Inspection·June 28, 2023

F 0584 Level of Harm - Minimal harm or potential for actual harm During an observation on 06/27/2023 at 9:42 AM, room [ROOM NUMBER] had crater-like damage to the wall by the recliner. During an observation on 06/28/2023 at 9:50 AM, room [ROOM NUMBER] had crater-like damage to the wall by the recliner. Residents Affected - Some 3. During an observation on 06/26/2023 at 10:58 AM, Resident #27 was in her room, room [ROOM NUMBER], multiple dark reddish stains were on the wall above her bed. Resident #27 was non-interviewable. During an observation on 06/27/2023 at 9:02 AM, room [ROOM NUMBER] had multiple dark reddish stains on the wall above her bed. During an observation on 06/28/2023 at 9:55 AM, room [ROOM NUMBER] had multiple dark reddish stains on the wall above her bed. During an interview on 06/28/2023 at 11:02 AM, the Environmental Supervisor said he was aware of the red stains on the wall in room [ROOM NUMBER], and he verbally told the Maintenance Director he would have to fix it because the housekeeping staff were not able to clean it off the wall. The Environmental Supervisor said the Maintenance Director was responsible for fixing damages to the wall. The Environmental Supervisor said it was important for the walls to be clean and free of damage because the facility was the residents' home, and they should have a clean environment. During an interview on 06/28/2023 11:10 AM, the Maintenance Director said to his knowledge nobody had told him about deep scratches that exposed the sheetrock on the wall behind the head of the bed in room [ROOM NUMBER], the crater-like damage to the wall in room [ROOM NUMBER], and the dark reddish stains on the wall in room [ROOM NUMBER]. The Maintenance Director said he did not make rounds of the residents' rooms to check for any damages. The Maintenance Director said the staff should be putting in a work order online for him to repair any damages. The Maintenance Director said it was important for the rooms to be free of damage for esthetics for the residents, and so the residents would not breathe in the powder from the sheet rock. During an interview on 06/28/2023 at 3:14 PM, the DON said she had seen the deep scratches on the wall in room [ROOM NUMBER], but the Maintenance Director was responsible for addressing it. The DON said she was not aware of the crater-like damage to the wall in room [ROOM NUMBER] and she was not aware of the dark reddish stains on the wall in room [ROOM NUMBER]. The DON said anybody that noticed there was a repair needed, should be putting in a work order for the Maintenance Director to address it. The DON said it was important for repairs to be made to the rooms because of the appearance of the room, and for the residents to feel good about their rooms. The DON said the damages to the walls could make the residents feel embarrassed and it could cause dignity issues. During an interview on 06/28/2023 at 4:25 PM, LVN A said she had noticed the deep scratches in room [ROOM NUMBER], and she had told the Maintenance Director verbally that it needed repair. LVN A said she was not aware of the damages in room [ROOM NUMBER] and room [ROOM NUMBER]. LVN A said it was important for repairs to be done to the rooms because the residents should be able to feel at home and comfortable. During an interview on 06/28/2023 at 4:51 PM, the Administrator said it had not been brought to her attention that room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER] required repairs. The Administrator said the Maintenance Director was responsible for ensuring all repairs were done to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675251 If continuation sheet Page 2 of 34 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 06/28/2023 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some the rooms, and she expected him to do this. The Administrator said it was important for the residents' rooms to not have any damages for their dignity. Record review of the work order report dated 03/23/2023 - 06/24/2023 indicated a work order to patch, texture, and paint walls in room [ROOM NUMBER]. The work orders did not specify the dates. There were no work orders indicated for room [ROOM NUMBER] and room [ROOM NUMBER]. Record review of the facility's document, titled, Nursing Facility Residents' Rights, dated November 2021, indicated, . Dignity and Respect You have the right to: Live in safe, decent and clean conditions . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675251 If continuation sheet Page 3 of 34 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 06/28/2023 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 0641 Ensure each resident receives an accurate assessment. 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 assessments accurately reflected the resident status for 1 of 17 residents (Resident #31) reviewed for MDS assessment accuracy. Residents Affected - Few The facility failed to accurately reflect Resident #31's nutritional approaches on the quarterly MDS assessment. This failure could place residents at risk for not receiving care and services to meet their needs. Findings included: Record review of Resident #31's face sheet dated 06/27/23 indicated an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #31 had a diagnoses which included type 2 diabetes (the way the body processes blood sugar), hypertension (force of the blood against the artery walls is too high) and schizoaffective disorder (mood disorder). Record review of Resident #31's quarterly MDS dated [DATE] indicated Resident #31 had a BIMS score of 99 due to Resident #31 was unable to complete the interview. The quarterly MDS indicated Resident #31 made himself-understood and had the ability to understand others. Section K of the MDS indicated Resident #31 had a parental/IV feeding while he was a resident at the facility. Record review of Resident #31's order summary report dated 06/27/23 did not indicate Resident #31 had a parental/IV feeding. Resident #31's orders indicated he received a regular texture diet with reduced concentrated sweets. Record review of Resident #31's care plan (no date) did not indicate Resident #31 had a parental/IV feeding. Resident #31's care plan initiated 2/17/22 indicated he had a potential nutritional problem related to dementia. The interventions indicated to serve diet as ordered. During an observation and interview on 06/26/23 at 11:11 AM, Resident #31 did not have a parental/IV feeding. Resident #31 stated he had never had a parental/IV feeding. During an interview on 6/28/23 at 10:37 AM, the MDS coordinator stated Resident #31 did not have a tube feeding or IV and never had one. The MDS coordinator stated she must have marked on the MDS that Resident #31 had a parental/IV feeding by mistake. The MDS coordinator stated she was responsible for completing all the MDS assessments in the facility and she should have caught the mistake when it triggered the care plan. The MDS coordinator stated the Corporate MDS nurse double checked all the MDS assessments at random for her. The MDS coordinator stated marking the MDS assessment incorrectly would, Have everyone looking for Resident #31's peg tube and he did not have one, it would throw off billing, it would make the care plan incorrect, and it would be fraud. During an interview on 6/28/23 at 10:118 AM, the DON stated the MDS coordinator was responsible for making sure the MDS assessment was correct and the Corporate MDS nurse was responsible for double checking the MDS coordinator. The importance of making sure the MDS assessment was correct would be to prevent fraud. During an interview on 6/28/23 at 11:17 AM, the Administrator stated the MDS coordinator was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675251 If continuation sheet Page 4 of 34 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 06/28/2023 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 0641 Level of Harm - Minimal harm or potential for actual harm responsible for making sure the MDS assessments were correct, and she expected them to be correct. The Administrator stated the Corporate MDS nurse checked the MDS assessments routinely and the IDT team talked about MDS's in their meetings. The importance of making sure the MDS assessment was correct would be because it impacted Resident #31's RUG level and if the MDS assessment was not correct, then the facility could get into trouble, and it would not be a true reflection of Resident #31. Residents Affected - Few During an interview on 6/28/23 at 11:17 AM, the Administer stated the facility did not have a policy on MDS assessments and the facility followed the RAI manual. