Health inspection·July 23, 2025

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Frequency was for 12 time periods, for a duration of 30 days, with an intensity of daily, and the certification period was for 4/18/2025-5/17/2025. The following goals were listed: Patient will perform L UE strengthening exercises x 8-10 minutes, in order to improve strength for bed mobility.Patient will tolerate 5-7 minutes PROM to R UE, in order to improve ROM and prevent contracture.Patient will safely perform bed mobility tasks with Mod (A) with use of siderails for use of compensatory strategies in order todecrease risk for skin breakdown.Patient/caregivers will demonstrate 85% accuracy for safety/compensatory strategies for bed mobility.These were signed off on by the medical director on 4/21/2025 and it stated, I certify the need for these medically necessary services furnished under this plan of treatment while under my care from 4/18/2025 through 5/17/2025.In an observation on 7/21/2025 at 11:18 AM with Resident #22 he was observed to not be responding to the state surveyors' questions with words, rather he was using his left hand to move his thumb in a sideways or upwards movement to indicate a thumbs-up when asked if he felt okay, was being treated well by staff, and if he participated in activities. In a confidential interview the person stated that when Resident #22 first admitted , they thought the facility was going to be giving the resident rehabilitation to regain his functions, but there seemed to be no improvement with the resident's abilities. They stated that staff report that the resident refused therapy. This person stated that every time they visit the resident would be lying in the same position in bed. They confirmed that the resident had right side paralysis, and that his Medicaid had not been approved yet, and the facility would not do anything until that was approved. In an interview on 7/22/2025 at 4:22 PM with the DOR she stated that Resident #22 had been ‘Medicaid pending' since his admission on [DATE], indicating that certain corporate procedures had to be followed to get the resident's therapy visits financially covered while his insurance was awaiting approval. She stated that she thought Resident #22 had rehabilitation potential for contracture management, to prevent more contractures, and she confirmed that he was not receiving any services at the time. His initial OT evaluation was conducted on 4/18/2025 and he had only received 5 visits between the time period of 4/18-4/25. When asked by the state surveyor if the facility conducted ‘facility authorizations' for residents who could benefit from rehab, but were still Medicaid pending, she stated that yes, the facility did do them, and that rehab would authorize 5 visits, but it was a corporate rule to only allow 5 residents a month, unless it was determined an additional resident really needed it. She stated that if a resident were to exhaust their 5 visits, they could be picked back up based on IDT meetings and then the ADM would approve the additional visits. In an interview with the BOM on 07/23/2025 at 11:46 AM she stated that Resident #22's Medicaid application was denied in error, and that their back office had re-submitted the necessary documentation recently. She stated that based on her experience his application would be approved. When asked about therapy, she stated that corporate does allow 5 initial therapy visits, and if the DOR felt the residents needed more, she could get more approved. In a follow up interview with the DOR on 07/23/2025 at 11:55 AM she stated that Resident #22 was not able to position the way he needed to, and he was only able to use his left hand to thumbs up or down when answering questions. The therapy goals would have helped him achieve being able to roll side to side and to use his bed rails for repositioning. She stated he still needed more therapy to continue being able to work toward those goals. When asked why he was not currently receiving therapy, she stated that she planned to pick him back up soon, and that the residents only got a certain amount of approved therapy visits. She also stated they were short staffed and the staff she had, already had full caseloads. She stated that she was the only full-time staff for about 4 months, so it was hard to keep additional people on case loads. She tried to prioritize residents with falls, contractures, decreased strength, and ADLs. She (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455478 If continuation sheet Page 2 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455478 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2025 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete stated that it was up to her discretion, and if she felt like he needed more therapy she could go through the steps of the policy, and she confirmed that she felt he needed more therapy. However, she felt she did not have the resources to continue providing him therapy previously, because most of her staff worked PRN. She stated that a negative outcome of the resident not receiving therapy services was an overall decrease in quality of life, inability to do for oneself, and not reaching their full potential with ADLs. In an observation on 07/23/2025 at 12:11 PM Resident #22 was observed to require extensive assistance by the DOR by her having to place both of her hands under his left side back to prop him up to assist