Inspection·June 30, 2023

F 0697 Level of Harm - Actual harm Residents Affected - Few pain, explained to resident that we can try some Tylenol and an ice pack to relieve pain, resident agreeable. N.O. (New Order) written for Tylenol 650 mg two tablets to be taken by mouth every six hours as needed, until narcotic medication available from pharmacy. At 10:45 PM, resident assisted to lay down and into position of comfort after administering Tylenol 650 mg. Ice pack prepared .a towel placed over right knee and large ice pack applied at this time. On 06/14/23 at 1:00 AM, resident continued to rest at this time without distress. Eyes closed, resp (respiratory) even, unlabored and regular. -LVN A Record Review on 06/29/23 at 11:43 AM of Nurse's Notes dated 06/14/23 at 2:30 AM, for Resident #1 reflected, resident c/o increased extreme pain, called spouse and 24-hour pharmacy to attempt to get pain medications filled. Informed nurse that his wife will be picking him up to get pain meds then will return to facility. On 06/14/23 at 4:15 AM, resident returned to facility and was assisted into bed. Told nurse that pharmacy was closed and that his wife will return in the morning to pick up meds and bring to facility. Resident requested Tylenol 650 mg and ice pack. Staff assisted resident to position of comfort, administered PRN Tylenol 650 mg as ordered. Towel placed over right knew and large ice pack in place. At 4:45 AM, continued with frequent visual checks by nurse and C.N.A., for any pain symptoms, resident continues to rest in with eyes closed, resp even, unlabored and regular. At 5:30 AM resident continues to rest at this time, no noted pain symptoms. Eyes closed, resp even unlabored, and regular. - LVN A Review of a written statement from the DON, dated 06/14/23 reflected, I was informed in the Clinical Meeting this [NAME] at 0915, that the above resident (Resident #1) was admitted yesterday, a few minutes before 1800 and still did not have anything for pain except Tylenol I text the charge nurse (LVN A) and asked her if the resident complained of pain last night. She text back yes I charted about it. I ask her why she didn't get it out of ER box she said she was not an agent. She also stated she did all she could for the man (Resident #1) see attached nurse note. Administrator asked her why she didn't call DON for assist and stated she never thought about it. She said it should have been taken care of by prior shift. DON told her it was her responsibility on her shift that residents are taken care of and she should have notified DON of the need for pain medication and notified the doctor to send a script to our pharmacy. LVN B was interview by Administrator and DON. She stated she ordered his (Resident #1) medications shortly after the resident arrived, however, none of his medications arrived on the night delivery due to horders were not received by 6:00 PM for night delivery. Resident came in with orders for Hydrocodone, however, physician sent triplicate for Oxycodone to local pharmacy. She also stated she was not aware that you have to have a triplicate in order to get medications. She stated she did go down there and check on resident during her shift, she just did not document it. She stated she did text LVN C around 10:00 PM, but did not get a response back. LVN C stated she did not see the text until to late. DON instructed LVN B to always report immediately to DON, ADON anytime she needed something for a resident, also that the doctor has to be notified immediately of anything that is ordered for resident and if we don't have it. Employee suspended until further investigation. Review of undated written statement of interview with C.N.A. D rebealed, she was interviewed by phone by the DON on 06/16/23 at 11:00 PM. LVN B stated on the night of 06/13/23, she assisted LVN A with placing an ice pack early in the shift and knew the nurse had given him pills but did not know what kind. She also stated she checked on the resident throughout the shift and he was resting. She also stated they assisted him to the care so he could go to the pharmacy. She stated, other than that, she did not know of anything going. Review of undated written statement of interview with LVN A revealed, she did all she knew to do (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675151 If continuation sheet Page 2 of 4 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 675151 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadowbrook Care Center 632 Windsor Way Van Alstyne, TX 75495 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 0697 Level of Harm - Actual harm Residents Affected - Few for Resident #1 the night that the resident was admitted from the hospital. She stated she gave him Tylenol twice during the night and repositioned him along with providing ice packs, due to the ice machine which was sent from the hospital was missing a chord. She stated the resident was in a pleasant mood and resting through most of the shift. The DON instructed