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675251 If continuation sheet Page 5 of 34 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 06/28/2023 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure individuals with mental health disorders were provided an accurate Preadmission Screening and Resident Review (PASRR) Screenings for 3 of 9 residents (Residents #37, #11 and #28) reviewed for PASRR. The facility failed to ensure Residents #37, #11 and #28's PASRR Level 1 screening indicated a diagnosis of mental illness. This failure could place residents at risk of not receiving needed assessments (PASRR Evaluation), individualized care and specialized services to meet their needs. Findings include: 1. Record review of Resident #37's face sheet, dated 06/28/2023, indicated Resident #37 was a [AGE] year-old female, admitted to the facility on [DATE] with a diagnoses which included Schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), unspecified mood disorder, and auditory/visual hallucinations (perception of hearing and seeing something that was not actually there). Record review of Resident #37's admission MDS, dated [DATE], indicated Section A1500 asked Is the resident currently considered by the state level II PASRR process to have serious mental ill ness and/pr intellectual disability or a related condition? This section was marked 0 which meant No. Section A.1510 Level II Preadmission Screening and Resident Review (PASRR) Conditions did not have A. Serious mental illness, B. Intellectual Disability, or C. Other related conditions checked. The assessment indicated Resident #37 sometimes understood others and sometimes made herself understood. The assessment indicated Resident #37 was severely cognitively impaired with a BIMS score of 5. Record review of Resident #37's care plan, with an initiated date of 09/02/2022, indicated Resident #37 used antipsychotic medications related to schizophrenia. The care plan interventions included monitors behaviors, observe for adverse side effects of medications, and keep environment free of clutter and safety hazards. Record review of Resident #37's PASRR Level 1 Screening, completed on 09/02/2022, indicated, in section C0100, no evidence of this individual having mental illness. 2. Record review of Resident #11's face sheet, dated 06/28/2023, indicated Resident #11 was a [AGE] year-old male, admitted to the facility on [DATE] with a diagnoses which included Schizoaffective Disorder (a disorder that affects a person's ability to think, feel, and behave clearly), unspecified mood disorder, and auditory/visual hallucinations (perception of hearing and seeing something that was not actually there) with periods of increased energy and decreased need for sleep over several days). Record review of Resident #11's comprehensive MDS, dated [DATE], indicated Section A1500 asked Is the resident currently considered by the state level II PASRR process to have serious mental ill ness and/pr intellectual disability or a related condition? This section was marked 0 which meant No. Section A.1510 Level II Preadmission Screening and Resident Review (PASRR) Conditions did not have A. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675251 If continuation sheet Page 6 of 34 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 06/28/2023 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Serious mental illness, B. Intellectual Disability, or C. Other related conditions checked. The assessment indicated Resident #11 sometimes understood others and sometimes made himself understood. The assessment indicated Resident #11 was moderately cognitively impaired with a BIMS score of 9. Record review of Resident #11's care plan, with an initiated date of 07/06/2022, indicated Resident #11 used antipsychotic medications related to schizophrenia. The care plan interventions included monitors behaviors, observe for adverse side effects of medications, and keep environment free of clutter and safety hazards. Record review of Resident #11's PASRR Level 1 Screening, completed on 10/26/2021, indicated, in section C0100, no evidence of this individual having mental illness. During an interview on 06/28/2023 at 1:44 p.m., the MDS coordinator stated she was responsible for ensuring the PASRR Level 1 was completed accurately for Resident #37 and #11. The MDS Coordinator stated she was unaware she should submit a PL1 correction, if the referring entity incorrectly completed the PL1, so the resident could be evaluated for PASRR services. The MDS Coordinator stated after reviewing Resident #37 and #11 medical records and saw they had a diagnosis which included mental illness a new PASRR Level 1 Screening should have been submitted. The MDS Coordinator stated not completing the PASRR accurately could result in residents not been evaluated for eligibility and services. During an interview on 06/28/2023 at 2:25 p.m., the Regional Care Management Specialist stated her expectation was for all PL1's to be completed accurately and timely on all residents. The Regional Care Management Specialist stated Schizophrenia and Schizoaffective Disorder would be considered a mental illness. The Regional Care Management Specialist stated the MDS nurse was responsible for completing the PL 1 correctly. The [NAME] Care Management Specialist stated the MDS Coordinator was responsible for monitoring to ensure the mental illness diagnosis were captured on the PL1's that was received from the referring entity. The Regional Care Management Specialist stated she monitors an accuracy audit twice a month. The [NAME] Care Management Specialist stated her last audit was done on 06/08/2023. The Regional Care Management Specialist stated she was unsure if Residents #37 and #11 were part of the resident sample reviewed. The Regional Care Management Specialist stated not completing the PASRR accurately could result in residents not receiving services they were entitled to. 3. Record review of a face sheet dated 06/28/2023 indicated, Resident #28 was a [AGE] year-old female, initially admitted to the facility on [DATE], and re-admitted on [DATE], with diagnoses which included acute and chronic respiratory failure, unspecified whether with hypoxia or hypercapnia (a condition where there's not enough oxygen or too much carbon dioxide in your body), hypertensive heart disease with heart failure (complications of high blood pressure that affect the heart), tracheostomy status (a surgically created opening on the neck for air passage to help you breathe when the usual route for breathing is somehow blocked or reduced), and bipolar disorder, current episode depressed, severe, with psychotic features (a disorder associated with episodes of mood swings ranging from depression lows to manic highs). Record review of the Comprehensive MDS assessment dated [DATE] indicated, Resident #28 was sometimes understood and was sometimes able to make herself understood. The MDS assessment indicated Resident #28 had a BIMS score of 3, which indicated her cognition was severely impaired. The MDS section, Preadmission Screening and Resident Review indicated Resident #28 did not have a serious mental illness. The section named Level II Preadmission Screening and Resident Review Conditions did not reflect a mental illness. The MDS section of Psychiatric/mood disorder indicated diagnoses of anxiety, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675251 If continuation sheet Page 7 of 34 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 06/28/2023 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 0644 depression, and bipolar disorder. Level of Harm - Minimal harm or potential for actual harm Record review of the care plan with a date initiated of 05/05/2023, indicated Resident #28 used antidepressant medication Citalopram related to depression. The care plan indicated Resident #28 used psychotropic (medications that alter mood, perceptions, and behavior), antianxiety (medications used for anxiety), and antipsychotic medications (medications used for mental illness). Residents