him in being able to turn and reach for his right-side bed rail. The resident lifted his left arm to reach the right bed rail and once he made contact, he grabbed it but made no attempt to maneuver his body. In a follow up interview with the DOR on 07/23/2025 at 12:13 PM she stated that when Resident #22 was receiving therapy services he would sometimes refuse, but they would attempt to come back 3 times before scheduling the visit for another day, and he did receive all 5 of his initial visits. She stated that the goal would have been (if he were to have continued therapy services) for him to have had better bed mobility, by reaching for items on his bedside table, repositioning, and assisting staff with ADLs. In an interview on 07/23/2025 at 1:59 PM with the DOO she stated that therapy was to be offered in 2-week increments (rather than 5 days) for residents on Medicaid pending status. She further clarified that the 1st 2 approved weeks, the administrator signed off for approval, the next 2 weeks, she (DOO) would sign off for approval and then the following 3 weeks, the Senior VP ofOperations signed off for approval. She stated that she would provide re-education to staff. In an interview on 07/23/2025 at 3:50 PM with the DON she stated she had only been working at the facility for 5 days, but that Resident #22 could have been experiencing no overall improvement in his well-being or quality of life due to not receiving necessary rehab services. Review of the facility's Medicaid Therapy Tracker policy dated 2/2025 revealed, If your facility has identified a need for therapy interventions on a Medicaid only resident, the following approval process will be implemented. 1st approval - request in writing the resident, reason for the request, which disciplines will be involved and frequency/duration of services. This step will also require the Administrator's signature. 2nd approval - request in writing the resident, reason for the request, which disciplines will be involved and frequency/duration of services. This step will also require the Administrator's and Regional's signature. 3rd Approval- request in writing the resident, reason for the request, which disciplines will be involved and frequency/duration of services. This step will also require the Administrator's, Regional's and Sr VP of Operations signature.This form will be submitted monthly to the Regional and Sr VP of Operations. Services should not be rendered until all required signatures are obtained.Review of the facility's undated Resident Rights policy revealed, 8. Safe Environment. The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Event ID: Facility ID: 455478 If continuation sheet Page 3 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455478 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2025 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interview, and record review the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident for 2 of 3 medication carts reviewed (East Cart, 1 [NAME] Back Cart). The facility failed to ensure narcotic logs on the East Cart and 1 [NAME] Back Cart were completely filled out and were not missing nurse signatures from 7/19/25-7/21/25.This failure could place residents at risk of drug outages due to drug diversions and poor inventory control which could result in the diminished health and well-being of residents.Findings included: Observation on 7/22/25 at 4:20 PM of the East Medication Cart Narcotic Log revealed 2 shifts with no narcotic counts recorded and 2 other shifts with partially completed entries. The 7/19/25 6PM line was missing a time and a signature of the off-going nurse for the count. The 7/20/25 6AM and 6PM shifts were both completely blank, indicating that 2 nurses failed to sign or count narcotics for those shifts. The 7/21/25 8AM line had only the signature of the oncoming medication aide and was missing a nurse's signature. Observation on 7/22/25 at 5:00 PM of the 1 [NAME] Back Medication Cart Narcotic Log revealed that the line for 7/20/25 6:05 PM had a blank box where the on-coming nurse should have signed. In an interview on 7/22/25 at 4:37 PM the DON stated that her expectations were that counts be completed prior to passing the narcotic keys every shift. She was not aware the counts had been missed prior to us discussing it and she denied knowing why they were missed. In an interview on 7/22/25 at 4:39 PM MA-B stated 2 agency nurses worked on the East Hall from 6 PM on 7/19/25- 6 AM on 7/21/25. She stated the nurses working on the shifts involved were LVN-A and LVN-B. She denied having any knowledge on why they did not sign out the narcotic count. In an interview on 7/23/25 at 4:30 PM MA-C stated the policy was for 2 nurses to count narcotics and sign the narcotic sheet. He stated it was important to count the narcotics with 2 people to verify and have a witness that the count was correct. He stated the negative outcome if count was missed was that narcotics could be short or missing, and residents could be neglected on their medications. He stated Agency nurses passed medications for the day and night shifts on the East Hall for the 7/19/25. and 7/20/25 shifts. In an interview on 7/23/25 at 4:35 PM RN-A stated, the policy was for 2 nurses to count narcotics and sign the narcotic sheet. She stated it was important to count the narcotics with 2 people to decrease chances of narcotic diversions and safely confirm that narcotics