Inspection·April 27, 2022

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some others and sometimes made himself understood. The MDS indicated Resident #35 had a BIMS score of 99 indicating Resident #35 was unable to complete the BIMS assessment. The MDS indicated Resident #35 had severely impaired cognitive skills for daily decision making. The MDS indicated Resident #35 exhibited physical behaviors directed towards other daily. The MDS indicated Resident #35 required extensive assistance with eating, transfers, bed mobility, toileting, and personal hygiene. The MDS indicated Resident #35 required extensive assistance with dressing. The MDS indicated Resident #35 required limited assistance with locomotion on and off the unit. Record review of the care plan updated on 4/25/22 indicated Resident #35's was updated on 4/25/22 to include resident was a wanderer (knocked and entered other persons rooms) with intervention including provide distractions, structured activities, and snack. The care plan indicated on 4/25/22 Resident #35's care plan was updated to include the resident had potential to be physically aggressive (by attempting to hug other persons) related to poor impulse control. The care plan was updated following surveyor inquiring about Resident #35's behaviors not being care planned. Record review of Resident #35's electronic medical records indicated he had been the aggressor in 7 resident-to-resident altercations from January 2022 through March 2022 in which he grabbed, scratched, and pulled on other residents. Record review of nursing progress note written by LVN D and dated 1/7/22 at 10:29 a.m. indicated the nurse witnessed Resident #35 rolling up behind another resident making kissing sounds as he grabbed the resident from behind, around his neck. The nursing progress note indicate the nurse redirected #35 which was ineffective as he just moved on to another. Record review of an incident report dated 1/7/22 indicated Resident #35 had went up behind another resident making kissing sounds and grabbing him tightly around the neck as if to hug him as he pulled him and his wheelchair backwards the incident report indicated the other resident did not take it well Resident #35 grabbing him and began to yell for nursing staff to assist him. The incident report indicated immediate action taken by the facility was to separate the residents, assess both resident for injuries, and redirect Resident #35. The incident report indicated Resident #35's family had been notified but continued to refuse medication intervention. The incident report indicated Resident #35's family was reassured Resident #35 would not be over sedated on the medication and interventions, and medications adjustments would be made in the case of oversedation. The incident report indicated Resident #35's family continued to refuse medication intervention. The incident report indicated Resident #35 required redirection throughout the day and redirection was usually successful after multiple attempts. Record review of an incident report written by RN C and dated 1/9/22 at 11:49 a.m. indicated Resident #35 grabbed another resident and left a scratch mark but did not break the skin. The incident report indicated immediate action taken by the facility was to separate and assess both residents and notify the psychiatric nurse practitioner of negative behaviors for medication intervention. The incident report indicated in the notes that Resident #35 had a recent history of attempting to grab onto other residents to try to kiss and hug them. The incident report indicated in the notes that Resident #35's family was now in agreeance with offering the resident medication intervention to help control negative behaviors. The incident report indicated Resident #35 continued to require redirection throughout the day, usually successful after multiple attempts, but very difficult. Record review of nursing progress note written by RN C and dated 1/9/22 at 2:55 p.m. indicated Resident #35 grabbed another resident by the arm and left a scratch mark but did not break the skin. Nursing progress notes indicated the psychiatric nurse practitioner and physician were notified of the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675251 If continuation sheet Page 2 of 30 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 675251 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadows of Corsicana, LLC 3301 Park Row Blvd Corsicana, TX 75110 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 0609 incident. Level of Harm - Minimal harm or potential for actual harm Record review of nursing progress note written by RN C dated 1/9/22 at 3:01 p.m. indicated Resident #35 had received new orders from the Psychiatric Nurse Practitioner for Vistaril (a medication to treat anxiety) 25 mg as needed for anxiety/agitation, and Depakote (a medication to treat bipolar disorder) 125 mg daily for mood disorder. Residents Affected - Some Record review of an incident report dated 1/14/22 at 11:00 a.m. indicated Resident #35 was in the beauty parlor and grabbed a female resident around the shoulders. The incident report indicated Resident #35 migrated his hands to the female resident's neck. The incident report indicated there was no bruising or redness to the other resident, and she denied pain. The incident report indicated immediate action taken by the facility was to separate the residents and notify the physician. The incident report indicated Resident #35 had a history of hugging, grabbing, and attempting to kiss and hug staff and other residents. The incident report indicated Resident #35 was often difficulty to redirect due to his diagnoses and aggressive desire to give affection to others. The incident report indicated Resident #35 was unaware of safety concerns and issues and unable to retain education given to him about keeping a safe distance from other staff and residents. The incident report indicted Resident #35's family had been notified and was seeking placement in a group home for more one-on-one supervision and that would be more suitable. The incident report indicated Resident #35 was admitted with a coccyx wound (a wound to the tailbone) that must be resolved before placement can occur. Record review of the Behavior Support Recommendations dated 2/22/22 indicated Resident #35 was described as a people person, very curious about what others were doing, had few words he used, was not defiant, and reportedly responded well to redirection that entailed a firm, stern tone of voice. The Behavior Support Recommendations indicated Resident #35 was very mobile and very busy and constantly on the go, and uses his wheelchair better than anyone which in turn he was able to access what and where he wanted to on his own and was difficult to interrupt when he wanted to something. The Behavior Support Recommendations indicated Resident #35 invaded the personal space of others and disregarded personal boundaries. The Behavior Support Recommendations indicated steps to prevent and intervene with Resident #35's behaviors were priming (preemptively teach what is ok and not ok), communication, response blocking, noncontingent access (provide frequent positive attention), and stop and redirect. The Behavior Support Recommendations indicated other recommendations for Resident #35 including continue all courses of interventions and continue to conduct further informal preference assessments with Resident #35 via conversation as much as possible and/or observations of what activities, snacks, and items with which he spends time and seems to enjoy. The Behavior Support Recommendations indicated the continued preference assessments could be incorporated as reinforcement for when Resident #35 demonstrated appropriate behaviors. Record review of nurse progress note written by LVN E and dated 2/26/22 at 10:33 a.m. indicated Resident #35 was noted in his room grabbing and pulling his roommate out of bed. The nurse progress note indicated Resident #35 was redirected by the nurse. The nurse progress note indicated the Social Worker was notified of the incident. Record review of nurse progress note written by LVN E and dated 2/26/22 at 5:50 p.m. indicated Resident #35 was in the front lobby grabbing and touching a female resident unwantedly. The nurse progress note indicated Resident #35 was redirected and the Administrator and Social Worker were notified. Record review of nurse progress note written by LVN E and dated 2/27/22 at 11:45 a.m. indicated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675251 If continuation sheet Page 3 of 30 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 675251 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadows of Corsicana, LLC 3301 Park Row Blvd Corsicana, TX 75110 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Resident #35 entered another resident's room, grabbed her legs, and took off her shoes causing pain and discomfort to her already sore and tender legs. The nurse progress note indicated attempts to redirect Resident #35 were unsuccessful. Record review of the nurse progress notes dated 2/28/22 at 11:03 a.m. indicated the psychiatric nurse practitioner was notified of Resident #35 behaviors and the facility received new medication orders. The nurse progress note indicated Resident #35 had new orders to increase Depakote 125 mg to three times a day, decrease Nuedexta (a medication used to treat certain mental/mood disorders) to daily for 3 days, then discontinue, and to start Risperidone (a medication used to treat schizophrenia, bipolar disorder, and irritability caused by autism) 0.5 mg daily. Record review of the nurse progress note written by LVN E and dated 3/13/22 at 2:22 p.m. indicated Resident #35 entered another resident's room and was touching and clawing at her. The nurse progress note indicated Resident #35 was removed without further incident. 2. Record review of the consolidated physician orders dated 4/27/22 indicated Resident #197 was an [AGE] year-old male, admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease, mild cognitive impairment, anxiety disorder, altered mental status, and major depressive disorder. Record review of the MDS dated [DATE] indicated Resident #197 was rarely/never understood others and was sometimes understood by others. The MDS indicated Resident #197 had a BIMS score of 99 indicated he was unable to complete the assessment. The MDS indicated Resident #197 had verbal behavior symptoms directed toward others 4 to 6 days a week, but not daily. The MDS indicated Resident #197 required extensive assistance with bed mobility, transfers, dressing, eating, toileting, and personal hygiene. Record review of the care plan updated on 4/25/22 indicated Resident #197 had a behavior problem related to his diagnoses of anxiety, depression, and adjustment disorder with interventions including explain/reinforce why behaviors are inappropriate and intervene when necessary. Record review of an incident report written by LVN D and dated 1/7/22 at 1:08 p.m. indicated Resident #197 was approached from the back by another resident while sitting in his wheelchair. The incident report indicated Resident #197 felt threatened that he was being choked as the other resident was trying to hug him tightly around the neck and pulling him backwards. The incident report indicated immediate action taken by the facility was to remove both residents from each other's visual sight and assess both residents for injuries. The incident report indicated Resident #197 had no injuries and was unable to recall the incident afterwards. The incident report indicated Resident #197 denied pain. The incident report did not document the assessment of Resident #197. 3. Record review of the consolidated physician orders dated 4/27/22 indicated Resident #7 was a [AGE] year-old female, readmitted to the facility on [DATE] with diagnoses including anxiety disorder, mild intellectual disabilities, schizoaffective disorder (a mental health condition including schizophrenia and mood disorder symptoms), and schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), . Record review of the MDS dated [DATE] indicated Resident #7 sometimes understood others and was sometimes understood by others. The MDS indicated Resident #7 had a BIMS score of 03 and was severely cognitively impaired. The MDS indicated Resident #7 had verbal behavior symptoms directed towards others daily. The MDS indicated Resident #7 had other behavioral symptoms not directed towards others. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675251 If continuation sheet Page 4 of 30 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 675251 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadows of Corsicana, LLC 3301 Park Row Blvd Corsicana, TX 75110 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some The MDS indicated Resident #7 independent with bed mobility, transfers, and eating. The MDS indicated Resident #7 required limited assistance with dressing, toileting, and personal hygiene. Record review of the care plan last updated 1/13/22 indicated Resident #7 had behavior problems with loud voices, television, and radio related to intellectual disability. The care plan indicated interventions included assist the resident to develop more appropriate method of coping and interacting with others and intervening when necessary. Record review of the nurse progress note written by RN C and dated 1/9/22 at 9:40 a.m. indicate Resident #7 was grabbed by another resident. The progress note indicated the nurse went to see what was going on when Resident #7 was calling out. The nurse progress note indicated Resident #7 reported the grabbing was unwelcomed. The nurse progress note indicated Resident #7 did not have any redness or bleeding to the area where she had been grabbed. The progress notes indicated Resident # 7's scratch was monitored following the incident for three days. Record review of an incident report written by RN C and dated 1/9/22 at 9:40 a.m. indicated Resident #7 was heard calling out. The incident report indicated Resident #7's arm was grabbed by another resident. The incident report indicated Resident #7 had a scratch on her arm. The incident report indicated Resident #7 did not have redness or bleeding to the affected arm. The incident report indicated Resident #7 had no injuries following the incident. The incident report indicated Resident #7 was in a pleasant mood and denied pain. During an interview on 4/25/22 at 4:10 p.m. Resident #7 said she was happy at the facility and felt safe. Resident #7 said Resident #35 grabbed her and other people. Resident #7 said she did not feel unsafe at the facility. 4. Record review of the consolidated physician orders dated 4/27/22 indicated Resident #11 was a [AGE] year-old female, readmitted to the facility on [DATE] with diagnoses including muscle wasting, anxiety disorder, major depressive disorder, pain, and weakness. Record review of the MDS dated [DATE] indicated Resident #11 sometimes understood others and was usually understood by others. The MDS indicated The MDS indicated Resident #11 had a BIMS score of 10 and was mildly cognitively impaired. The MDS indicated Resident #11 did not have physical or verbal behavior symptoms directed towards others. The MDS indicated Resident #11 independent with bed mobility, transfers, dressing, toileting, and eating. The MDS indicated Resident #11 required supervision with personal hygiene. Record review of the care plan last updated 5/17/21 indicated Resident #11 had impaired cognitive function/dementia or impaired thought process related to history of stroke. The care plan indicated Resident #11 had a communication problem related to history of a stroke. Record review of an incident report written by RN C and dated 1/14/22 at 11:00 a.m. indicated Resident #11 was in the beauty parlor when another resident grabbed her around the shoulders and migrated his hands towards her neck. The incident report indicated Resident #11 did not have any redness or bruising to her shoulders and denied pain. The incident report indicated Resident #11 stated, She was not afraid of the other resident and that she understands that the other resident is not all with it. The incident report indicated nursing staff was able to redirect the other resident out of the beauty parlor with no further incident. The incident report indicated Resident #11 was not fearful of a resident or staff member at the facility. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675251 If continuation sheet Page 5 of 30 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 675251 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadows of Corsicana, LLC 3301 Park Row Blvd Corsicana, TX 75110 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 0609 Level of Harm - Minimal harm or potential for actual harm Record review of the nurse progress note dated 1/14/22 at 12:57 p.m. Resident #11 was in the beauty parlor when another resident grabbed her around the shoulders and migrated his hands towards her neck. The nurse progress note indicated Resident #11 did not have any redness or bruising to her shoulders and denied pain. The nurse progress note indicated Resident #11's family and physician were notified of the incident. Residents Affected - Some During an interview on 4/25/22 at4:15 p.m. Resident #11 said she vaguely remembered the incident in the beauty parlor. Resident #11 said the other resident did not grab her. Resident #11 said her memory was not very good. 5. Record review of the consolidated physician orders dated 4/27/22 indicated Resident #18 was an [AGE] year old female, re-admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease, schizoaffective disorder (a mental health condition including schizophrenia and mood disorder symptoms), bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), anxiety disorder, mood disorder, and cellulitis (a common potentially serious bacterial skin infection) of the lower limb. Record review of the MDS dated [DATE] indicated Resident #18 sometimes understood others and was sometimes understood by others. The MDS indicated Resident #18 had a BIMS score of 12 and was mildly cognitively impaired. The MDS indicated Resident #18 did not had and physical or verbal behavior symptoms directed toward. The MDS indicated Resident #18 required supervision with bed mobility, transfers, dressing, and eating. The MDS indicated Resident #18 required extensive assistance with toileting and personal hygiene. Record review of the care plan updated on 1/27/22 indicated Resident #18 had impaired cognitive function/dementia or impaired thought process related to Alzheimer's Disease, schizoaffective, mood, and bipolar disorders. The care plan indicated Resident #18 had a communication problem related to communication deficit and Alzheimer's Disease. Record review of nurse progress note written by LVN E and dated 2/27/22 at 11:45 a.m. indicated Resident #18 had another resident enter her room, grab her by the legs, ad take her shoes off. The nurse progress note indicated the incident caused Resident #18 increased pain and discomfort in her already sore, tender legs. The nurse progress note indicated the Administrator and Social Worker were notified. An attempt to interview Resident #11 on 4/27/22 at 11:02 a.m. was unsuccessful as the resident was unavailable. 6. Record review of the consolidated physician orders dated 4/27/22 indicated Resident #198 was a [AGE] year-old female, admitted to the facility on [DATE] with diagnoses including bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), cognitive communication deficit, persistent mood disorder, and generalized anxiety disorder. Record review of the MDS dated [DATE] indicated Resident #198 had a BIMS score of 13 and was cognitively intact. The MDS indicated Resident #198 did not had and physical or verbal behavior symptoms directed toward. The MDS indicated Resident #198 required supervision with bed mobility and eating. The MDS indicated Resident #198 required extensive assistance with transfers, dressing, toileting, and personal hygiene. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675251 If continuation sheet Page 6 of 30 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 675251 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadows of Corsicana, LLC 3301 Park Row Blvd Corsicana, TX 75110 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 0609 Record review of the care plan updated on 4/18/22 indicated Resident #198 had limited physical mobility. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #198's electronic medical records indicated she discharged from the facility on 4/18/22. Residents Affected - Some Record review of nurse progress note dated 3/13/22 at 2:24 p.m. indicated Resident #198's family reported another resident had entered Resident 198's room and was touching and clawing her. The other resident was removed from Resident #198's room without further incident. During an interview on 4/25/22 at 4:53 p.m. the Administrator said the facility did not have policies regarding resident-to-resident altercations, one on one monitoring, resident behaviors, or incidents and accidents. During an interview on 4/25/22 at 5:00 p.m. the Nurse Practitioner said she was familiar with Resident #35. The Nurse Partitioner said Resident #35 was being seeing by psychiatric services for behavior management and medication interventions. The Nurse Practitioner said Resident #35's behaviors accelerated after he was admitted to the facility. The Nurse Practitioner said the facility had looked for alternate placement for Resident #35. The Nurse Practitioner said she was notified of resident-to-resident altercations (if there is physical contact). During an interview on 4/26/22 at 8:21 a.m. the Psychiatric Nurse Practitioner said she had been told and notified of Resident #35's behaviors. The Psychiatric Nurse Practitioner said they had made medication adjustments to help in his behaviors. The Psychiatric Nurse Practitioner said with Resident #35's intellectual disabilities she expected the resident to have some behavior issues. During an interview on 4/26/22 at 8:45 am RN C said in the event of a resident-to-resident altercation the residents should be immediately separated. RN C said the residents should have a head-to-toe assessment completed after being separated. RN C said the family, DON, abuse coordinator, and physician should be notified of the resident-to-resident altercation. RN C said Resident #35 was not aware of personal boundaries. RN C said during resident-to-resident altercations involving Resident #35 he was not agitated with aggression but wanting human interaction. RN C said the Resident #35 had a hospitalization after admission to the facility and while at the hospital was take off all his psychiatric medications. RN C said his guardian was resistive to putting Resident #35 back on psychiatric medication. RN C said after several incidents involving resident to resident altercations with Resident #35, the guardian agreed to start the resident back on psychiatric medications. RN C said Resident #35 was currently receiving psychiatric care and medication adjustments have been made as needed. RN C said the resident can be difficult to redirect and is very active. RN C said the facility provides snacks and music to aide in redirecting the resident. During an interview on 4/26/22 at 8:52 a.m. the Social Worker said Resident #35 was positive for Preadmission Screening and Resident Review (PASRR) (an admission screening for mental illness or intellectual and developmental disabilities). The Social Worker said Resident #35 had intellectual disabilities and was expected to have behaviors. The Social Worker said the Resident #35 had a psychiatric services referral and was currently receiving psychiatric services. The Social Worker said Resident #35's family had been resistive to psychiatric medications. The Social Worker said Resident #35 was admitted to the facility from a group home with a pressure wound to his coccyx. The Social Worker said Resident #35 received Mental Health and Mental Retardation (MHMR) services. The Social Worker said the MHMR services said Resident #35 cannot return to a group home until the wound he was admitted (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675251 If continuation sheet Page 7 of 30 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 675251 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadows of Corsicana, LLC 3301 Park Row Blvd Corsicana, TX 75110 