Inspection·June 26, 2023

F 0551 benefits, and needs for maximum independence. Level of Harm - Minimal harm or potential for actual harm Review of Resident #1's POA document found in the EMR revealed FM designated as POA and form dated 9/13/2017. Residents Affected - Few During an interview on 6/16/23 at 12:30 pm, the FM stated her Resident #1 had back-to-back strokes and was admitted on [DATE] to the facility for rehab. The FM stated on 5/1/23 Resident #1 exited out a side door to a fenced area and was let back in by staff. The FM stated the next day, 5/2/23, she came up to the facility for a meeting with the AD and DON regarding the incident and she was informed Resident #1 would be discharged on 5/10/23. Because she had plateaued. The FM stated she was not given anything in writing but was told verbally about the upcoming discharge. During an interview on 6/16/23 at 1:24 pm, the SW stated she handed the NOMNC discharge form to the FM on the day of the discharge, 5/11/23, when she came to the facility. She stated she mailed it as well but could not provide any documentation or notes about mailing the form. She stated she normally documents it in the EMR but forgot to this time. She stated she had Resident #1 sign the form on 5/3/23 because that's what they usually do, and the resident was able to sign the form. She stated she left the form in the room for the FM. Then the SW stated she spoke to FM on 5/8/23, in person at the facility about the form and appeal process but stated she had no notes or documentation to reflect this conversation or events. The SW stated she was aware the resident had memory problems and that the FM was POA, but if resident is able to sign the form, that's what they do. During an interview on 6/16/23 at 2:32 pm, the FM stated she received no correspondence from the facility in the mail on the discharge and was never asked to sign any forms. She stated no one from the facility talked to her about coverage ending or the appeal process. She stated she didn't find out about any of this until she came to pick Resident #1 up on 5/11/23, when they gave her the NOMNC form, and it was too late to file an appeal. She stated she found out Resident #1 signed the form but stated Resident #1 would not have known what she was signing, that's why FM was POA. The FM stated she was not included in any discharge planning for Resident #1. During an interview on 6/16/23 at 4:48 PM, the SW stated her understanding is any resident is able to sign NOMNC forms unless the court had done adjudication saying they can't. She stated she spoke to Resident #1 regarding the form and said, I need you to sign this. She stated she told her the coverage was ending. She stated she never discussed the appeal process because it is spelled out in the form. She stated she was aware that Resident #1 had a POA, but she was not available at that time. She stated she left a copy of the form in the room. She stated she did not document this anywhere in the EMR. Review of facility policy Discharge Summary and Plan of Care dated 10/24/22 reflected it is the policy of this facility to ensure that a discharge planning process is in place which addressed each resident's discharge goals and needs, including caregiver support and referral to local contact agencies. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675251 If continuation sheet Page 2 of 5 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 06/26/2023 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 observation, interview, record review, the facility failed to ensure that residents were free from accidents for 1 of 3 residents (Resident #1) reviewed for accident, hazards, and supervision. The facility failed to ensure that all exits were adequately alarmed/secured which resulted in a resident elopement on 5/1/2023. This failure could place residents at risk of injuries, hospitalization, pain and decreased quality of life. Findings included: Review of Resident #1's face sheet dated 6/16/2023, reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including Encephalopathy (damage or disease that affects the brain), Dementia (progressive loss of intellectual functioning with memory impairment), Cerebral Infarction (stroke) Aphasia (loss of ability to understand or express speech), Cognitive Communication Deficits (difficulty with thinking and using language) and altered mental status. Resident #1's FM / RP was her #1 emergency contact. Review of Resident #1's MDS assessment , dated 05/04/23, reflected a BIMS of 99 in Section C0500, indicating resident #1 was unable to complete the interview. It further reflected in section C0600 - Staff Assessment for Mental Status - a code of 1 indicating resident was unable to complete the BIMS. The staff assessment section reflected that resident had a short- and long-term memory problem and was severely impaired with regard to daily decision making. Review of Resident #1's progress notes by ADON revealed Resident #1 was observed in her room on 5/1/23 at 2000 (8 PM) and then found at 2030 (8:30 PM) pulling at the door on D Hall from the outside. Resident appeared confused and was walking without her wheelchair. Staff completed a head-to-toe assessment, and no injuries were found. Notes indicated monitoring was put in place and a wander-guard device was put in place for safety. Notes further revealed FM was contacted as well as AD, DON, and PCP. Review of Resident #1's SW - Wandering Evaluation dated 4/27/23 at 9:55 AM, completed by SW, revealed Resident #1 had a score of 7 on her wandering evaluation indicating Category: Moderate risk During an interview on 6/16/23 at 12:30 pm, the FM stated REsident #1 had back-to-back strokes and was admitted on [DATE] to the facility for rehab. The FM stated when Resident #1 left the hospital, she could not walk and used a wheelchair. The FM stated on 5/1/23 she was notified that Resident #1 exited out a side door to a fenced area and was let back in by staff. The FM stated resident had no history of wandering prior to admission or at the hospital and had not walked since she had her strokes. During an interview on 6/16/23, DON stated she had received a call that Resident #1 was knocking at the door on D Hall and had gone out the E Hall door. She was informed that the alarm on E Hall door was not working at the time. She stated Maintenance checks the perimeter doors and batteries daily M-F and the Nurses check wander guards every shift. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675251 If continuation sheet Page 3 of 5 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 06/26/2023 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 During an interview on 6/16/23 at 4:48 PM the SW stated she is responsible for completing a wandering assessment in the EMR within the first 24 hours of admission. She stated she completed a wander assessment on Resident #1 on 4/27/23 and it indicated she was low risk for wandering or elopement. She stated if a resident has a high score, she notifies nursing, and they get an order for a wander guard for the resident. Residents Affected - Few During an interview on 6/16/23 at 4:59 PM, MTD stated perimeter doors are checked 5 days a week for proper operation. He stated the magnetic lock on D Hall door and E hall door were both functioning on the morning of 5/1/23 and after the incident on 5/2/23. He stated he heard in a meeting on 5/2/23 that Resident #1 had gone out the breakroom door, undid the deadbolt on the outside door and exited the building then came back in D Hall door . He stated he does not remember who was in the meeting or who stated Resident # 1 went out the break room door. He stated he started in July of 2022 and the break room door has not had a lock on it from the hallway, and the perimeter door off the breakroom has not had an alarm on it since he was worked here. He stated anyone could access the breakroom door from the hall and go out the perimeter door to the back, fenced area. He stated several days after the incident, he ordered a push bottom lock/keypad for the break room door, but it had not come in yet. During an interview on 6/16/23 at 5:39 PM, LVN A he stated he was working on the night of 5/1/23 when Resident #1 eloped. He stated after the event, he went down to the D Hall door with the door key and discovered the door alarm was not working. He stated he noticed the housing was loose and one of the wires was disconnected. He stated he fixed the wire and loose housing and checked the door alarm again and it was working. He stated he had seen Resident #1 around the facility in her wheelchair but had never seen her walking. He stated there is a perimeter fence around the building from all the resident halls and a sidewalk that goes from D Hall to E Hall. He stated he had not observed any exit seeking or wandering behaviors from Resident #1 since her admission. He stated he did not witness what door resident had left the building. He stated elopement training had been provided by the facility and staff were familiar with what to do. During an interview on 6/16/23 at 6:30 PM, CNA B she stated she was walking towards F Hall when she heard a knock at E Hall door. She stated she went to answer it and Resident #1 was standing at the door which out her wheelchair. She let Resident # 1 back in the building and called for the nurse. She stated resident appeared to have walked around the building and seemed tired and out of breath when she found her at the door. She stated they got her wheelchair and put her in it and the nurse assessed her . She stated she did not witness what door resident had left the building. She stated elopement training had been provided by the facility and staff were familiar with what to do. During an interview on 6/16/23 at 7:07 PM the ADON stated she had come up to the facility the night of the incident and spoke to staff, but she did not get any written statements. She stated an incident report was filled out and she made sure the wander guard was in place on Resident #1. During an interview on 6/16/23 at 7:15 PM the DON stated Resident #1 was gone no more than 30 minutes. The DON stated her report was that Resident #1 went out E hall Door and came back in D Hall door. She stated there was no accounting of events except for the state report. She stated she is unsure if any written statements were taken but the ADON came up that night and talked to all the staff - it's in the progress notes. During an interview on 6/19/23 at 11:54 AM, LVN C stated she was the nurse working D Hall on the evening of 5/1/23. She stated she didn't really remember all the details because she had been out on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675251 If continuation sheet Page 4 of 5 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 06/26/2023 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 medical leave. She stated she remembered the incident with Resident #1 and filled out an incident report. She stated resident was seen in her room by another staff that evening and then a little while later was discovered by a CNA knocking at the door to E Hall. She stated she did not witness what door resident had left the building. She stated she completed a head-to-toe assessment on Resident #1 and the resident was in excellent condition, no skin issues no injuries and no complaint of pain or any other issues. She stated they immediately checked all the doors and one staff discovered E hall door was not working at the time. She stated LVN A looked at E Hall door and fixed it but they also notified maintenance and AD. She stated they provided Resident #1 with a wander guard device and completed every 15 minutes checks for the remainder of her shift which was 7 am on 5/2/23. There were no further incidents. She stated she had been working at the facility over 2 years and could not recall any other resident elopement incidents: Not to my knowledge, no. She stated elopement training had been provided by the facility and staff were familiar with what to do. During a phone call on 6/21/23 at 9:23 AM, written staff statements were again requested from AD for the incidents on 5/1/23. The AD stated she would check but had not been able to find any. An observation on 6/16/23 at 6:00 pm with the MTD revealed the breakroom door from the hall unlocked and the perimeter door off the breakroom secured by a dead bolt. Observation revealed MD turned the dead bolt and was able to exit the building. Further observation revealed there was a fence around the back of the building that encompassed B, C, D and E halls (resident halls). Review of facility policy Incidents and Accidents dated 8/15/22 revealed It is the policy of this facility for staff to report, investigate, and review any accidents or incidents that occur or allegedly occur, on facility property and may involve or allegedly involved a resident., further, #14: If an incident/accident was witnessed by other people, the supervisor or designee will obtain written documentation of the vent by those that witnessed it and submit that documentation to the Director of Nursing and/or Administrator. Review of additional documents provided by the AD via email on 6/21/23 at 11:11 AM revealed 3 (three), one sentence, typed, staff statements with no date, time or staff signature on the statements. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675251 If continuation sheet Page 5 of 5