were not missing. She stated not counting narcotics could affect residents if a medication supply was low and a resident could not get their medications. In an interview on 7/23/25 at 4:45 PM the DON stated, the policy was for 2 nurses to count narcotics and sign the narcotic sheet between shift changes. She stated staff could not go home or take the narcotic keys until narcotics were counted and documented. She stated it was important to count the narcotics with 2 people to verify the count was correct. She stated not counting could affect residents if medications were diverted and the medication count was off. She stated, if that happened, then the medication may not be available for the resident, or it could cause a medication dosage error by leading to a missed dose or a duplicated dose. She stated the rule was that if they did not document something, then it was assumed it didn't happen. She stated that this morning she had tried to call the agency nurses that did not sign out but they had not called her back. In an interview on 7/23/25 at 5:02 PM the ADM stated the policy was to count narcotics at shift change and record the count on the log. She stated count should be done by 2 people, so no one could take narcotics. She stated it could affect residents by making them miss medications they needed. In an interview on 7/23/25 at 5:23 PM MA-A stated in a telephone interview with the DON present, that RN-A counted with her on 7/21/25 at 8 AM. In an interview on 7/23/25 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455478 If continuation sheet Page 4 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455478 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2025 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete at 5:30 PM, RN -A stated she did count with MA-A on 7/21/25 at 8 AM and she must have forgotten to sign the sheet. Interview on 7/23/25 at 6:09 PM attempted with LVN-B but she did not answer, and the phone would not accept a message. No call back was received. In an interview on 7/23/25 at 6:20 PM LVN-A stated she worked the weekend shifts for 7/19/25 at 6 PM-7/21/25 at 6 AM. She stated she did not remember why they didn't sign off the narcotic sheets. She stated they did count each day, and she counted with a facility staff nurse. She stated it was important to count with 2 people to prevent medications from being stolen and to catch if a wrong medication had been given. She stated that she did not think missing counts would affect residents. A record review of the facility policy titled; Controlled Substance Administration & Accountability dated 2025 reflected the following:All controlled substances obtained from a non-automated medication cart are recorded on the designated usage form. Written documentation must be clearly legible with all applicable information provided. For areas without automated dispensing systems, two licensed nurses account for all controlled substances and access keys at the end of each shift. Event ID: Facility ID: 455478 If continuation sheet Page 5 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455478 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2025 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 on 07/22/2025 to ensure dietary CK 2 used proper hand hygienewore gloves while plating food for service on the line. The facility failed on 07/22/2025 to ensure CK 1 wore a beard net while preparing food for the residents. The facility failed on 07/22/2025 to ensure dietary CK 1 washed his hands or changed his gloves while preparing pureed food for the residents and in between tasks. The facility failed on 07/22/2025 to ensure dietary CK 1 cleaned and sanitized the food processer in between pureed food items. These failures could place residents at risk for food contamination and/or foodborne illness. In an observation on 07/22/2025 at 9:35 AM of the facility's only kitchen revealed CK 1 was near the food preparation table preparing food and was not wearing a beard net. CK 1 had a visible beard and mustache no more than one inch in length.In an observation on 07/22/2025 at 10:39 AM of the facility's only kitchen revealed CK 1 was in the kitchen near the food preparation table, and three compartment sink area with his beard net pulled below his bottom lip. CK 1 was wearing gloves while moving about touching other surfaces (food processor, kitchen sink handles, sink, food processor) in the kitchen without changing his gloves after encountering different surfaces and then resumed his food handling with the same gloves.Observation on 07/22/2025 at 11:00 AM, revealed CK 1's beard net was pulled below his bottom lip while preparing pureed chicken with chicken broth. CK 1 washed the food processor in the three-compartment sink, rinsed it with running water, but did not sanitize it. CK 1 proceeded to puree broccoli using the food processor and repeated the same process. CK 1 then proceeded to puree garlic bread with the unsanitized food processor. CK 1 then grabbed a dirty towel with food particles and brown spots off the dirty cart. CK 1 wiped down the food processor base and food preparation area with the same dirty towel. During the entire process of pureeing the chicken, broccoli, and garlic bread, dietary CK 1 did not change his gloves or wash his hands in between tasks.In an observation on 07/22/2025 at 11:20 AM CK 1 was near the stove and food preparation area with his beard net pulled below his