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some with was completely healed. The Social Worker said Resident #35 had a behavior plan in place through the MHMR services. During an interview on 4/26/22 at 9:06 a.m. the MDS Coordinator said when Resident #35 was admitted from the group home he was very lethargic related to being overmedicated and had a Stage 4 pressure sore. The MDS coordinator said Resident #35 had psychiatric medications discontinued after being admitted to the facility. The MDS Coordinator said Resident #35's behaviors increased after his psychiatric medications were discontinued. The MDS Coordinator said Resident #35's behaviors had evolved since his admission due to medication changes. Resident #35 said with the psychiatric referral and medication adjustment the Resident #35 had started calming down. The MDS Coordinator said Resident #35 had exhibited attention seeking behaviors more than anything. During an interview on 4/26/22 at 9:15 a.m. the Administrator said Resident #35 required redirecting frequently. The Administrator said when Resident #35's wound healed he would be returning to a group home. The Administrator said she would not say Resident #35 had several resident-to-resident altercations. The Administrator said Resident #35's family had been resistive to psychiatric medication treatment for the resident. The Administrator said once the family consented to resuming psychiatric medication treatment Resident #35's behaviors had improved and he was more easily redirected. The Administrator said she did not report the resident-to-resident altercations involving Resident #35 to the state agency because she does think he was aware of what he was doing. The Administrator said she reports Resident to Resident altercations to the state agency if both parties are in their right mind or if the aggressor seeks out a specific resident willingly and knowingly. The Administrator said Resident #35 does not willingly or knowingly act out. The Administrator said Resident #35 absolutely was not aware of what he was doing. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675251 If continuation sheet Page 8 of 30 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 675251 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadows of Corsicana, LLC 3301 Park Row Blvd Corsicana, TX 75110 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure all alleged violations of abuse were thoroughly investigated and failed to prevent further potential abuse from 1 of 6 residents reviewed for investigation allegations of abusing other residents (Resident #35). Residents Affected - Some The facility failed to thoroughly investigate 4 of 7 resident to resident altercations involving Resident #35 as the aggressor. This failure could place residents at risk for not having reported allegations investigated to prevent abuse, neglect, and exploitation. Findings Record review of the Abuse, Neglect, and Exploitation policy dated December 2017 indicated, Our residents have the right to be free from abuse/neglect/misappropriation of resident property/corporal punishment/and involuntary seclusion Our facility is committed to protecting our residents from abuse by anyone including but not necessarily limited to: employees/other residents/consultants/volunteers/family member/visitors/or any other individual .Our facility will protect residents from harm during investigations of alleged abuse. During investigations of alleged abuse, residents will be protected from harm by the following measures .c. If the abuse involves another resident, the accused resident's representative and attending physician will be informed of the alleged abuse incident and that there may be restrictions on the accused resident's ability to visit other resident's rooms unattended. If, necessary, the accused resident's family members may be required to help meet this requirement .Reports of alleged resident abuse, neglect, and injuries of unknown source shall be promptly and thoroughly investigated by facility management . 1. Record review of the consolidated physician orders dated 4/27/22 indicated Resident #35 was an [AGE] year-old male, re-admitted to the facility on [DATE] with diagnoses including cerebral palsy (a congenital disorder of movement, muscle tone, or posture), severe intellectual disabilities, schizoaffective disorder (a mental health condition including schizophrenia and mood disorder symptoms), unspecified mood disorder, bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), impulse disorder (mental health disorders that are characterized by the inability to control impulses). The physician orders indicated Resident #35 had orders for Depakote (medication used to treat bipolar disorder) 125 mg three times daily starting 2/28/22 and Risperidone 0.5 mg twice daily starting 3/18/22. Record review of the most recent MDS dated [DATE] indicated Resident #36 sometimes understood others and sometimes made himself understood. The MDS indicated Resident #35 had a BIMS score of 99 indicating Resident #35 was unable to complete the BIMS assessment. The MDS indicated Resident #35 had severely impaired cognitive skills for daily decision making. The MDS indicated Resident #35 exhibited physical behaviors directed towards other daily. The MDS indicated Resident #35 required extensive assistance with eating, transfers, bed mobility, toileting, and personal hygiene. The MDS indicated Resident #35 required extensive assistance with dressing. The MDS indicated Resident #35 required limited assistance with locomotion on and off the unit. Record review of the care plan updated on 4/25/22 indicated Resident #35's was updated on 4/25/22 to include resident was a wanderer (knocked and entered other persons rooms) with intervention (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675251 If continuation sheet Page 9 of 30 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 675251 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadows of Corsicana, LLC 3301 Park Row Blvd Corsicana, TX 75110 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some including provide distractions, structured activities, and snack. The care plan indicated on 4/25/22 Resident #35's care plan was updated to include the resident had potential to be physically aggressive (by attempting to hug other persons) related to poor impulse control. The care plan was updated following surveyor inquiring about Resident #35's behaviors not being care planned. Record review of Resident #35's electronic medical records indicated he had been the aggressor in 7 resident-to-resident altercations from January 2022 through March 2022 in which he grabbed, scratched, and pulled on other residents. Record review of nurse progress note written by LVN E and dated 2/26/22 at 10:33 a.m. indicated Resident #35 was noted in his room grabbing and pulling his roommate out of bed. The nurse progress note indicated Resident #35 was redirected by the nurse. The nurse progress note indicated the Social Worker was notified of the incident. Record review of nurse progress note written by LVN E and dated 2/26/22 at 5:50 p.m. indicated Resident #35 was in the front lobby grabbing and touching a female resident unwantedly. The nurse progress note indicated Resident #35 was redirected and the Administrator and Social Worker were notified. Record review of accidents and incidents dated 11/01/21 through 4/25/22 indicated there was no incident report for the resident-to-resident altercation on 2/26/22. Record review of nurse progress note written by RN C and dated 2/27/22 at 11:45 a.m. indicated Resident #35 entered another resident's room, grabbed her legs, and took off her shoes causing pain and discomfort to her already sore and tender legs. The nurse progress note indicated attempts to redirect Resident #35 were unsuccessful. Record review of accidents and incidents dated 11/01/21 through 4/25/22 indicated there was no incident report for the resident-to-resident altercation on 2/27/22. Record review of the nurse progress note dated 3/13/22 at 2:22 p.m. indicated Resident #35 entered another resident's room and was touching and clawing at her. The nurse progress note indicated Resident #35 was removed without further incident. Record review of accidents and incidents dated 11/01/21 through 4/25/22 indicated there was no incident report for the resident-to-resident altercation 3/13/22. During an interview on 4/25/22 at 4:53 p.m. the Administrator said the facility did not have policies regarding resident-to-resident altercations, one on one monitoring, resident behaviors, or incidents and accidents. During an interview on 4/26/22 at 8:45 am RN C said in the event of a resident-to-resident altercation the residents should be immediately separated. RN C said the residents should have a head-to-toe assessment completed after being separated. RN C said the family, DON, abuse coordinator, and physician should be notified of the resident-to-resident altercation. During an interview on 4/27/22 at 10:15 a.m. LVN E said she had been employed with the facility 20 years. LVN E said she was familiar with Resident #35. LVN E said she had been working during all four incidents involving Resident #35 that did not have incident reports. LVN E said in the event of a resident-to-resident altercation in the facility the nurse should document in progress notes, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675251 If continuation sheet Page 10 of 30 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 675251 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadows of Corsicana, LLC 3301 Park Row Blvd Corsicana, TX 75110 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610 Level of Harm - Minimal harm or potential for actual harm complete an incident report, notify the physician, family, and DON. LVN E said she did not complete an incident report for these four incidents because she had considered it just Resident #35 behaviors. LVN E said Resident #35 had been having resident to resident altercations since he had been admitted to the facility. LVN E said she now sees where she should have completed incident reports. LVN E said completing an incident report was how the facility knew an investigation should be completed on an incident. Residents Affected - Some During an interview on 4/27/22 at 10:29 a.m. the DON said she had spoken with the LVN E, nurse on duty during the four residents to resident altercations that did not have incident reports. The DON said LVN E was able to identify who three of the four residents were. The DON said the facility was unable to identify who Resident #35's roommate was that he tried to pull out of bed on 2/26/22. The DON said it was not documented who the roommate was and without incident report being completed they were unable to determine who the roommate was. During an interview on 4/27/22 at 2:42 p.m. the DON said it was the charge nurse's responsibility to complete the incident reports. The DON said an incident report should be completed within 2 hours of an incident occurring. The DON said an incident report should be completed for incidents including but not limited to skin changes, falls, and resident to resident interactions. The DON said she and the ADON ensured incident reports were completed. The DON said incident reports were not completed for the resident-to-resident altercations involving Resident #35 in February and March was due to the altercations happening on the weekends. The DON said completing an incident report was the first step in investigating an incident. The DON said the altercations were part of Resident #35's normal attention seeking behavior and not understanding boundaries. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675251 If continuation sheet Page 11 of 30 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 675251 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadows of Corsicana, LLC 3301 Park Row Blvd Corsicana, TX 75110 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to develop, review and revise a comprehensive care plan of each resident that included measurable objectives and timetables to meet a resident's medical, nursing and mental and psychosocial needs for 2 of 13 residents reviewed for care plans (Resident #39 and Resident #35). The facility failed to ensure Resident #39's care plan was updated and revised to reflect significant weight loss since 1/8/2022. The facility failed to ensure Resident #35's care plan addressed his behaviors. These failures could place residents at risk of not having their individualized needs met in a timely manner and communicated to providers and could result in injury and/or a decline in physical well-being. Findings included: 1. Record review of consolidated physicians' orders dated 4/27/2022, indicated Resident #39 was [AGE] years old, admitted on [DATE] with diagnoses including: Huntington's Disease (progressive degeneration of nerve cells in the brain that affects movement, cognitive functions, and emotions), Major Depression (persistent feeling of sadness and loss of interest), and lack of coordination (Impairment of the ability to perform smoothly coordinated voluntary movements). Record review of the most recent comprehensive MDS dated [DATE], indicated Resident #39 had unclear speech, usually made himself understood and usually understood others. The MDS indicated Resident #39's BIMS (brief interview for mental status) score was a 99, meaning staff were unable to complete the interview. The MDS indicated Resident #39 required supervision for bed mobility, transfers, locomotion on and off the unit, dressing, eating, and toilet use. The MDS indicated Resident #39 required extensive assist for personal hygiene and bathing activity itself did not occur. Record review of the undated care plan indicated Resident #39 had an ADL self-care performance deficit related to disease process of Huntington's disease and impaired balance, movement disorder with an initiated date of 9/2/2021. The interventions included, provide finger foods when the resident has difficulty using utensils with date initiated 9/2/2021; the resident requires supervision with set up assistance by staff to eat with date initiated 11/9/2021; discuss with resident/family/POA any concerns related to loss of independence, decline in function with date initiated 11/9/2021; monitor/document/report as needed any changes, any potential for improvement, reasons for self-deficit, expected course, declines in function with date initiated 11/9/2021. The care plan indicated Resident #39 had a regular diet, regular texture, regular liquids consistency, for high protein double portions, frequently changes his mind about what he wants and likes to eat, frequently becomes demanding needing to exert control over when and what he eats, frequently is unreasonable and staff have a hard time getting the resident to accept help or reason with meals and mealtimes, frequently unable to redirect with date initiated 11/9/2021. The care plan did not address significant weight loss. Record review of physician's orders dated 4/27/2022 indicated Resident #39 had orders for regular diet for high protein double portions ordered 9/2/2021 and 2 Cal House Supplement to be offered to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675251 If continuation sheet Page 12 of 30 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 675251 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadows of Corsicana, LLC 3301 Park Row Blvd Corsicana, TX 75110 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 resident twice a day between meals as needed or as requested by resident ordered 4/4/2022. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #39's weights indicated on 1/08/2022, the resident weighed 174.5 lbs. On 4/13/2022, the resident weighed 160 pounds which is a -8.31% loss. Residents Affected - Few Record review of Resident #39's weight log indicated weights of: *4/13/2022 160.0 pounds * 3/9/2022 163.0 pounds * 2/15/2022 165.2 pounds *1/8/2022 174.5 pounds * 12/8/2021 173.9 pounds * 11/10/2021 171.8 pounds * 10/11/2021 172.2 pounds * 8/30/2021 173.6 pounds * 8/27/2021 176.4 pounds Record review of the facility PIP (Performance Improvement Plan) dated 2/16/2022 indicated .Immediate interventions: Designated nursing staff collecting weights. Staff to be checked for competency in obtaining weights. Scale to be calibrated as soon as possible and on a routine basis. Dietician, ST, and FNP/MD to continue to review weight loss and put interventions in place .Re-Education All residents that have orders to be assisted with meals are in the dining room or have their trays set and/or assisted with meals .In-service staff regarding weight loss. Offers resident's a house supplement if they eat less than 50% of meal and document if refused. Continue to offer snacks between meals and at bedtime .Weight Variance Assessment 2/16/2022 No weights are entered into weight/variance .Reason for variance states behavioral issues and increased calorie-burn with disease process .Response Health Shakes BID between meals .Liberize diet . Record review of the Nurse Practitioners notes for Resident #39 dated 2/22/2022 indicated .Weight log reviewed per facility protocol .Noted with 9 pound weight loss in one month .Patient is having increase in Huntington's Chorea muscle movement, suspect burning more calories than he is consuming .Orders: No new orders . Record review of the Nurse Practitioners notes for Resident #39 dated 4/19/2022 indicated .Weight log reviewed per facility protocol .Noted with 7.5 pound weight loss in one month .Patient is on hospice .Orders .No new orders . Record review of a Weight Variance Assessment for Resident #39 dated 4/15/2022 indicated .6 months -5.0%, 3 months -7.5%, 1 month -7.5% .Reason for variance behavioral issues ADL decline r/t injury, resident continues to decline with Huntington's Disease causing agitation and negative behaviors to be exhibited especially during meal times .Continues with Bristol Hospice .Response Discontinue (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675251 If continuation sheet Page 13 of 30 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 675251 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadows of Corsicana, LLC 3301 Park Row Blvd Corsicana, TX 75110 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 weights, hospice patient . Level of Harm - Minimal harm or potential for actual harm During an observation and interview on 4/25/2022 at 11:13 a.m., Resident #39's family said Resident #39 called her this morning and wanted her to bring him tacos. She said she brought him 8 tacos and a box of cheddar jalapeno nuggets. Resident #39 was sitting up in a chair at the dining room table eating tacos. Resident # 39's family member said she brought him 9 tacos. Resident #39 had eaten 7 tacos and 75% of the jalapeno cheddar nuggets. Residents Affected - Few During an interview on 4/25/2022 at 4:36 p.m., The 11:00 a.m to 6:00 p.m. [NAME] said she had witnessed Resident #39's behavior when he wants food. She said he acts out mostly at breakfast. She said Resident #39 will get up out of his wheelchair and walk in the kitchen and to the nurse station mad and yelling. The [NAME] said they have to lock both kitchen doors sometimes so he will not bust in the kitchen. She said at lunch they try to give Resident #39 his tray first so he does not get upset and come to the door. The [NAME] said he does not come to the dining room at dinner anymore. She said they do not give him a snack at breakfast or lunch when is not behaving correctly and asking for food. The [NAME] said snacks go out at 2:00 p.m. to include cakes, milk, yogurt, cheese crackers and sandwiches are made at 8:00 p.m. and sent out. She said he gets a sandwich at night. During an interview on 4/25/2022 at 4:43 the DON said the dietician comes at least monthly with no set date. She said the dietary manager will make a list of new admissions, wounds, and triggers for weight loss. She said that list is given to the nurse practitioner and she makes the dietary recommendations and then the NP recommendations are given to the dietary manager and she will agree or disagree. The DON said the Dietician does not usually make additions to the Nurse Practitioners recommendations. During an observation and interview on 4/25/2022 at 4:55 p.m. Resident #39 was lying in bed resting. He said he was not going to the dining room this evening because he is chilling. He said he does not get a sandwich as a snack at night. During an interview on 4/25/2022 at 5:06 p.m. the Nurse Practitioner said the facility monitors the residents weights and if there is a variance weather positive or negative and exceeds the parameters, the ADON prints a weight variance assessment that is computer generated. She said the weight variance assessment is given to her or the physician and she would look at medications to see if there is anything that would cause anorexia. The Nurse Practitioner said she would sometime tell staff to start mirtazapine as an appetite stimulant if needed. She said now that Resident #39 was on hospice changing medications and the notification of weight loos would go up the hospice chain. She said she was aware that Resident # 39 was resistant to care. She said Resident #39 is being seen by the psychiatric Nurse Practitioner. The Nurse Practitioner said she also saw hospice patients and generally discouraged staff from weighing hospice patients. She said if a resident was begging for food or had behaviors related to food she would hope staff would give them food. During an interview on 4/26/2022 at 9:24 a.m., The Dietary Manager said Resident #39 would come knock on the door and come in the kitchen saying he is hungry. He said the staff would tell him 5 more minutes or however long it takes to finish fixing the meal. The Dietary Manager said Resident #39 eats 3 fried eggs and 2 pieces of sausage every morning for breakfast and 21 chicken nuggets for lunch and dinner. The Dietary Manager said he doesn't like snacks but states a family member will bring him snacks like beef jerky and he eats it all and would refuse breakfast or lunch. The Dietary Manager said weight loss is discussed in morning meeting every week. He said he does not make a list of weight loss/wounds/new admissions. He said the dietician gives him a list of weight loss. He said he (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675251 If continuation sheet Page 14 of 30 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 675251 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadows of Corsicana, LLC 3301 Park Row Blvd Corsicana, TX 75110 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few is made aware of new orders when the nurse writes a new order and fills out a communication form that is given to dietary. He said Resident #39 likes to eat by himself but staff have been trying to help him eat recently. The Dietary Manager said a week ago they started serving Resident #39 his meals 5 minutes early to try to prevent his behaviors. He said sometimes his staff get upset with Resident #39 because they cannot understand what he is requesting. The Dietary Manager said he does not report Resident #39's behaviors when he enters the kitchen angry demanding food. During an interview on 4/26/2022 at 9:40 p.m., the MDS Coordinator said she was aware of Resident #39's weight loss because it was brought up weekly in morning meeting since the weight loss started months ago. She said she did not add it to the care plan because it was an oversight. She said she should have added it immediately when she was informed about it. She said his weight loss was only added to the care plan yesterday, 4/25/2022. She said if staff notice an inconsistency in weight or the weight is off the staff will re-weigh the resident. She said Resident #39 was admitted to Hospice on 3/9/2022 because he had a rapid decline in voluntary movements and was not making progress. She said they have been trying to find placement elsewhere for him because he does not fit in the nursing home. She said he was young and doesn't enjoy the activities the other residents do. The MDS coordinator said meetings are done once a week. She said hospice normally discontinues weights. During an interview on 4/26/2022 at 10:08 a.m. Resident #39's family member said Resident 39 had not been eating dinner for the last couple of weeks. She said she visits Resident #39 about 4 times a week and brings him dinner except the last few weeks because he has asked her