Affected - Some Record review of Resident #28's PASRR Level 1 Screening completed on 05/04/2023 indicated in section C0100 no evidence of this individual having mental illness. During an interview on 06/28/2023 at 2:10 PM, the MDS Coordinator said she was responsible for PASRR. The MDS Coordinator said Resident #28 had been diagnosed with bipolar disorder after admission. The MDS Coordinator said she did not notify PASRR services to have her screened for mental illness. The MDS Coordinator said she was under the impression Resident #28 did not have to be referred for screening due to not being hospitalized at a psychiatric facility. The MDS Coordinator said she had spoken to the local authority from PASRR services, and they had instructed her to refer any resident with a mental illness diagnosis. The MDS Coordinator said it was important for the residents to be screened for PASRR so they could get extra services. The MDS Coordinator said if they were not referred appropriately, they would not be able to get services that the PASRR program offered. During an interview on 06/28/2023 at 4:35 PM, the Administrator said the MDS nurse was responsible for PASRR. The Administrator said she expected for her to make referrals as appropriate. The Administrator said it was important to properly refer to PASRR so the residents could get all the resource they were eligible for. The Administrator said not properly referring to PASRR could affect the residents because they would not be getting the services, they were eligible for. The Administrator stated there was not a policy and procedure regarding PASRR. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675251 If continuation sheet Page 8 of 34 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 06/28/2023 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 observation, interview, and record review, the facility failed to implement a comprehensive person-centered care plan to meet resident's medical, nursing, mental and psychosocial needs identified in the comprehensive assessment for 3 of 17 residents (Resident #21, Resident #39, ad Resident #28) reviewed for care plans. The facility failed to ensure Resident #21's care plan indicated he used oxygen. The facility failed to ensure Resident #39's care plan indicated the proper usage of her grab bar. The facility failed to care plan Resident #28's tracheostomy. These failures could place the residents at increased risk of not having their individual needs met and a decreased quality of life. Findings included: 1. Record review of Resident #21's face sheet, dated 06/27/2023, indicated Resident #21 was a [AGE] year-old male, originally admitted to the facility on [DATE] with diagnoses which included type 2 diabetes mellitus (blood sugar disorder), Parkinson's disease (nervous system disorder that impacts movement) and heart failure (heart doesn't pump blood adequately). Resident #21's order summary report dated 06/27/23 indicated oxygen at 1 liter per minute as needed for oxygen under 88% and oxygen at 2 liters per minute via nasal cannula as needed for shortness of breath. Record review of Resident #21's quarterly MDS assessment, dated 02/12/2023, indicated Resident #21usually understood others and usually made himself understood. The MDS assessment indicated a BIMS score of 12 indicating moderately impaired cognition. The MDS indicated Resident #21 was on oxygen therapy. Record review of Resident #21s care plan (no date) did not indicate that Resident #21 was on oxygen. During an observation and interview on 06/28/23 at 01:25 PM, Resident #21 stated he wore his oxygen every night. Resident #21's oxygen concentrator was next to his bed and set at 2 liters via nasal cannula. During an interview on 6/28/23 at 10:37 AM, the MDS coordinator stated she was responsible for care planning Resident #21's oxygen. The MDS coordinator stated Resident #21 did not always wear his oxygen and she usually did not care plan oxygen if the resident did not use it. The MDS coordinator stated the oxygen should have been care planned because she marked oxygen on the MDS assessment. The MDS coordinator stated the importance of care plans being correct, was so nursing staff knew what to expect and was aware of the goals and interventions for individual residents. During an interview on 6/28/23 at 10:18 AM, the DON stated the MDS coordinator was responsible for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675251 If continuation sheet Page 9 of 34 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 06/28/2023 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some care planning oxygen on Resident #21 because it was on the MDS assessment. The DON stated the importance of care planning oxygen on Resident #21 was so staff would know Resident #21's goal and they would be aware of his interventions. The DON stated if the care plan was not correct, then something important could have gotten missed. During an interview on 6/2/23 at 11:17 AM, the Administrator stated care plans should be correct so staff would know how to care for each resident, and they would be able to meet their individual needs. The Administrator stated the MDS coordinator was responsible for making sure the care plans were correct and she expected them to be correct. The Administrator stated care plans were reviewed quarterly in the care plan meetings. 2. Record review of Resident #39's face sheet, dated 06/27/2023, indicated Resident #39 was a [AGE] year-old female, originally admitted to the facility on [DATE] with diagnosis which included type 2 diabetes mellitus (blood sugar disorder), schizoaffective disorder (mood disorder) and epileptic seizures (brain imbalance that impacts consciousness). Record review of Resident #39's quarterly MDS assessment, dated 05/20/2023, indicated Resident #39 sometimes understood others and sometimes made herself understood. The MDS assessment indicated a BIMS score of 99 indicating Resident #39 was not able to complete the interview. The MDS assessment indicated Resident #39 required extensive assistance with bed mobility and one-person physical assist. The MDS indicated Resident #39 required extensive assistance with transfers and one-person physical assist. The MDS indicated Resident #39 required substantial/maximal assistance with rolling from lying on her back to the left and right side. The MDS indicated Resident #39 required maximal assistance to move from sitting on the side of the bed to lying flat in the bed. Record review of Resident #39's care plan (no date) indicated Resident #39 used physical restraint bed rails related to safety, security, and bed mobility. The interventions indicated to anticipate and intervene for potential causes that had precipitated prior falls or accidents. During an observation and interview on 06/27/2023 at 5:46 PM, Resident #39 was in her bed asleep and had a grab bar attached to one side of the hospital bed not facing the wall. During an interview on 6/28/2023 at 10:18 AM, the ADON stated she was responsible for making sure the care plan was correct and she made the mistake of indicating Resident #39's grab bar was used as a restraint. The ADON stated she thought all grab bars were care planned as restraints and she knew better now and would go back and fix it. The ADON stated that during care plan meetings each department went over the care plans to make sure they were correct. The ADON stated care plan meetings were quarterly for every resident. During an interview on 6/28/2023 at 10:37 AM, the MDS Coordinator stated the ADON was responsible for care planning the grab bar on Resident #39, and she was responsible for overlooking the care plan to make sure it was correct. The MDS Coordinator stated she must have overlooked the word restraint. The MDS Coordinator stated Resident #39 did not have a grab bar that was used as a restraint. The MDS coordinator stated Resident #39 used her grab bar for assistance with positioning in bed. The MDS coordinator stated the importance of care planning correctly was so nursing staff knew what to expect with residents. The MDS coordinator stated if something was not care planned correctly, then staff might know the goals or interventions for that resident. The MDS coordinator stated Resident #39 should not have been care planned that she had a grab bar as a restraint, and it was an oversight. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675251 If continuation sheet Page 10 of 34 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 06/28/2023 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 6/28/2023 at 10:18 AM, the DON stated Resident #39 was able to use the grab bar on her bed to assist with moving around in the bed. The DON stated the ADON was responsible for care planning the grab bar correctly and it should not have been care planned as a restraint. The DON stated the importance of care planning correctly was so the team was aware of how to properly care for the residents and followed the interventions and goals provided. The DON stated the ADON had made a mistake care planning the grab bar as a restraint and it could have resulted in staff not knowing the grab bar was not used as a physical restraint. During an interview on 6/28/2023 at 11:17 AM, the Administrator stated the importance of care planning correctly was to ensure staff knew how to care for each resident and how to meet their individual needs. The Administrator stated the MDS coordinator was responsible for making sure the care plans were correct and she expected them to be done correctly. The Administrator stated care plans were reviewed quarterly in the care plan meetings. 3. Record review of a face sheet dated 06/28/2023 indicated, Resident #28 was a [AGE] year-old female, initially admitted to the facility on [DATE], and re-admitted on [DATE], with diagnoses which included acute and chronic respiratory failure, unspecified whether with hypoxia or hypercapnia (a condition where there's not enough oxygen or too much carbon dioxide in your body), hypertensive heart disease with heart failure (complications of high blood pressure that affect the heart), and tracheostomy status (a surgically created opening on the neck for air passage to help you breathe when the usual route for breathing is somehow blocked or reduced). Record review of the Comprehensive MDS assessment dated [DATE] indicated, Resident #28 was sometimes understood and was sometimes able to make herself understood. The MDS assessment indicated Resident #28 had a BIMS score of 3, which indicated her cognition was severely impaired. The MDS assessment indicated Resident #28 required extensive assistance with bed mobility, transfers, locomotion on and off unit, dressing, eating, toilet use, and personal hygiene. The MDS assessment indicated Resident #28 had tracheostomy care while a resident at the facility. Record review of the Order Summary Report dated 06/28/2023, indicated Resident #28 had the following orders: Change tracheostomy collar, tracheostomy tubing, oxygen tubing, and condensation trap as needed start date 05/17/2023 Change tracheostomy collar, tracheostomy tubing, oxygen tubing, and condensation trap at bedtime every 7 day(s) start date 05/17/2023 Remove reusable inner cannula. Place in sterile water and clean. Replace once inner cannula cleaned as needed for copious secretions start date 05/17/2023 Remove reusable inner cannula. Place in sterile water and clean. Replace once inner cannula cleaned every day shift for tracheostomy care Suction tracheostomy as needed for tracheostomy care as needed for increased secretions start date 05/17/2023 Tracheostomy care - Cleanse with normal saline with 4X4 around tracheostomy stoma (opening in the neck), pat dry, apply T-drain sponge and secure with tracheostomy collar as needed for copious secretions start date 05/17/2023 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675251 If continuation sheet Page 11 of 34 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 06/28/2023 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Tracheostomy care - Cleanse with normal saline with 4X4 around tracheostomy stoma, pat dry, apply T-drain sponge and secure with tracheostomy collar every day shift start date 05/17/2023 Tracheostomy humidification set at 28% with continuous O2 at 5LPM via concentrator. Compressor settings at 32psi (pressure setting) as needed for per resident request. Tracheostomy humidification start date 05/17/2023 Tracheostomy humidification set at 28% with continuous O2 at 5LPM via concentrator. Compressor settings at 32psi at bedtime start date 05/17/2023. Record review of the care plan initiated on 05/05/2023 indicated, the care plan did not include Resident #28's tracheostomy. During an observation on 06/26/2023 at 8:03 AM, Resident #28 was in her bed, tracheostomy observed with oxygen being provided. During an interview on 06/28/2023 at 2:00 PM, the MDS Coordinator said she was responsible for making sure the care plans were completed. The MDS Coordinator said the ADON should have put Resident #28's tracheostomy in her care plan. The MDS Coordinator said the care plans were reviewed quarterly by the interdisciplinary team to ensure they were complete. The MDS Coordinator said it was important for Resident #28's tracheostomy to be included in her care plan because it gave staff a footprint to go by so they could provide her care. The MDS Coordinator said the care plans made the residents care personalized. During an interview on 06/28/2023 at 2:53 PM, the ADON said she was not responsible for care planning Resident #28's tracheostomy. The ADON said the MDS Coordinator should have included Resident #28's tracheostomy in her care plan. The ADON said it was important for Resident #28's tracheostomy to be in her care plan because it helped troubleshoot the problems and have better interventions for her care. The ADON said the tracheostomy not being part of Resident #28's care plan could cause harm to her. During an interview on 06/28/2023 at 3:23 PM, the DON said the ADON and MDS coordinator reviewed the care plans randomly to ensure they were complete. The DON said they had noticed some of the care plans missing items, and if they found something missing it would immediately be corrected. The DON said it was important for Resident #28's tracheostomy to be included in her care plan so the interdisciplinary team would know that she had it, and if there were any interventions that needed to be added they could be added. The DON said it was important to ensure all the residents care plans were individualized to provide them the best quality of life. During an interview on 06/28/2023 at 4:59 PM, the Administrator said the MDS Coordinator was responsible for completing and ensuring the care plans were tailored to each person. The Administrator said she expected the MDS Coordinator to do this. The Administrator said it was important for the care plan to be tailored to each person so they could effectively care for the residents and ensure all of the residents' needs were met. The Administrator said not having an individualized care plan could result in the residents not receiving the care they needed, and things could get missed. Record review of the facility's policy titled, Comprehensive Care Plans, implemented 10/24/2022, indicated, It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675251 If continuation sheet Page 12 of 34 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 06/28/2023 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. The comprehensive care plan will describe, at a minimum, the following: The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . all Care Assessment Areas triggered by the MDS will be considered in developing the plan of care. The care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment . Event ID: Facility ID: 675251 If continuation sheet Page 13 of 34 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 06/28/2023 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming and personal hand oral hygiene for 1 of 3 residents (Resident #34) reviewed for Activities of Daily Living. Residents Affected - Few The facility did not provide scheduled showers for Resident #34. This failure could place residents at risk of not receiving services/care and a decreased quality of life. Findings Include: Record review of the consolidated physician order dated 6/28/2023 indicated, Resident #34 was a [AGE] year-old female, admitted to the facility on [DATE] with diagnoses which included Nontraumatic subarachnoid hemorrhage (a blood vessel that burst into the brain), Aphasia, (loss of ability to understand or express speech), Age-related osteoporosis (weak or brittle bones), Pain in right