bottom lip. In an observation on 07/22/2025 at 11:45 AM, CK 2 did not put on gloves before preparing trays on the serving line. In an interview on 07/22/2025 at 10:39 AM with the DM, she stated the kitchen staff was to always wear gloves and hair/beard nets when preparing food, which included the puree food process. She stated all staff were required to change their gloves and wash hands in between tasks and whenever they touched anything contaminated. This was to avoid cross contamination and sanitation issues. She stated if the kitchen staff were moving about touching other surfaces in the kitchen while preparing food, they must change gloves, wash their hands, and put on new gloves. She stated the food processor should go in the dish washer to be cleaned and sanitized in between uses. She stated the food processor base should be cleaned after each use with soap and water. She stated the staff had sanitizing buckets, one with soap and water and one with water kept under the cooking station. She stated the staff should be pulling the clean towel out of the soapy water and sanitizing the equipment after each use, and when done staff should put the dirty towel in the dirty bin. 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 07/22/2025 at 12:15 PM, CK 2 stated she did not put gloves on before preparing trays on the serving line. She stated she was trained on proper hand hygiene. She stated all staff should be washing hands and wearing gloves on the serving line. She stated she was trained to wash and sanitize the blender in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455478 If continuation sheet Page 6 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455478 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2025 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 FORM CMS-2567 (02/99) Previous Versions Obsolete between pureed items. She stated the proper technique for cleaning and sanitizing the blender was to use the three-compartment sink to wash with soap and water and air dry in between pureed items. She stated a potential negative outcome of not properly washing and sanitizing the blender in between puree food items was food poisoning and cross contamination. She stated anyone that entered the kitchen was supposed to wear the appropriate hair and beard net to prevent hair from falling into food. She stated she had been trained but did not recall the date.In an interview on 07/22/2025 at 12:30 PM, CK 1 stated he did not change his gloves while preparing food for the residents. He stated he was required to change his gloves and wash hands in between tasks and after touching anything contaminated. He stated the germs on his gloves may spread to the food. He stated he did not wash and sanitize the food processor in between pureed items, and he was running behind on time. He stated the proper technique for cleaning and sanitizing the food processor was to use the three-compartment sink to wash with soap and water and air dry in between pureed items. He stated a potential negative outcome of not properly cleaning and sanitizing the food processor was the residents could get sick. He stated his beard, and mustache was short, and he did not think he needed a beard net with his beard and mustache being short. He stated he was trained but did not recall the date.Record review of facility's undated food processor cleaning policy reflected 1. Disassemble Unplug the food processor from the power outlet. Carefully detach all removable parts: the lid, feeder tube, blade, and bowl.2. Clean the parts Remove large food particles: Rinse the bowl, lid, and blade under warm water to eliminate any remaining food particles. Handwashing: Wash the bowl, lid, blade, and pusher with warm, soapy water and a soft cloth or sponge. Hard -to-reach areas: Utilize a nylon or soft bristled brush to thoroughly clean crevices and areas around the blade that are difficult to access. Base and Power Cord: Wipe down the base and power cord with a damp, soapy cloth. Never immerse the base in the water or any other liquids.3. Sanitize After washing, rinse all parts (except the motor base) with clean water to remove any soapy residue. Sanitize the food contact surface with an approved sanitizer, such as a diluted bleach solution, following the manufacturer's instructions for concentration and contact time. Optional: In a three-compartment sink, immerse the disassembled items in the third sink, which contains hot water (at least 117 degrees) for 30 seconds, or use a properly prepared chemical sanitizing solution.Important consideration for nursing homes PPE: Staff should wear appropriate PPE, including gloves, when handling food during the cleaning process to further minimize the risk of contamination.Following these cleaning and sanitation procedures for food processors and other kitchen equipment will help maintain a safe and hygienic environment for the residents and staff in the nursing home. Change gloves between the line and the dirty station/sinks. Wash processor between each food item change. 