not to bring him anything. She said she does not know why he is not eating dinner. The family member said she was aware Resident #39 had a weight loss but did not know how much. She said was aware staff put Resident #39 on protein shakes but he does not drink them because he does not like them. The family member said she has not seen any snack trays at nurses station in this facility, only once in a great while. The family member said she does bring bread and peanut butter to Resident #39 to keep in his room and staff say they make him sandwiches at night but she does not know for sure. She said the facility usually only serves soup and sandwiches at night and Resident #39 cannot eat soup because he would spill it everywhere due to his uncontrolled movements. She said staff have not assisted Resident #39 in eating until just recently. During an interview on 4/26/2022 at 10:26 a.m. the Hospice Nurse said she was not aware of Resident #39's significant weight loss. She said she did see his weights on admission 3/9/2022. The Hospice Nurse said she did not write and order to discontinue weights, she said they normally continue to have residents weighed monthly because they need it for recertification. The Hospice Nurse said she knows that Resident #39 had a good appetite so she did not order him Remeron (appetite stimulant) which she would normally order for residents who have no appetite. The Hospice Nurse said she was aware of Resident #39's behaviors in the dining room regarding food and he was ordered Tegretol 3/17/2022 to help with his behaviors. She said she knows Resident #39 is very time oriented with most tasks including eating times and will misbehave if things don't happen at the time. During an interview on 4/26/2022 at 11:21 a.m., the DON said she did not have a good explanation for why Resident #39's weight loss was not care planned. She said it was discussed in PAR meetings weekly and should have been updated immediately by the MDS Coordinator. She said at one point in February 2022, Resident #39 did trigger for weight loss. The DON said in February 2022 the facility had the scales re-calibrated. She said if the facility had a weight discrepancy, they would calibrate the scale and do a re-weight. She said a that was done with Resident #39 when a significant weight loss was noticed. The DON said his weights were accurate. He was normally weighed in his WC and then we weigh his WC separately and subtract the difference. The Restorative aide is was responsible for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675251 If continuation sheet Page 15 of 30 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 675251 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadows of Corsicana, LLC 3301 Park Row Blvd Corsicana, TX 75110 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few weighing all residents. The DON said she ensures that staff are following care planned interventions by adding the item to the MAR or TAR. During an observation and interview on 4/26/2022 at 12:20 p.m., Resident #39 was sitting up in a chair at the dining room table. He was eating chicken nuggets only. He said he had 21 chicken nuggets and did not want anything else. During an interview on 4/26/2022 at 12:27 p.m. the Dietician said she comes every 2-3 weeks to see residents. She said she was not aware of Resident #39's weight loss for this month. She said her normal routine was to get printout of weights from the DON and go over them, she said most of the time she will go over the recommendations that have already been made by the Nurse Practitioner or physician and she would usually agree with them and add additional orders if needed. She said the last time she saw Resident #39 in February 2022. She said she could not say if Resident #39 had wounds right now. The Dietician said she would normally put a resident on protein if they were not eating well of if they were going to the wound care clinic/VOHRA. She said she would also start them on Vitamin C, Zinc, and a multivitamin. The Dietitian said supplements should definitely be started with weight loss. She said even if a resident had an appetite, she would still put them on a supplement for weight loss. The Dietician said she could not recall what interventions had been tried with Resident #39, she said she would have to look at her notes. The Dietician said she was not aware of the behaviors Resident #39 had in the dining. She said is he was having behaviors he should be the first one to be served if there was enough staff to do that. The Dietician said if Resident #39 was hungry the staff should be able to pre make items for him to eat while he waits for his tray. The Dietician said she was not aware Resident #39 had been refusing dinner. She said no staff had notified her. The Dietician said she gave her recommendation to either the DON or ADON or leaves it on their desk. She said she has not watched Resident #39 eat in the last couple of months. She said if the Dietary Manager is aware of weight loss or behaviors, she would expect him to notify her. During an interview on 4/26/2022 at 1:49 p.m. the Dietician said she talked to the [NAME] and went over Resident #39 refusing starches and vegetables. She said the [NAME] told her Resident #39 wanted specific meats only. She said the [NAME] told her the staff offer extra items and he would refuse them. She said she did not know the rules with the current corporate but the owners before did not want appetite stimulants. The Dietician said she never asked the facility what their policy was on appetite stimulants. During an interview on 4/27/2022 at 10:13 a.m., The MDS Coordinator said she was responsible for updating the care plan and the failure of not updating the care plan could mean further decline for the president's health. During an interview on 4/27/2022 at 11:14 a.m., The DON said the MDS coordinator, and the Social Worker set up care plan meetings and sent out the invites. She said she verified that invites were sent out by talking to the MDS Coordinator and Social Worker. The DON said care plan invites should be documented in a progress note by the Social Worker and MDS Coordinator of acceptance or refusal. She said she followed up at the end of the week when care plans are done to ensure the notes are in after the care plan meeting. The DON said herself, the Activity Director, MDS Coordinator, Social Worker, and dietary usually attend the care plan meetings. The DON said she can't always attend every care plan meeting. She said she expected staff to enter the progress note regarding the care plan meeting and the family to be notified of the meeting in advance. During an interview on 4/27/2022 at 2:18 p.m., The Administrator said weight loss should be care (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675251 If continuation sheet Page 16 of 30 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 675251 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadows of Corsicana, LLC 3301 Park Row Blvd Corsicana, TX 75110 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm planned to prevent further decline. The Administrator said if the family or the resident was not invited to the care plan meeting, they could miss something that was important about the care of the resident. During an interview on 4/27/2022 at 2:59 p.m., the DON said the failure for not having the care plan updated could result in resident's further decline in health. Residents Affected - Few 2. Record review of the consolidated physician orders dated 4/27/22 indicated Resident #35 was an [AGE] year-old male, re-admitted to the facility on [DATE] with diagnoses including cerebral palsy (a congenital disorder of movement, muscle tone, or posture), severe intellectual disabilities, schizoaffective disorder (a mental health condition including schizophrenia and mood disorder symptoms), unspecified mood disorder, bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), impulse disorder (mental health disorders that are characterized by the inability to control impulses). Record review of the most recent MDS dated [DATE] indicated Resident #36 sometimes understood others and sometimes made himself understood. The MDS indicated Resident #35 had a BIMS score of 99 indicating Resident #35 was unable to complete the BIMS assessment. The MDS indicated Resident #35 had severely impaired cognitive skills for daily decision making. The MDS indicated Resident #35 exhibited physical behaviors directed towards other daily. The MDS indicated Resident #35 required extensive assistance with eating, transfers, bed mobility, toileting, and personal hygiene. The MDS indicated Resident #35 required extensive assistance with dressing. The MDS indicated Resident #35 required limited assistance with locomotion on and off the unit. Record review of the care plan updated on 4/25/22 indicated Resident #35's was updated on 4/25/22 to include resident was a wanderer (knocked and entered other persons rooms) with intervention including provide distractions, structured activities, and snack. The care plan indicated on 4/25/22 Resident #35's care plan was updated to include the resident had potential to be physically aggressive (by attempting to hug other persons) related to poor impulse control. The care plan was updated following surveyor inquiring about Resident #35's behaviors not being care planned. Record review of Resident #35's electronic medical records indicated he had been the aggressor in 7 resident-to-resident altercations from January 2022 through March 2022 in which he grabbed, scratched, and pulled on other residents. During an interview on 4/25/22 at 4:59 p.m. the MDS Coordinator said it was her responsibility to ensure care plans were updated. The MDS Coordinator said the DON and Social Worker assisted her in updating care plans. During an interview on 4/26/22 at 9:06 a.m. the MDS Coordinator said she thought Resident #35's behaviors were already care planned. The MDS Coordinator said when Resident #35 was admitted from the group home he was very lethargic related to being overmedicated and had a Stage 4 pressure sore. The MDS Coordinator said Resident #35 had psychiatric medications discontinued after admission and had an increase in behaviors. The MDS Coordinator said Resident #35's behaviors had evolved since his admission due to medication changes. The MDS Coordinator said with the psychiatric referral and medication adjustments that Resident #35 had started calming down. The MDS Coordinator said Resident #35 exhibited attention seeking behaviors more than anything. The MDS Coordinator said it was an oversight on her part that Resident #35's behaviors were not care planned. During an interview on 4/26/22 at 9:15 a.m. the Administrator said she expected Resident #35's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675251 If continuation sheet Page 17 of 30 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 675251 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadows of Corsicana, LLC 3301 Park Row Blvd Corsicana, TX 75110 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete behaviors to care planned. The Administrator said she was unaware of Resident #35's behaviors not being care planned and was unsure why they had not been included in the care plan. Record review of Care Planning policy revised December 2017 indicated, A comprehensive, person-centered care plan is developed and implemented for each resident to meet the resident's physical, psychosocial, and functional needs .The care plan is based on the resident's comprehensive assessment and is developed by a Care Planning/Interdisciplinary Team which included, but is not necessarily limited to the following personnel: a. and RN who has responsibility for the resident, b. The Dietary Manager/Dietician, c. The Social Services Worker responsible for the resident, d. The Activity Director, e. Therapists (speech, occupational, recreational, etc.), f. Consultants, g. DON, h. The Charge Nurse responsible for resident care, i. Nursing Assistants responsible for the resident's care, and j. Others as appropriate or necessary to meet the needs of the resident .The resident and his or her representative are encouraged to participate in the resident's assessment and in the development, implementation, and revisions to the resident's care plan . Event ID: Facility ID: 675251 If continuation sheet Page 18 of 30 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 675251 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadows of Corsicana, LLC 3301 Park Row Blvd Corsicana, TX 75110 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and time frames to meet the resident's mental and psychosocial needs for 2 of 13 resident's reviewed for care plans. (Resident #14 and Resident #4) The facility failed to invite Resident's #14's family member to participate in the development, review, and revision of their care plan. The facility failed to invite Resident #4 to participate in the development, review, and revision of their care plan. This failure could place residents at risk for not receiving necessary care and services. 