LVN A to do a late entry, stating all of the care that was provided throughout the shift. LVN A stated it did not occur to her to call the DON for assistance in getting the resident stronger pain medication. The DON and Administrator informed her when she takes report it is her responsibility to make sure all residents are cared for in a timely manner, no matter what the prior shift had done. LVN A admitted she was wrong and that she had made a mistake. She was suspended until further investigation could be completed. Record review of in-services dated 06/14/23 revealed, staff were in-serviced on Abuse and Neglect and Pain Management. Observation of Resident #1 was not possible, as the resident was discharged from the facility on 06/24/23. An interview on 06/29/23 at 1:08 PM with the Administrator, revealed the Oxycodone medication was not administered to Resident #1 on the evening of 06/13/23 and night hours of 06/14/23. She stated she did not fully understand why LVN A did not access the Emergency Kit, so she could administer the Oxycodone to the resident. She stated LVN A eventually admitted that she knew what should had done, however, she was trying to prove a point, in order to invoke change. The Administrator stated LVN B was new to the facility, but not new to long term care nursing. She stated LVN B was the admitting nurse and she did submit the facility physician's orders to the pharmacy, however, it was too late for them to be delivered to the facility that night. She stated LVN B should have contacted herself or the DON, when she realized the medications would not be delivered that night. She stated she was not sure if LVN A had access to the Emergency Kit or not, however, she did know that she could have called herself or the DON for guidance on how to access it. She stated the Resident #1 did not have to be uncomfortable at all, had the nurses did what they were supposed to do. Attempts to contact LVN A and LVN B on 06/29/23 at 2:00 PM, were unsuccessful, as neither nurse returned the calls. A phone interview on 06/29/23 at 5:15 PM with Resident #1 revealed, he stated he felt fine when he arrived at the facility on 06/13/23. He stated he remembered first complaining of pain around 10:30 PM, that night. He stated he started feeling pain before then, but it was not bad enough to complain about. He stated he could not remember what time he first started to feel discomfort. He stated the nurse told him they did not have his medications and could only give him Tylenol. He stated he was fine with that. He stated his pain was at a nine when he complained to the nurse. He stated the Tylenol took it to an eight. He stated he dealt with it because he was able to fall asleep. He stated he had gotten text earlier in the evening about his prescription being ready, so he decided to go get it, since the facility did not have anything stronger than the Tylenol, however, the pharmacy was closed when he got there. He stated the nurse gave him more Tylenol when he returned to the facility and placed another ice pack on his knee. He stated he felt the staff did what they could do to accommodate him, so he did not have any complaints. He stated he did not feel neglected. He stated he was a strong man and he made it through the night and he did not have any complaints about his care that night. An interview on 06/30/29 at 10:00 AM with the DON, revealed LVN A had access to the Emergency Kit, however, she admitted ly did not access the medications needed. She stated LVN B should have called (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675151 If continuation sheet Page 3 of 4 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 675151 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadowbrook Care Center 632 Windsor Way Van Alstyne, TX 75495 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 0697 Level of Harm - Actual harm Residents Affected - Few the DON or the Administrator to receive instruction as to how to gain access to the Emergency Kit. She stated Resident #1's pain could have been properly relieved had the nurses done what they had been educated to do. The DON stated the she accessed the Emergency Kit and administered Hydrocodone to the resident, after speaking with him and assessing him. His medication from the pharmacy arrived in time for the next dose. Review of an undated document entitled How to Access Narcotics from the ER Kit reflected 7. CALL DON OR ADON WITH ANY ISSUES. Review of the facility policy, Pain Management, dated 05/05/23, reflected: The purpose of this policy is to ensure that residents receive treatment and care in accordance with professional standards of practice., the comprehensive care plan, and the resident's choices, related to pain management .If the resident's pain has not been adequately controlled, it may be necessary to reconsider the current approaches and revise or supplement them as indicated . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675151 If continuation sheet Page 4 of 4