3 compartment sinks, soap, rinse, sanitize, and return between each food itemRecord review of FDA food code dated 2022 revealed 2-402 hair restraints reflected2-402.11 Effectiveness(A) Except as provided in (B) of this section, Food Employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed Food; clean Equipment, Utensils, and Linens; and unwrapped Single-Service and Single-Use Articles.Record review of the facility's policy titled ‘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 is up to the facility to ensure facility equipment is cleaned and sanitized. Event ID: Facility ID: 455478 If continuation sheet Page 7 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455478 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2025 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 4 of 4 residents (Residents #15, #25, #34, and #70) and 1 of 1 laundry carts reviewed for infection control. The facility failed on 07/21/2025 to ensure laundry staff handled and stored linens during transport in a manner to ensure cleanliness, protect from dust, and to prevent cross-contamination and the spread of infections. The facility failed on 07/22/2025 to ensure MA-A sanitized reusable equipment (BP cuff) between Residents #15, #25, #34, and #70. This failure could place residents at risk for development of communicable diseases and infections that could diminish a residents' quality of life. Findings included: Record review of Resident #15's undated face sheet, revealed she was a [AGE] year-old female admitted [DATE] with diagnoses of Hypothyroidism (low thyroid), Ocular Hypertension, Hypertension (High BP in the eye), and Schizophrenia (mental illness). Record review of Resident #15's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 15, which indicated the resident's cognitive ability was not impaired. Record review of Resident #15's Care Plan, reflected a Focus area was initiated for Hypertension on 10/2/15 and revised on 6/20/25 with a goal to have no side effects from BP medications. Resident #15's interventions included to check BP. Record review of Resident #25's undated face sheet, revealed she was a [AGE] year-old female admitted [DATE] with diagnoses of Congestive Heart Failure, Kidney Transplant, Hypertension, and Chronic Obstructive Pulmonary Disease (lung disease). Record review of Resident #25's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 15, which indicated the resident's cognitive ability was not impaired. Record review of Resident #25's Care Plan, reflected a Focus area was initiated for Hypertension on 2/11/25 with a goal to remain free from symptoms of Hypertension. Resident #25's interventions included to give anti-hypertensive medications and monitor for side effects. Record review of Resident #34's undated face sheet, revealed he was a [AGE] year-old male admitted [DATE] with diagnoses of Hemiplegia (paralysis on 1 side), Bipolar Disorder (mood disorder), Hypertension, and Cerebral Infarct (stroke).Record review of Resident #34's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 08, which indicated the resident's cognitive ability was moderately impaired. Record review of Resident #34's Care Plan, reflected a Focus area was initiated for Hypertension on 2/12/25 with a goal to remain free from symptoms of hypertension. Resident #34's interventions included to give anti-hypertensive medications and monitor for side effects. Record review of Resident #70's undated face sheet, revealed he was a [AGE] year-old male admitted [DATE] with diagnoses of Multiple Sclerosis (muscle weakening disease), Elevated [NAME] Blood Cell Count, Hypertension, and Elevated Liver Enzyme Levels. Record review of Resident #70's chart reflected that his MDS assessment had not been completed yet related to his recent admission date. Record review of Resident #70's Care Plan, reflected a Focus area was initiated for Hypertension on 7/22/25 with a goal to remain free from complications. Resident #70's interventions included to monitor and document blood pressure readings. Observation on 7/21/25 at 12:42 PM revealed LS-A pushing the laundry cart down the hall on the [NAME] Nursing Unit. The top of the cart was covered with a cloth, but the sides were completely uncovered and open to the air on both sides. Residents and visitors were observed moving down the hall also. Multiple resident's hanging clothes were observed in the exposed area of the cart. Observation on 7/22/25 at 8:56 AM revealed MA-A passing medications. She picked up the blood pressure cuff without cleaning it and entered Resident #34's room and proceeded to take his blood pressure. Upon returning to the medication cart, she placed the uncleaned blood pressure cuff on the top of the Residents Affected - Some (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455478 If continuation sheet Page 8 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455478 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2025 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 cart near the area she was preparing medications. She proceeded to give him his medications then performed hand hygiene but did not clean the cuff. Observation on 7/22/25 at 9:10 AM revealed MA-A passing medications. She picked up the uncleaned blood pressure cuff and entered Resident #70's room and proceeded to take his blood pressure. Upon returning to the medication cart, she placed the uncleaned blood pressure cuff on the top of the cart near the area she was preparing medications. She proceeded to give him his medications then performed hand hygiene but did not clean the cuff. Observation on 7/22/25 at 9:31 AM revealed MA-A passing medications. She picked up the uncleaned blood pressure cuff and entered Resident #25's room and proceeded to take her blood pressure. Upon returning to the medication cart, she placed the