1. Record review of consolidated physicians' orders dated 4/27/2022, indicated Resident #14 was [AGE] years old, admitted on [DATE] with diagnoses including: Alzheimer's Disease (problems with memory, thinking and behavior) and Hypertension (high blood pressure). Record review of the most recent comprehensive MDS dated [DATE], indicated Resident #14 had clear speech, usually made herself understood and usually understood others. The MDS indicated Resident #14's BIMS (brief interview for mental status) score was a 99, meaning staff were unable to complete the interview. The MDS indicated Resident #14 required extensive assist with bed mobility, transfers, locomotion on and off the unit, dressing, eating, and toilet use. The MDS indicated Resident #14 required limited assist for personal hygiene and bathing activity itself did not occur. Record review of the undated care plan indicated Resident #14 had an ADL self-care performance deficit related to severe unavoidable weakness with inevitable decline due to disease processes (Alzheimer's) and resident is currently on Hospice Care with an admit date of 3/9/2022. Record review of an admission record indicated Resident #14's family member was the care plan conference contact. Record review of a progress noted dated 12/9/2021 written by the MDS Coordinator indicated Resident #14 had a care plan meeting to include therapy, the DON, the Activity Director, the Social Worker, and the MDS Coordinator. The note did not include Resident #14's family member her RP. The note did not indicate invitation of the RP or resident to the care plan meeting or declination. Further review of progress notes did not indicate any other care plan meetings. During an interview on 4/26/2022 at 2:57 p.m., Resident #14's family member said Resident #14 had been in the facility for 5-6 years and the facility use to call her for care plan meetings, but they don't call anymore. She said it had been over a year since she was involved in a care plan meeting. She said she would like to be included in Resident #14's care and if they would send her a notice in the mail, she would ask for time off. During an interview on 4/27/2022 at 11:01 a.m., tThe Social Worked said she had previously sent out (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675251 If continuation sheet Page 19 of 30 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 675251 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadows of Corsicana, LLC 3301 Park Row Blvd Corsicana, TX 75110 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few care plan invites by mail and she was getting a lot of return mail. She said Resident #14's family member had been invited to a care plan meeting in December of 2020 and showed me a Care Plan list. The Social Worker said Resident #14's family member had been invited to care plan meetings and when asked for documentation she said the system of mailing letters did not work in 2020. She said a care plan meeting was held on 12/9/2021 with Therapy/DON/Activities/SW and family member by phone. She said she was due for an update on 5/22/2022. She said she does not have any documentation of inviting RP/residents to the Care Plan meeting. 2. Record review of consolidated physicians' orders dated 4/27/2022, indicated Resident #4 was a [AGE] year-old male, admitted on [DATE] with diagnoses including: Type1 Diabetes (pancreas produces little or no insulin), End Stage Renal Disease (kidneys cease functioning on a permanent basis), and hypertension (high blood pressure). Record review of the of the most recent comprehensive MDS dated [DATE] indicated Resident #4 had clear speech, usually made himself understood and sometimes understood others. The MDS indicated Resident #4's BIMS score was a 10 indicating moderately impaired cognition. The MDS indicated Resident #4 required supervision with bed mobility, transfers, locomotion, dressing, eating, toilet use, personal hygiene, and bathing did not occur. Record review of the undated care plan indicated Resident #4 was a full code, was dependent on staff for meeting emotional, intellectual, physical, and social needs related to disease process (kidney disease). The care plan indicated Resident #4 had an ADL self-care performance deficit related to right leg amputation and has a prosthesis. The care plan indicated Resident #4 needed hemodialysis related to end stage renal disease. Record review of an admission record indicated Resident #4 was his own responsible party. Record review of progress notes did not indicate Resident #4 had any care plan meetings. During an interview on 4/26/2022 at 3:55 p.m., Resident #4 said the staff did not ask him to attend care plan meetings. He said, What is a care plan meeting?. He said he did not recall being invited to a care plan meeting or being involved in his treatment plan. During an interview on 4/27/2022 at 10:13 a.m., The MDS Coordinator said she was responsible for updating the care plan. She said the Social Worker sends out Care Plan meeting invites. She said Care Plan meetings are done quarterly. The MDS Coordinator said care plan meeting are done in person and sometimes over the phone. During an interview on 4/27/2022 at 10:17 a.m., The Social Worker said she would call or mail letters to family members to invite them to care plan meetings. She said she does not always document when she calls or mails out letters because she does not always have time. The Social Worker said she may also see a family member in the facility and invite them verbally but does not always document that either. She said care plan meetings are done quarterly, with a change of condition and at the request of a resident or family member. She said she knows when the Care Plan meeting is due because the MDS tells her. She said she documents in her notes under care plans/social work/investigations/complaints/grievances. During an interview on 4/27/2022 at 10:50 a.m., The Social Worker said Care Plan meetings usually included herself, the MDS coordinator, and the DON. She said different people would attend depending (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675251 If continuation sheet Page 20 of 30 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 675251 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadows of Corsicana, LLC 3301 Park Row Blvd Corsicana, TX 75110 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few on the need and it could include therapy, dietary, or whoever requested to be there. The Social Worker said Resident #4 was admitted on [DATE]. She said she did an admission care plan, and then updates on 8/1/2021, discharge on [DATE] and then quarterly on 8/15/2021, 11/1/2021 and 5/4/2022. She said she could show me that the meeting occurred by looking at the updated care plan. She said she did not have documentation of who attended the care plan meeting. She said Resident #4 was present as far as she knows during the 8/15/2022 and 11/1/2022 but no other family member was present. The Social Worker said Resident #4 was his own RP. She is was not able to present documentation for care plan meetings. During an interview on 4/27/2022 at 11:14 a.m., The DON said the MDS coordinator, and the Social Worker set up care plan meetings and sent out the invites. She said she verifies that invites are sent out by talking to the MDS Coordinator and Social Worker. The DON said care plan invites should be documented in a progress note by the Social Worker and MDS Coordinator of acceptance or refusal. She said she followed up at the end of the week when care plans are done to ensure the notes are in after the care plan meeting. The DON said herself, the Activity Director, MDS Coordinator, Social Worker, and dietary usually attend the care plan meetings. The DON said she can't always attend every care plan meeting. She said she expected staff to enter the progress note regarding the care plan meeting and the family to be notified of the meeting in advance. She said family should be called and get an invite in the mail. The DON said staff should try to figure out what the correct address is if they are getting return mail. She said she would expect the MDS coordinator to document when the RP/Resident was invited and if they accepted or declined. The DON said if the Social Worker or MDS Coordinator was out the back up would herself. She said if the RP or the resident was not sent an invite then they would not have any input in their care. During an interview on 4/27/2022 at 2:18 p.m., The Administrator said care plan meetings should be done quarterly with the MDS schedule. She said the Social Worker and MDS Coordinator normally coordinate sending out invites and making the schedule together. She said the care plan team included, food services, the Social Worker, activities, the MDS coordinator and the family/RP. The Administrator said everywhere else she had worked the facility sent out letters and kept letters for record of proof. She said the Social Worker told her she had not been sending invites out or keeping a record. She said she told the Social Worker that the facility would start sending out the letter for the invite and keeping a copy for their records and if they had to call and invite, she would expect them to document an acceptance or refusal in a progress note. She said she expected staff to invite the resident and family members. The Administrator said if the family or the resident was not invited to the care plan meeting, they could miss something that is important about the care of the resident. During an interview on 4/27/2022 at 2:59 p.m., the DON said the failure for not having the care plan updated could result in resident's further decline in health. Record review of a facility care plan policy with a revision date of December 2017 indicated .a comprehensive, person-centered care plan is implemented for each resident to meet the resident's physical, psychosocial, and functional wellbeing .and care plans shall incorporate goals and objectives that lead to the resident's highest obtainable level of independence . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675251 If continuation sheet Page 21 of 30 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 675251 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadows of Corsicana, LLC 3301 Park Row Blvd Corsicana, TX 75110 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure each resident received adequate supervision for 1 of 12 residents reviewed for supervision (Resident #35). The facility failed to provide adequate supervision for Resident #35 to address the underlying reasons for the behaviors and identify interventions to try to prevent his disruptive or intrusive interactions and behaviors. This failure could place the residents at risk of injures, inadequate supervision and neglect. Findings 1. Record review of the consolidated physician orders dated 4/27/22 indicated Resident #35 was an [AGE] year-old male, re-admitted to the facility on [DATE] with diagnoses including cerebral palsy (a congenital disorder of movement, muscle tone, or posture), severe intellectual disabilities, schizoaffective disorder (a mental health condition including schizophrenia and mood disorder symptoms), unspecified mood disorder, bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), impulse disorder (mental health disorders that are characterized by the inability to control impulses). The physician orders indicated Resident #35 had orders for Depakote (medication used to treat bipolar disorder) 125 mg three times daily starting 2/28/22 and Risperidone 0.5 mg twice daily starting 3/18/22. Record review of the most recent MDS dated [DATE] indicated Resident #36 sometimes understood others and sometimes made himself understood. The MDS indicated Resident #35 had a BIMS score of 99 indicating Resident #35 was unable to complete the BIMS assessment. The MDS indicated Resident #35 had severely impaired cognitive skills for daily decision making. The MDS indicated Resident #35 exhibited physical behaviors directed towards other daily. The MDS indicated Resident #35 required extensive assistance with eating, transfers, bed mobility, toileting, and personal hygiene. The MDS indicated Resident #35 required extensive assistance with dressing. The MDS indicated Resident #35 required limited assistance with locomotion on and off the unit. Record review of the care plan updated on 4/25/22 indicated Resident #35's was updated on 4/25/22 to include resident was a wanderer (knocked and entered other persons rooms) with intervention including provide distractions, structured activities, and snack. The care plan indicated on 4/25/22 Resident #35's care plan was updated to include the resident had potential to be physically aggressive (by attempting to hug other persons) related to poor impulse control. The care plan was updated following surveyor inquiring about Resident #35's behaviors not being care planned. Record review of Resident #35's electronic medical records indicated he had been the aggressor in 7 resident-to-resident altercations from January 2022 through March 2022 in which he grabbed, scratched, and pulled on other residents. Record review of nurse progress note written by LVN E and dated 2/26/22 at 10:33 a.m. indicated Resident #35 was noted in his room grabbing and pulling his roommate out of bed. The nurse progress note indicated Resident #35 was redirected by the nurse. The nurse progress note indicated the Social Worker was notified of the incident. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675251 If continuation sheet Page 22 of 30 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 675251 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadows of Corsicana, LLC 3301 Park Row Blvd Corsicana, TX 75110 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of nurse progress note written by LVN E and dated 2/26/22 at 5:50 p.m. indicated Resident #35 was in the front lobby grabbing and touching a female resident unwantedly. The nurse progress note indicated Resident #35 was redirected and the Administrator and Social Worker were notified. Record review of accidents and incidents dated 11/01/21 through 4/25/22 indicated there was no incident report for the resident-to-resident altercation on 2/26/22. Record review of nurse progress note written by RN C and dated 2/27/22 at 11:45 a.m. indicated Resident #35 entered another resident's room, grabbed her legs, and took off her shoes causing pain and discomfort to her already sore and tender legs. The nurse progress note indicated attempts to redirect Resident #35 were unsuccessful. Record review of accidents and incidents dated 11/01/21 through 4/25/22 indicated there was no incident report for the resident-to-resident altercation on 2/27/22. Record review of the nurse progress note dated 3/13/22 at 2:22 p.m. indicated Resident #35 entered another resident's room and was touching and clawing at her. The nurse progress note indicated Resident #35 was removed without further incident. Record review of accidents and incidents dated 11/01/21 through 4/25/22 indicated there was no incident report for the resident-to-resident altercation 3/13/22. During an interview on 4/25/22 at 4:53 p.m. the Administrator said the facility did not have policies regarding resident-to-resident altercations, one on one monitoring, resident behaviors, or incidents and accidents. During an interview on 4/26/22 at 8:45 am RN C said in the event of a resident-to-resident altercation the residents should be immediately separated. RN C said the residents should have a head-to-toe assessment completed after being separated. RN C said the family, DON, abuse coordinator, and physician should be notified of the resident-to-resident altercation. During an interview on 4/27/22 at 10:15 a.m. LVN E said she had been employed with the facility 20 years. LVN E said she was familiar with Resident #35. LVN E said she had been working during all four incidents involving Resident #35 that did not have incident reports. LVN E said in the event of a resident-to-resident altercation in the facility the nurse should document in progress notes, complete an incident report, notify the physician, family, and DON. LVN E said she did not complete an incident report for these four incidents because she had considered it just Resident #35 behaviors. LVN E said Resident #35 had been having resident to resident altercations since he had been admitted to the facility. LVN E said she now sees where she should have completed incident reports. During an interview on 4/27/22 at 10:29 a.m. the DON said she had spoken with the LVN E, nurse on duty during the four residents to resident altercations that did not have incident reports. The DON said LVN E was able to identify who three of the four residents were. The DON said the facility was unable to identify who Resident #35's roommate was that he tried to pull out of bed on 2/26/22. The DON said it was not documented who the roommate was and without incident report being completed they were unable to determine who the roommate was. During an interview on 4/27/22 at 2:42 p.m. the DON said it was the charge nurse's responsibility (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675251 If continuation sheet Page 23 of 30 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 675251 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadows of Corsicana, LLC 3301 Park Row Blvd Corsicana, TX 75110 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few to complete the incident reports. The DON said an incident report should be completed within 2 hours of an incident occurring. The DON said an incident report should be completed for incidents including but not limited to skin changes, falls, and resident to resident interactions. The DON said she and the ADON ensured incident reports were completed. The DON said incident reports were not completed for the resident-to-resident altercations involving Resident #35 in February and March was due to the altercations happening on the weekends. The DON said the altercations were part of Resident #35's normal attention seeking behavior and not understanding boundaries. Record review of the Abuse, Neglect, and Exploitation policy dated December 2017 indicated, Our residents have the right to be free from abuse/neglect/misappropriation of resident property/corporal punishment/and involuntary seclusion Our facility is committed to protecting our residents from abuse by anyone including but not necessarily limited to: employees/other residents/consultants/volunteers/family member/visitors/or any other individual .Our facility will protect residents from harm during investigations of alleged abuse. During investigations of alleged abuse, residents will be protected from harm by the following measures .c. If the abuse involves another resident, the accused resident's representative and attending physician will be informed of the alleged abuse incident and that there may be restrictions on the accused resident's ability to visit other resident's rooms unattended. If, necessary, the accused resident's family members may be required to help meet this requirement .Reports of alleged resident abuse, neglect, and injuries of unknown source shall be promptly and thoroughly investigated by facility management . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675251 If continuation sheet Page 24 of 30 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 675251 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadows of Corsicana, LLC 3301 Park Row Blvd Corsicana, TX 75110 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to ensure all drugs were stored in a locked compartment and only accessible by authorized personnel for 1 of 16 residents reviewed for medication storage (Resident #10). The facility did not ensure Resident #10's medications were kept in a secured location. Resident #10 had an open jar of Chest Rub (a mentholated topical petroleum jelly-based ointment intended to assist with minor medical conditions that impair breathing, including the common cold) and a jar of Arctic Ice Pain Relieving gel at the bedside. This failure could place residents at risk for overuse and adverse effects of medication and harm. Findings included: Record Review of the consolidated physicians' orders dated 4/27/2022, indicated Resident #10 was [AGE] years old, re-admitted on [DATE] and had diagnosis including osteoarthritis(degenerative joint disease), chronic obstructive pulmonary disease ( a group of lung diseases that block airflow and make it difficult to breath), bipolar ( a disorder with episodes of mood swings), psychosis ( a mental disorder characterized by a disconnection with reality), macular degeneration (eye disease causing vision loss), and schizophrenia (a disorder that affects a persons ability to think, feel, and behave clearly). The physician's orders did not address the Chest Rub or the Arctic Ice pain relieving gel. Record review of the most recent comprehensive MDS dated [DATE], indicated Resident #10 sometimes made herself understood and sometimes understood others. The MDS indicated Resident #10 had moderately impaired vision. The MDS indicated Resident #10 had a BIMS (brief interview for mental status) score of 12 (mildly impaired). The MDS indicated Resident #10 required extensive assistance with bed mobility, dressing, toileting, and personal hygiene. Record review of the care plan dated 6/7/2021 indicated Resident #10 had impaired visual function related to diabetes and macular degeneration. The care plan indicated Resident #10 had impaired cognitive function/dementia or impaired thought processes related to cerebral infarction (stroke) with interventions for the facility to administer medications as ordered and monitor/document for side effects and effectiveness. The care plan indicated Resident #10 had an ADL self-care performance deficit related to a previous stoke. During an observation and interview on 4/25/2022 at 10:30 a.m., Resident #10 was sitting up in her wheelchair in her room. An open jar of Chest Rub and a jar of Arctic Ice Pain relieving gel was on her bedside table. Resident #10 said she used the medications when she needed them. Resident #10 was not aware if facility knew she had the medications. During an observation on 4/25/2022 at 2:15 p.m., an open bottle of Chest Rub and Arctic pain-relieving gel were on Resident #10's bedside table. During an observation and interview on 4/26/2022 at 10:30 a.m., Resident #10 said she often had (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675251 If continuation sheet Page 25 of 30 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 675251 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadows of Corsicana, LLC 3301 Park Row Blvd Corsicana, TX 75110 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 0761 Level of Harm - Minimal harm or potential for actual harm back pain that required medications. Resident #10 said she used the topical pain relief but was not sure where the jar was at this time. An open jar of Chest rub was on Resident #10's bedside table. During an observation on 4/26/2022 at 2:30 p.m., Resident #10 had an open bottle of Chest Rub on the bedside table. Residents Affected - Few During an observation and interview on 4/27/2022 at 8:40 a.m., Resident #10 had an open jar of Chest Rub on her bedside table. Resident #10 said she used the chest rub for her chest congestion. During an interview on 4/27/2022 at 9:58 a.m., LVN D said she had worked in the facility for approximately 9 months. LVN D said medications should not be at the bedside without an order to be at the bedside. LVN D said it was dangerous for medications to be at the bedside because it would