Cleaning and Disinfection of Resident-Care Items and Equipment dated 03/01/22, reflected Reusable items are cleaned and disinfected or sterilized between residents. The policy categorized blood pressure cuffs as non-critical items which can be decontaminated where they are used. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455478 If continuation sheet Page 12 of 14 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 06/13/2024 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 0919 Make sure that a working call system is available in each resident's bathroom and bathing area. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to be adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area for 1 of 5 residents (Resident #40) reviewed for physical environment. Residents Affected - Few The facility failed to ensure Resident #40 had a working call light in the room. This failure could place residents at risk of not being able to get assistance when needed. Findings include: Record review of Resident #40's face sheet, dated 06/13/24, reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included pulmonary embolism (a blood clot in the lung that creates a blockage) without acute cor pulmonale (enlarged ventricle), cognitive communication deficit, unspecified atrial fibrillation (irregular and rapid heart rhythm that can lead to a stroke, heart failure or other complications), and dementia (loss of cognitive function that interferes with daily life) in other diseases classified elsewhere- unspecified severity- without behavioral disturbance, psychotic disturbance-,mood disturbance and anxiety ((A group of symptoms that affects memory, thinking and interferes with daily life.). Record review of Resident #40's quarterly MDS assessment, dated 04/01/24, reflected a BIMS score of 04, which indicated severe cognitive impairment. Section GG for functional abilities reflected Resident #40 was completely dependent on personal hygiene and toileting; and required maximal assistance with dressing and showers. Record review of Resident #40's care plan, last revised 06/14/24, reflected Falls Risk- [Resident #40] is at risk for falls related to dependence upon staff to provide assistance for stability to complete ADL's, functional incontinence and poor safety awareness secondary to cognitive impairment. Interventions for the identified problem in the care plan included, Anticipate and meet the resident's needs. Be sure the residents call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. An observation and interview on 06/11/24 at 01:44 PM revealed Resident #40 in her bed with the call light cord observed at the bedside to the right of the resident. The call light cord was frayed and hung by a thin white cable, and a black cable was observed completely severed from the push-button end of the cord. Resident #40 was asked to test the call light and upon pushing the button it was observed neither the green light at the base of the call light, nor the light outside of Resident #40's room was activated. Resident #40 stated she was not sure how long the call light had been out because she usually just waited for staff to enter her room to ask for assistance, she said they checked (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455478 If continuation sheet Page 13 of 14 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 06/13/2024 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 0919 on her frequently. Level of Harm - Minimal harm or potential for actual harm An observation and interview on 06/11/24 at 01:52 PM revealed LVN A attempt to push Resident #40's call light to test for functionality; the call button was pushed, and the call light was observed not functioning in the room or flashing outside of the resident's room. LVN A stated this is the first time she noticed the call light not functioning but it was probably due to the frayed wires. She was unable to determine how long the call light was damaged prior to that moment. LVN A stated a negative outcome to Resident #40 not having a functioning call light would be the resident could sit there wet or soiled due to needing staff assistance with incontinent care. LVN A stated she would promptly report it to maintenance to have it resolved and was observed bringing Resident #40 a hand bell to ring if she needed assistance in the meantime. Residents Affected - Few In an in interview on 06/13/24 at 03:32 PM with the DON, she stated it was her expectation that residents call lights were functioning and placed within reach of the residents to call for help as needed. She stated functionality was tested by MNT, but nursing staff also did rounds to check for placement. The DON stated a resident having a non-functioning call light was negligence because they could not be getting their needs met. The DON said after the problem with Resident #40 was identified they did an audit of all residents to ensure their call lights were functioning. No major concerns were identified though the audit. In an interview on 06/13/24 at 03:44 PM with the ADM she stated it was her expectation all residents had a functioning call light in reach to call for help as needed. She said if anyone identified a concern with a call light staff were required to let MNT know. The ADM stated they had Angel Rounds which is a system where the heads of the departments check on functionality and placement of call lights in resident's rooms daily. The ADM stated a negative outcome to residents not being able to call for assistance would be the residents not getting the help they need which could potentially lead to a fall in some residents. In an interview on 06/13/24 at 04:00 PM with MNT, he stated the residents call lights were checked for functionality and placement every morning during Angel Rounds. He also stated if a concern was identified staff were required to immediately let him know. The MNT said there was a maintenance system they had that would also prompt him to complete a full call light system audit regularly. The MNT said as soon as the problem was identified with Resident #40, she was given a hand bell and the call light cord was replaced later the same day. The MNT said a negative outcome to a resident not having a functioning call light could potentially lead to a fall with injury. Record review of the facility's, undated, policy titled Call Lights: Accessibility and Timely Response reflected: The purpose of this policy is to assure the facility is adequately equipped with a call light at each resident's bedside, toilet, and bathing facility to allow residents to call for assistance. Call lights will directly relay to a staff member or centralized location to ensure appropriate response. Ensure the call light system alerts staff members directly or goes to a centralized staff work area. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455478 If continuation sheet Page 14 of 14