uncleaned blood pressure cuff on the top of the cart near the area she was preparing medications. She proceeded to give the resident her medications then performed hand hygiene but did not clean the cuff. Observation on 7/22/25 at 9:36 AM revealed MA-A passing medications. She picked up the uncleaned blood pressure cuff and entered Resident #15's room and proceeded to take her blood pressure. Upon returning to the medication cart, she placed the uncleaned blood pressure cuff on the top of the cart near the area she was preparing medications. She proceeded to give the resident her medications then performed hand hygiene but did not clean the cuff. In an interview on 7/22/25 at 9:45 AM MA-A stated that she forgot to clean the blood pressure cuff between residents. She stated the policy is to clean the cuff to prevent from spreading infections between residents. In an interview on 7/21/25 at 12:42 PM, LS-A stated that only the top of the linen cart had to be covered. She stated that small undergarments were delivered in the closed bin drawers below. She stated the policy of the facility was to just cover the top of the cart and she denied any concerns/risk with the exposed linens. In an interview on 7/23/25 at 4:10 PM, LM stated the policy on delivering linens/clothes to residents was to bring in all the resident's clothes on a cart that was covered all the way around. She stated it was important to keep linens covered to prevent cross contamination and the negative outcome to residents if linens were not covered was residents could catch infections and get sick. In an interview on 7/23/25 at 4:24 PM, CNA-A stated, the policy on delivering linens/clothes to residents was to bag them and transfer them to their room. She stated it was important to keep linens covered to keep germs and bacteria from cross contaminating the clothing and the negative outcome to residents if linens were not covered was, they could get sick because ultimately they would be exposed to germs and bacteria. She stated the policy on cleaning reusable equipment (BP Cuffs) between residents was to wipe the BP cuff with the sanitizing wipes provided and wait the appropriate time to use. She stated it was important to clean the cuffs to prevent cross contamination and the negative outcome to residents if cuffs were not cleaned was the resident could get sick from cross contamination. In an interview on 7/23/25 at 4:30 PM, MA-C stated the policy on cleaning reusable equipment (BP Cuffs) between residents was to sanitize the cuff between each resident. He stated this was important to prevent spread of infections and the negative outcome to residents if the cuffs were not cleaned was residents could get infections from other residents and get sick. In an interview on 7/23/25 at 4:35 PM, RN-A stated the policy on delivering linens/clothes to residents was to keep carts covered. She stated it was important to keep linens covered for Infection control and the negative outcome to residents if linens were not covered was, they could be exposed to germs and infectious material and get sick. She stated the policy on cleaning reusable equipment (BP Cuffs) between residents was to clean between each resident and let the cuff sit for the designated kill time. She stated it was important to clean the cuffs because if not residents could get sick. In an interview on 7/22/25 at 4:45 PM, the DON stated the policy on delivering linens/clothes to residents was to deliver them covered. She stated this was important for infection control and the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455478 If continuation sheet Page 9 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455478 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2025 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 FORM CMS-2567 (02/99) Previous Versions Obsolete negative outcome to residents if linens were not covered was they could get infections. She stated the policy on cleaning reusable equipment (BP Cuffs) between residents was to clean between each resident with an approved cleanser and follow the guidelines for the number of minutes to wait before reuse. She stated it was important to clean the cuffs to keep infections down and not doing so could possibly give residents infections. In an interview on 7/23/25 at 5:02 PM, the ADM stated the policy on delivering linens/clothes to residents was to deliver covered in bags or on a fully covered cart. She stated it was important to keep linens covered for infection control and to keep linens clean until they were delivered. She stated the negative outcome to residents if linens were not covered could be exposure to dirt and it could make residents sick. She stated the policy on cleaning reusable equipment (BP Cuffs) was to clean them between each resident. She stated the policy was to sanitize all equipment between every use. She stated it was important to clean the cuffs to prevent residents from getting sick from exposure to germs.A record review of the facility's undated policy titled, Infection Prevention and Control Program reflected the following:All reusable equipment requiring cleaning or disinfection shall be cleaned in accordance with current procedures governing soiled or contaminated equipment. Non-sterile supplies are stored and maintained as clean prior to use.Laundry staff shall handle and transport linens to prevent spread of infection.Clean linens shall be delivered to resident care units on covered linen carts with covers down. Event ID: Facility ID: 455478 If continuation sheet Page 10 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455478 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2025 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 0926 Have policies on smoking. 