not be documented when taken and the resident could take too much of the medication or another resident could take the medication. During an interview on 4/27/2022 at 10:02 a.m., RN C said medications should not be at the bedside without an order to be at the bedside whether prescribed or over the counter. RN C said the resident could take too much of the medication. RN C said she was not aware Resident #10 had medications of any kind at her bedside. RN C said Resident #10 had not had a recent cognitive decline and she could possibly get an order for her to keep those medications at the bedside. RN C said Resident #10 did not currently have an order to have medications at the bedside. During an interview on 4/27/2022 at 10:05 a.m., the DON said Resident #10 should not have chest rub or pain-relieving gel at the bedside without an order for it to be at the bedside. The DON said she was not aware Resident #10 had these medications at the bedside and did not have an assessment or any orders to have medications as the bedside. The DON said if residents wanted to keep any type of medications at the bedside an assessment for self-administration had to be completed and the MD had to approve for the resident to self-administer those medications. The DON said this was important to ensure the safety of residents so they did not take too much medication or take any medications that may interact with the other medication being administered by the facility. The DON said the facility made daily ambassador rounds to check for these types of issues. The DON said the charge nurses and medication aides should also be watching for medications at the bedside while they are in resident rooms providing care. During an interview on 4/27/2022 at 10:06 a.m., the Administrator said in the past she thought residents were able to keep medications at the bedside if they were alert and aware of what the medications were and the side effects. The Administrator said this should be documented in the resident's chart. The Administrator said she had only been employed at the facility for 4 months and was not aware of exactly what the facilities policy was on medications at the bedside. The Administrator said she was unaware Resident #10 had medications at her bedside. The Administrator said Resident #10 received a lot of mail and she may have received the medications through the mail. The Administrator said nurses were responsible for watching for medications at the bedside. Record review of a policy titled Medications Brought to the facility by the Resident/Family dated 2017 indicated medications brought into the facility not approved for the resident's use shall be returned to the family. Record review of a policy titled Medication and Treatment Orders dated 2017, indicated orders for medications and treatments would be kept in the electronic and/or paper chart. The policy indicated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675251 If continuation sheet Page 26 of 30 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 675251 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadows of Corsicana, LLC 3301 Park Row Blvd Corsicana, TX 75110 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 0761 medications would be administered upon the written order of a person duly licensed and authorized to prescribe such medications. 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: 675251 If continuation sheet Page 27 of 30 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 675251 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadows of Corsicana, LLC 3301 Park Row Blvd Corsicana, TX 75110 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that the menus were followed for 3 of 3 residents reviewed for menu accuracy (Residents #10, 15 and 17) The facility served hamburgers without cheese, instead of the cheeseburgers listed on the menu. This deficient practice could affect residents who receive kitchen prepared meals by contributing to dissatisfaction, poor intake, and weight loss. The findings include: Record review of Resident #10's face sheet dated 4/27/2022 indicated she was a [AGE] year old female admitted to the facility on [DATE] with diagnosis of primary generalized osteoarthritis (the gradual wearing down of cartilage in the joints), type 2 diabetes, chronic obstructive pulmonary disease, and primary hypertension. Record review of Resident #10's most recent quarterly MDS dated [DATE] indicated a BIMS (brief interview for mental status) of 12, reflecting moderate cognitive impairment. Record review of Resident #15's face sheet dated 4/27/2022 indicated he was a [AGE] year old male admitted to the facility on [DATE] with diagnosis of Muscle wasting and reduction, Type 2 Diabetes, Primary hypertension, and Moderate to severe brain injury without loss of consciousness (awareness). Record review Resident #15's most recent quarterly MDS dated [DATE] indicated a BIMS score of 8, reflecting moderate cognitive impairment. Record review of Resident # 17's face sheet dated 4/27/2022 indicated he was a [AGE] year old male admitted to the facility on [DATE] with diagnosis of Cognitive social or emotional deficit following an unspecified cerebrovascular disease (conditions affecting blood flow and blood vessels of the brain), Type 2 Diabetes, and Chronic obstructive pulmonary disease. Record review of Resident #17's most recent quarterly MDS dated [DATE] indicated a BIMS score of 7, reflecting severely impaired cognitive impairment. Observation of the facility's lunch menu for 4/25/2022 at 11:35 am revealed the main entrée to be cheeseburgers. During an interview with on 4/25/2022 at 12:10 pm, Resident #10 said she would like cheese on her hamburger. During an interview on 4/25/2022 at 12:12 pm, Resident #15 said he would prefer cheese on his hamburger. During an interview on 4/25/2022 at 12:13 pm, Resident #17 said he would prefer cheese on his hamburger. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675251 If continuation sheet Page 28 of 30 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 675251 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadows of Corsicana, LLC 3301 Park Row Blvd Corsicana, TX 75110 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an Interview on 4/25/2022 at 1:45 pm the DM said he was not aware the residents had only been served hamburgers, not the cheese burgers listed on the menu. The DM said they did have cheese at the facility for the resident's cheeseburgers. The DM said he would need to talk to the cook who assembled the resident's lunch meal. During an interview on 4/25/2022 at 1:57 pm, [NAME] A said she assembled the lunch meal. [NAME] A she said she thought it was just hamburgers, not cheeseburgers being served to the residents. [NAME] A said she the cheese was usually laid out ahead when cheeseburgers were being served for the meal. [NAME] A said she worked as one of the afternoon cooks for the facility. [NAME] A said the morning cook was responsible for putting out the needed items needed for that day's lunch. [NAME] A said cooks know what is on the menu by looking at the menu book prior to preparing a meal. [NAME] A said residents should receive what is on the menu. [NAME] A said residents might get upset if they were not served what is listed on the menu. During an interview on 4/27/2022 at 10:21 am, [NAME] B said she the menu is posted daily. [NAME] B said she looks at the menu the day before to know what will be served the following day. [NAME] B said the cooks are supposed to look at the menu the day before to make sure the facility has all the need items in advance. [NAME] B said she did not know how it would be disadvantageous to residents if they were not served what was posted on the menu to facility. During an interview on 4/27/2022 at 12:15 pm, the DM said he was the cook responsible for setting out the items needed menu items for lunch on 4/25/2022. The DM said he made a mistake and just didn't put out the cheese needed to assemble the cheeseburgers for lunch that day. The DM said there is a weekly menu posted for what is to be served each meal. The DM said he was distracted. The DM said he talks with residents regularly and they give him feedback when something is not right. The DM was asked how it could be disadvantageous to residents when the facility failed to serve items listed on the posted menu. The DM said the residents will ask for what they want. The DM said cognitively impaired residents would be given a choice of what they wanted to eat. During an interview on 4/27/2022 at 2:15 pm, the Administrator said she expected the menu to be followed. The Administrator said when residents are not served what is listed on the menu, it could limit their choices and not give them what they want. The Administrator was asked to provide a copy of the policy regarding facility's responsibly to serve residents food and drink items on. Prior to the exit conference, a policy was not provided to the team. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675251 If continuation sheet Page 29 of 30 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 675251 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadows of Corsicana, LLC 3301 Park Row Blvd Corsicana, TX 75110 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 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 food in accordance with professional standards for food safety in the facility's only kitchen. Residents Affected - Few The facility failed to ensure food items stored in facility refrigerators were used by their best by date. This failure could place residents at risk for food-born illness and food contamination. The findings include: During an Observation on 4/25/2022 at 8:45 am, the following items were found in the facility designated refrigerator for single serve resident beverages: Twelve cartons of orange juice with a best by date of 4/23/2022 were found in this refrigerator. During an interview on 4/25/2022 at 9:15 AM, the DM said none of the orange juice cartons with a best by date of 4/23/2022 had been served to residents. The DM said the cartons came out of a new box just opened after breakfast was served this morning. The DM said the shipment came in last Thursday 4/21/2022. The DM said best buy/expiration dates are checked when food/drink containers are received from the vendor. The DM said he is usually the person to receive shipment orders. During an interview on 4/27/2022 at 10:21 PM, [NAME] B said she checked the dates on all food and beverages prior to serving them to residents. [NAME] B said when she would dispose of any observed a food or beverage item that was past its best by date. [NAME] B said residents could get sick if served food that is past its best buy date. During an interview on 4/27/2022 at 1:57 PM, [NAME] A said she checked food containers for best by date prior to serving them to residents. [NAME] A said when she come across a food/beverage item that is past it's best by date, she will put it in the trash, and not serve it residents. [NAME] A said residents served food/beverage past the best by date might get sick. During an interview on 4/27/2022 at 2:02pm, the DM said all kitchen staff to include: the cooks, dietary assistants, and himself, are responsible for checking the best by dates prior to serving them to residents. The DM said older juice cartons got mixed in with the new ones. The DM said the vendor delivered the cases last Thursday, 04/21/2022. The DM said he usually checked everything when shipments arrive. The DM said the facility serves older products first to prevent residents from receiving products past their best by date. The DM said serving pre-packaged food and beverages past their best by date could cause digestive problems for residents. During an interview on 4/27/2022 at 2:10pm, the Administrator said food/beverages past their best by dates should not be served to residents. The Administrator said serving residents food/beverages past their best by dates could cause residents illness. The Administrator did not provide, prior to the exit conference, a requested copy of a facility policy regarding the serving of food/beverage to residents past best by date. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675251 If continuation sheet Page 30 of 30