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 implement their established policy regarding smoking, smoking areas, and smoking safety for 1 (Resident #49) of 8 residents reviewed for smoking. The facility failed to inform Resident #49 of the facility's smoking policy prior to 7/21/2025.The facility failed on 7/21/2025 to maintain a clean smoking area for staff and residents. These failures could result in unwanted fire hazards and pose safety risks to residents and staff. Findings included:Review of Resident #49's comprehensive MDS assessment dated [DATE] reflected a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses that included, amputation, anemia, coronary artery disease (narrowed or blocked arteries caused by plague buildup), diabetes, high cholesterol, hyperlipidemia (high levels of fats in the blood), mild cognitive impairment, and limitation of activities due to disability. Her BIMS score was an 11, indicating she had moderate cognitive impairment. In Section J - Health Conditions, Resident #49 was marked as ‘Yes' for J1300 Current Tobacco Use. Review of Resident #49's care plan dated last revised 7/7/2025 reflected that she was care planned for an intervention of Encourage resident to refrain from smoking. due to a diagnosis of coronary artery disease related to hypercholesterolemia (high cholesterol). There was no indication Resident #49 had been informed of the smoking policy.In an observation on 7/21/2025 at 1:49 PM of a smoking break, Resident #49 had a pouch where her smoking materials were kept, and there were no cigars observed. Resident #49 was observed going up to a male resident and asking him for a cigar, when the AD interrupted and stated they could not do that. The smoking area was observed to be littered with cigarette butts and cigar wrappers. Additionally, cigarette butts were observed to be in plant pots by one of the facility's exit doors. In an interview on 07/21/2025 at 1:57 PM with the AD who was providing the smoke break to residents she stated that she provided smoke breaks to residents at 1:45 and 4pm daily when she worked. She stated that she would think it was housekeeping or maintenance's responsibility to clean up the cigarette butts off the ground. She stated that a fire could happen if the butts were put out and/or left in the plant pots and stated that it did look bad out there due to the trash and cigarette butts on the ground. Resident #49 usually smoked [a certain brand] and she came out during every smoke break. When shown a copy of the list of smokers provided to the state survey team, which did not include the name of Resident #49, and asked how she knew if the resident was permitted to smoke, she stated that it was communicated to her from nursing, who conducted the safe smoking assessments. She stated that Resident #49 was newly admitted to the facility, and the DON told the AD that the smoking policy was in the resident's admission packet, when asked if Resident #49 was aware of the smoking rules.In an interview on 07/22/2025 at 12:04 PM with Resident #49 she stated she was never informed of the rules about smoking or that she could not share, until 7/21/25 when the AD stated she could not borrow a cigar from a male resident because the state was present. She stated that her FM would bring her cigars when she ran out or she would ask another resident who smoked the same brand, and they would lend her one. In a follow up interview on 07/23/2025 at 3:24 PM with the AD she stated that Resident #49 would borrow cigars from any resident who smoked the same type as her. She confirmed the name of the resident whom Resident #49 was observed asking from during the 1:45 PM smoke break on 7/21, and that Resident #49 had in the past borrowed from him. She stated that it was the responsibility of the staff providing the smoke break to inform all smokers of the rules. When asked why residents should not share smoking materials, she stated that it was due to incidents years ago where residents would borrow from others after stating they would return the favor, or pay the loaner back, and fail to follow through on those promises, which led to problems, so the policy was put into place. In an interview on 07/23/2025 at 3:40 PM with Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455478 If continuation sheet Page 11 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455478 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2025 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 0926 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete the DON she stated that she had only been working at the facility for 5 days, however, if a resident was not compliant with the smoking policy, the staff would address it.Review of the facility's undated Smoking policy revealed, Residents are prohibited from sharing or loaning tobacco products to others.Review of the facility's undated Resident Rights policy revealed, 6. 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. 8. Safe Environment. The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Event ID: Facility ID: 455478 If continuation sheet Page 12 of 12