arm, Hemiplegia (paralysis of one side of the body) affecting the right dominant side. Record review of the quarterly MDS dated [DATE] indicated, Resident #34 sometimes understood others and sometimes made herself understood. The MDS indicated Resident #34 was unable to complete the interview with a BIMS interview. The MDS indicated Resident #34 had a short- and long-term memory problem. The MDS indicated Resident #34 did not reject evaluation or care. Resident #34 required extensive assistance with transferring, dressing, and personal hygiene. Record review of the comprehensive care plan initiated 05/19/2023 indicated, Resident #34 had an activities of daily living (ADL) self-care performance deficit related to injury to shoulder and CVA. The care plan indicated interventions included Resident #34 required total dependence x1 staff for showering 3 times weekly and as necessary. Record review of the Shower List updated on 06/08/2023 indicated, Resident #34 was scheduled for showers 3 times weekly. Record review of the Shower Sheet dated 06/15/2023 indicated, Resident #34 received a shower on 6/15/2023. There were no showers/baths documented between 06/15/2023 through 06/28/2023. Record review of Resident #34's nursing notes dated 6/15/2023 through 06/28/2023 showed no refusals of showering/bathing. During an observation on 06/26/2023 at 08:11 AM, Resident #34 was observed with disheveled, uncombed oily hair, and ½ inch facial hairs on chin and across upper lip. During an observation on 06/27/2023 at 07:53 AM, Resident #34 was observed in dining hall eating breakfast. Resident #34 had ½ inch facial hairs on chin and across upper lip. During an interview and observation on 06/27/2023 at 09:17 AM, RN F said Resident #34 did not reject care. RN F said Resident #34 was nonverbal for the most part and usually only nodded her head for yes or no. RN F was observed providing treatment to Resident #34's toes. Resident #34 was observed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675251 If continuation sheet Page 14 of 34 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 06/28/2023 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 0677 with combed oily hair and ½ inch facial hairs on chin and across upper lip. Level of Harm - Minimal harm or potential for actual harm During an observation on 06/28/2023 at 07:53 AM, Resident #34 was observed in lobby area. Resident #34 had combed oily hair and ½ inch facial hairs on chin and across upper lip. Residents Affected - Few During an observation on 06/28/2023 at 03:15, Resident #34 was observed in lobby area. Resident #34 had combed oily hair and ½ inch facial hairs on chin and across upper lip. During an interview on 06/28/2023 at 02:51 PM, CNA B said the CNAs were responsible for giving the residents their showers. CNA B said there was a shower schedule posted at the nurse's station in the shower logbook to let the CNAs know who needed a shower on what day and shift. CNA B said it was important for residents to receive their showers to prevent infections and to be healthy. CNA B said she felt like female residents with chin hairs was undignified. CNA B said once the shower was completed, the shower sheet was placed in the shower sheet logbook. CNA B said she reported to the nurse if bathing was incomplete because they checked with the resident and made another offer. During an interview on 06/28/2023 at 02:59 PM, CNA G said the CNAs were responsible for giving the residents their showers. CNA G said there was a shower schedule posted at the nurse's station in the shower logbook to let the CNAs know who needed a shower on what day and shift. CNA G said it was important for residents to receive their showers to prevent infections and promote good appearance. CNA G said she knew female residents required facial shavings due to face hair. CNA G said the completed shower sheets were placed in the shower sheet logbook once the bath was done. CNA G said she reported to the nurse if the bath was incomplete, because the nurse checked with the resident and made another offer. During an interview on 06/28/2023 at 03:05 PM, CNA H said the CNAs were responsible for giving the residents their showers. CNA H said there was a shower schedule posted at the nurse's station to let the CNAs know who needed a shower on what day and shift. CNA H said it was important for residents to receive their showers so staff could observe their skin and to maintain the resident's cleanliness. CNA H said the completed shower sheet was placed in the shower sheet logbook. CNA H said if a resident refused, or a shower/bath was not given to a resident, she reported to her floor nurse so that someone else could try to ask the resident. During an interview on 06/28/2023 at 03:10 PM, LVN K said the CNA should report when a resident was not showered/bathed to the charge nurse. LVN K said it was the charge nurse's responsibility to follow up on refusals or baths not completed after communicated by the CNAs. LVN K said she expected the residents to receive their scheduled showers to prevent infections, maintain skin integrity, and maintain hygiene. LVN K said there was a shower schedule posted at the nurse's station to let the CNAs know who needed a shower on what day and shift. LVN K said no staff reported a refusal of showering/bathing to her. LVN K said she noticed Resident #34 was disheveled yesterday, after the CNA assigned had left the facility. LVN K said she could not locate the shower sheet of Resident #34 yesterday, but often the sheets had not been placed in the shower logbook properly by the CNAs. LVN K said ultimately if showers and bathing were un-resolved, she notified the ADON or DON. During a telephone interview on 06/28/2023 at 03:15PM, CNA L said she gave Resident #34 a bed bath on 06/27/2023 because she did not have enough time to give a shower. CNA L said she forgot to fill out the shower sheet because it was time to go off her shift. CNA L said, it slipped her mind to let the nurse know that she had not washed Resident #34's hair or shaved the facial hairs per the Plan of Care. CNA L said she had not completed those items. CNA L said Resident #34 refused because of her (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675251 If continuation sheet Page 15 of 34 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 06/28/2023 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few arm. CNA L said she should had notified the nurse so that someone else could attempt to provide the necessary care. CNA L said it was important for residents to receive their scheduled showers to be clean and healthy. During an interview on 06/28/2023 at 03:24 PM, the DON said it was the CNAs responsibility to give the residents their showers. The DON said there was a shower list that identified what resident received a shower on which day and shift. The DON said the CNAs performed showers on the residents, but any of the nursing staff could and should perform showers when needed. The DON said she expected the CNAs to communicate with the charge nurses daily to ensure resident's needs met. The DON expected the shower sheets completed by the CNAs and turned into the shower logbook daily. The DON said she expected the charge nurses to verify the showers given by the CNAs daily by checking the shower logbook. The DON said if a resident refused, she expected staff to try again a couple times or send a different staff member to ask the resident. The DON said if a resident continued to refuse, she expected staff to report the refusal to the family and document the refusal. The DON said she was responsible to ensure the oversight of resident 's bathed and showered appropriately according to the resident's Plan of Care. The DON said the importance of the residents receiving their scheduled showers was to maintain dignity, hygiene, skin integrity, skin inspections and prevent skin infections. During an interview 06/28/2023 at 04:01 PM, the administrator said she expected baths/showers as scheduled or as requested by the resident. The Administrator said clinical staff are responsible for making sure the baths/showers were provided for the residents. The Administrator said if the residents refused ADL care, the staff educated the residents. The Administrator said if a resident refused, she expected staff to try again a couple times or send a different staff member to ask the resident. The DON said if a resident continued to refuse, she expected staff to report the refusal to the family and document the refusal. The Administrator said it was important for the residents to receive baths/showers for hygiene purposes and to make the residents feel good, infection control and dignity. Record review of facility policy and procedure titled, Activities of Daily Living (ADLs) implemented 5/26/23, indicated . Care and services will be provided for the following activities of daily living: 1. Bathing, dressing, grooming and oral care .Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene . 6. Documentation shall be completed at the time of service, but no later than the shift in which care service occurred. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675251 If continuation sheet Page 16 of 34 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 06/28/2023 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 0679 Provide activities to meet all resident's needs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide an ongoing program of activities in accordance with the comprehensive assessment to meet the interests and the physical, mental, and psychosocial well-being for 1 of 17 residents (Resident #28) reviewed for activities. Residents Affected - Few The facility failed to provide activities for Resident #28. The facility failed to ensure Resident #28 had activities care planned. These failures could place residents at risk for not having activities to meet their interests or needs and a decline in their physical, mental, and psychosocial well-being. Findings included: Record review of a face sheet dated 06/28/2023 indicated, Resident #28 was a [AGE] year-old female, initially admitted to the facility on [DATE], and re-admitted on [DATE], with diagnoses which included acute and chronic respiratory failure, unspecified whether with hypoxia or hypercapnia (a condition where there's not enough oxygen or too much carbon dioxide in your body), hypertensive heart disease with heart failure (complications of high blood pressure that affect the heart), and tracheostomy status (a surgically created opening on the neck for air passage to help you breathe when the usual route for breathing is somehow blocked or reduced). Record review of the Comprehensive MDS assessment dated [DATE] indicated, Resident #28 was sometimes understood and was sometimes able to make herself understood. The MDS assessment indicated Resident #28 had a BIMS score of 3, which indicated her cognition was severely impaired. The MDS assessment indicated Resident #28 required extensive assistance with bed mobility, transfers, locomotion on and off unit, dressing, eating, toilet use, and personal hygiene. The staff interview for Resident #28 for activity preferences on the MDS assessment indicated it was very important to her to have books, newspapers, and magazines to read, to listen to music, to be around animals such as pets, to keep up with the news, to do things with groups of people, to do her favorite activities, to go outside to get fresh air when the weather was good, and to participate in religious services or practices. Record review of the care plan initiated on 05/05/2023 indicated Resident #28 did not have activities in her care plan. During an observation on 06/26/2023 at 8:03 AM, Resident #28 was in bed with TV on. During an observation and interview on 06/26/2023 at 10:30 AM, Resident #28 was in bed her TV was on. Resident #28 said she was blind and stayed in her bed most of the time due to her tracheostomy (opening on the neck for air passage to help you breathe) and requiring oxygen. Resident #28 said staff was not going into her room to do any activities. Resident #28 said she would enjoy having company in her room because she was usually alone. During an observation on 06/26/2023 at 4:19 PM, Resident #28 was in bed with TV on. During an observation on 06/27/2023 at 9: 50 AM, Resident #28 was in bed with TV on. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675251 If continuation sheet Page 17 of 34 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 06/28/2023 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 0679 During an observation on 06/27/2023 at 2:50 PM, Resident #28 was in bed with TV on. Level of Harm - Minimal harm or potential for actual harm During an interview on 06/28/2023 at 9:49 AM, the Activity Director said he started in May 2023. The Activity's Director said residents that were bedbound or did not leave their room received in-room one-on-one activities. The Activity Director said the last time he did a one-on-one activity with Resident #28 was in May 2023 and he did not remember the exact date. The Activity Director said he was new, and he was working on forming his activity program and the one-on-one activities for residents who were bed bound or did not leave their room. The Activity Director said he should have been doing one-on-one activities with Resident #28 daily, but he had not had time due to trying to catch up because he was behind due to being new. The Activity Director said he did not document anything on paper, if he did an activity with a resident, he documented it in the electronic health record. The Activity Director said he was responsible for including activities in the residents' care plans. The Activity Director said he did not know why Resident #28 was not care planned for activities. The Activity Director said it was important for the all the residents to have activities to improve their quality of life. The Activity Director said not doing the one-on-one activities could affect Resident #28's overall mental health. The Activity Director said it was important for activities for the residents to be care planned so the staff know what the residents like to do. Residents Affected - Few During an interview on 06/28/2023 at 3:25 PM, the DON said the Activity Director was responsible for ensuring the residents received activities, including one-on-one activities. The DON said Resident #28's care plan should include activities, and the Activity Director was responsible for putting activities in the care plan. The DON said it was important for Resident #28 to receive one-on-one activities because she was blind and spent most of the time in her bed. The DON said it was important for activities to be in the residents' care plans so that staff would know what the residents' interests were and provide them things they enjoy doing. During an interview on 06/28/2023 at 4:41 PM, the Administrator said she tried to be involved in the activities, but the Activity Director was responsible for providing the activities for the residents. The Administrator said the Activity Director did not have a set plan for one-on-one activities, but that the one-one-one activities should be care planned. The Administrator said it was important for the residents to have activities, including one-on-one, for their livelihood and for their social interaction. The Administrator said not having activities could make the residents feel lonely and depressed. Record review of the undated Job Description for the Activity Director, provided by the Administrator in place of a policy, indicated, The Activity Director will be responsible for planning, coordinating, and directing the resident's activity program and the maintenance of necessary documentation. Essential Functions Organize both individual and group activities based on the needs of the residents Ensure that multiple activities are occurring for both high and low functioning residents . Develop the activities component of the Comprehensive Care Plan from the completed activity assessment . Provide activities for residents that are bedfast and/or unable to participate in group activities one to one and documents in the appropriate record . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675251 If continuation sheet Page 18 of 34 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 06/28/2023 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for 1 out of 2 residents (Resident #9) reviewed for pressure ulcers. Residents Affected - Few LVN A failed to follow the physician orders when providing wound care to Resident #9. This failure could place residents at risk of complications which include worsening of existing wounds, development of new wounds, and infection. Findings included: Record review of a face sheet dated 06/28/2023, indicated Resident #9 was a [AGE] year-old male initially admitted to the facility on [DATE] with diagnoses which included type 2 diabetes mellitus with hyperglycemia (a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel with high blood sugars), paraplegia (paralysis of all or part of your trunk, legs, and pelvic organs), and hypertensive heart disease with heart failure (complications of high blood pressure that affect the heart). Record review of the Quarterly MDS assessment dated [DATE], indicated Resident #9 was able to make self-understood and sometimes understood others. The MDS assessment indicated Resident #9 had a BIMS score of 11, which indicated his cognition was moderately impaired. The MDS assessment indicated Resident #9 required extensive assistance with bed mobility, transfer, dressing, toilet use and personal hygiene. The MDS assessment indicated Resident #9 was at risk of developing pressure ulcers/injuries. The MDS assessment did not indicate Resident #9 had pressure ulcers/injuries. Record review of the care plan with date initiated 04/03/2022 did not indicate Resident #9 had a pressure ulcer. Record review of Resident #9's Order Summary Report dated 06/26/2023 indicated clean wound to right buttock with wound cleanser or normal saline, pat dry with gauze, apply collagen powder and barrier cream, and cover with a dry dressing every day shift for stage 2 wound with an order start date of 06/20/2023. During an observation on 06/26/2023 starting at 2:41 PM, LVN A did not perform hand hygiene prior to beginning wound care on Resident #9. LVN A applied gloves and removed the dirty dressing. LVN A did not change gloves or perform hand hygiene after removing the dirty dressing. LVN A used the dirty gloves and cleaned Resident #9's wound with normal saline, patted it dry, applied anapest gel (ointment used for wounds) and collagen powder, covered with calcium alginate, and applied a clean dressing to the wound. Using the same dirty gloves LVN A repositioned resident and covered him with his sheets. After this, LVN A removed the dirty gloves and performed hand hygiene. During an interview on 06/28/2023 at 2:41 PM, the ADON said she was responsible for overseeing the wound care orders and making sure the nurses were following the physician orders when providing wound care. The ADON said she monitored this by performing the annual competencies. The ADON said the wound care for Resident #9 included to clean the wound pat it dry, apply collagen and barrier cream (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675251 If continuation sheet Page 19 of 34 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 06/28/2023 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few and cover the wound with a dry dressing. The ADON said the anasept and calcium alginate should not have been applied to Resident #9's wound to right buttock. The ADON said it was important to follow the wound care orders because that was how the physician would like it to be. The ADON said not following the physician's order could cause the wound to worsen. During an interview on 06/28/2023 at 3:39 PM, the DON said the ADON monitored wound care and the orders. The DON said she expected for the nurses to follow the physician orders for wound care. The DON said it was important to follow the physician order for wound care to ensure the wound care was healing and would not deteriorate. During an interview on 06/28/2023 at 5:03 PM, the Administrator said nurse management was responsible for ensuring the nurses followed the physician's orders for wound care. The Administrator said she expected for the nurses to follow the physician's orders for wound care. The Administrator said it was important to make sure that the wound did not deteriorate, and that the treatment was effective. During an interview on 06/26/2023 at 6:00 PM, LVN A said wound care should be provided per the physician's orders. LVN A said she thought she looked at the order and the anasept and the calcium alginate were part of the wound care order for Resident #9. LVN A said it was important to follow the physician's order for wound care because the physician knew what was best for the wound. LVN A said not following the physician's order for wound care could affect the healing of the wound. Record review of the facility's policy titled, Pressure Injury Prevention and Management, implemented on 08/15/2022, indicated, This facility is committed to the prevention of avoidable pressure injuries and the promotion of healing of existing pressure injuries . After completing a thorough assessment/evaluation, the interdisciplinary team shall develop a relevant care plan that includes measurable goals for prevention and management of pressure injuries with appropriate interventions . The facility shall establish and utilize a systematic approach for pressure injury prevention and management, including prompt assessment and treatment; intervening to stabilize, reduce or remove underlying risk factors; monitoring the impact of interventions; and modifying the interventions as appropriate . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675251 If continuation sheet Page 20 of 34 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 06/28/2023 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 0692 Provide enough food/fluids to maintain a resident's health. 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 residents maintained acceptable parameters of nutritional status for 1 of 17 residents (Resident #35) reviewed for nutrition. Residents Affected - Few The facility did not ensure dietary recommendations was implemented for Resident #35. This failure could place residents at risk for decreased nutritional status, decline in health, serious illness, or hospitalization. Findings included: Record review of Resident #35's face sheet, dated 06/28/2023, indicated Resident #35 was a [AGE] year-old female, originally admitted to the facility on [DATE] with diagnoses which included end stage renal disease, essential hypertension (high blood pressure), and type 2 diabetes mellitus (chronic condition that affects the way the body processes blood sugar). Record review of Resident #35's physician order summary report, dated 06/27/2023, indicated an active physician's order for active liquid protein (nutritional supplement), 30 ml by mouth two times a day for health with a start date 02/17/2023. The physician order summary report indicated Resident #35 attended hemodialysis on Mondays, Wednesdays, and Fridays with chair time from 4:00 p.m.- 8:00 p.m. with an order date of 12/08/2022. Record review of Resident #35's quarterly MDS, dated [DATE], indicated Resident #35 sometimes understood others and sometimes made herself understood. The assessment indicated Resident #35 was unable to complete the interview for the BIMS score. Record review of Resident #35's care plan, with an initiated date of 04/18/2023, indicated Resident #35 had a nutritional problem or potential nutritional problem related to ESRD, DMII and poor appetite. The care plan interventions included administer medications as ordered-liquid protein for weight gain, monitor/document/report PRN any s/s of dysphagia (trouble swallowing), and provide, serve diet as ordered. Record review of the quarterly renal nutritional assessment completed by the dietician dated 05/24/2023 revealed increase active liquid protein to 60 ml by mouth two times a day from 30 ml by mouth two times a day. During an interview on 06/28/2023 at 1:53 p.m., the DON stated usually when the dietician comes to the facility and make any recommendations, the dietitian would inform her by providing documentation of those changes. The DON stated she would then implement the changes with the MD approval. The DON stated she was unsure if documentation was provided, or the dietician input her note in PCC. When asked how the dietician recommendation was missed, the DON stated, it was human error. The DON stated there was not an effective system in place to ensure dietary recommendations were left undone. The DON stated the potentially failure could cause changes in her homeostasis (a state of balance among all the body systems needed for the body to survive and function correctly). An attempted telephone interview on 06/28/2023 at 2:20 p.m. with the Dietitian, was unsuccessful. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675251 If continuation sheet Page 21 of 34 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 06/28/2023 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 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete During an interview on 06/28/2023 at 3:08 p.m., the Administrator stated she expected all dietary recommendations to be followed. The Administrator stated this failure could cause Resident #35 to not get adequate protein. Record review of the Dietary Manual dated 11/10/2021, indicated . patients who need to increase their protein intake may also benefit from supplementation with protein foods. You can help these patients meet their needs by adding commercial protein powder or liquid to foods and beverages per facility protocol Event ID: Facility ID: 675251 If continuation sheet Page 22 of 34 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 06/28/2023 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 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 and interview the facility failed to ensure all drugs were stored in a locked compartment, only accessible by authorized personnel, and labeled and dated correctly for 1 of 4 medication carts (Hall A/B/room [ROOM NUMBER] nurse medication cart) reviewed for storage of medications. The facility failed to ensure Hall A/B/room [ROOM NUMBER] nurse medication cart was secured and unable to be accessed by unauthorized personnel. These failures could place residents at risk for not receiving drugs and biologicals as needed and a drug diversion. Findings included: During an observation and interview starting on 06/26/2023 at 2:17 PM, LVN A was in a resident room and the Hall A/B/room [ROOM NUMBER] nurse medication cart was in the hallway in front of the resident's room facing away from the entrance unlocked. LVN A came out of the resident's room and said, I must have forgot to lock it, I usually do. LVN A said the medication cart should be locked anytime she walked away from it, and it was out of sight. LVN A said it was important to keep the medication cart locked at all times so that someone won't get the medications, and the residents could hurt themselves if they got any medications from the unlocked medication cart. LVN A said the medication cart should be locked to make sure somebody did not walk off with something. During an interview on 06/28/2023 at 2:50 PM, the ADON said the medication carts should always be locked when the nurses were away from it. The ADON said all the staff were responsible for making sure the nurses locked the medication cart. The ADON said it was important for the medication carts to be locked so the residents would not get in them, and so drugs would not be diverted. During an interview on 06/28/2023 at 3:11 PM, the DON said the medication carts should always be locked when the nurses walk away. The DON said all the staff were responsible for making sure the medication carts were kept locked. The DON said the ADON and her monitored the nurses to ensure they were locking the medication carts by performing the annual competency checks, and the pharmacy consultant also monitored the nurses for this on their visits. The DON said it was important to keep the medication carts locked to make sure the residents were not getting medications they were not supposed to get. The DON said if the medication carts were not locked the residents could hurt themselves by getting a medication they were not supposed to have. During an interview on 06/28/2023 at 4:49 PM, the Administrator said the nurses were responsible for making sure the mediation carts were locked at all times. The Administrator said any staff member that saw an unlocked medication cart should bring it to the nurse's attention. The Administrator said she expected the medication carts to be locked when not in use. The Administrator said it was important for the medication carts to be locked when not in use because there were thins in the medication cart that could potentially harm the residents. During an interview with the DON on 06/28/2023 at 3:40 PM, a policy regarding medication storage was requested and not provided prior to exit of the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675251 If continuation sheet Page 23 of 34 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 06/28/2023 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 0803 Level of Harm - Minimal harm or potential for actual harm 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. Based on observation, interviews, and record review, the facility failed to ensure the meals served to residents met the nutritional needs of residents for 1 of 1 meal (the lunch meal), as evidenced by: Residents Affected - Few The facility failed to ensure [NAME] D followed the recipe for pureeing the pork loin, green beans, and rice pilaf during the lunch meal. These failures could place residents at risk for weight loss, not having their nutritional needs met, and a decreased quality of life. Findings included: During an interview on 06/27/2023 beginning at 11:15 a.m., [NAME] D was preparing to puree the residents' meal. [NAME] D stated she knew the recipe and the proper procedures but did not have a recipe to follow. [NAME] D stated the recipes were not provided by the previous dietary manager. [NAME] D stated she guessed on how much food was needed for the 4 pureed residents. [NAME] D stated she eye-balled the consistency, she wanted the consistency to be thinner than a pudding but thicker than a nectar/shake. [NAME] D stated she used broth or milk to ensure the consistency was met. [NAME] D stated following the menu was important to maintain the nutrient value of food and residents' weights. During an interview on 06/28/2023 at 1:10 p.m., the Food Service Supervisor stated due to the facility not having a dietary manager since 06/26/2023 she was here to in service and implement the policy and procedures. The Food Service Supervisor stated a pureed menu should be followed at all times to ensure proper consistency and nutrition. The Food Service Supervisor stated the recipes were not provided by the previous dietary manager. The Food Service Supervisor stated following the menu was important to maintain the nutrient value of food and residents' weights. During an interview on 06/28/2023 at 3:08 p.m., the Administrator stated she expected dietary staff to follow the menu and the recipes for pureed food. The Administrator stated she expected the Food Service Supervisor to ensure recipes were printed for each meal. The Administrator stated the importance of following the recipe was to ensure residents had the appropriate nutrients and consistency. Record review of the Menu Planning policy, last revised on 06/01/2019, did not address following pureed recipes or preparing pureed meals. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675251 If continuation sheet Page 24 of 34 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 06/28/2023 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 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, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen. Residents Affected - Some The facility failed to ensure: 1. Food items were dated and labeled. 2. Dented can good were removed from the shelve. 3. Sanitation bucket included the correct sanitation. 4. The ice machine was clean and free from debris. These failures could place residents at risk for cross contamination and foodborne illness. Findings included: During an observation of the kitchen freezer on 06/26/2023 starting at 8:09 a.m. revealed a half bag of chocolate chip cookies unlabeled and undated, and a half bag of French fries undated and unlabeled. During an observation and interview with the Dietary Manager of the kitchen walk in refrigerator on 06/26/2023 at 8:10 a.m. revealed a large plastic container with a brown liquid substance that was identified by the dietary manager as cooking grease unlabeled and undated. During an observation on 06/26/2023 at 8:12 a.m., Dietary Aide E placed a small capful of bleach in a green bucket. During an observation on 06/26/2023 at 8:20 a.m. located in the dry storage room revealed (3) 50 oz dented chicken noodle soup cans noted on the shelf with stock items to be used. During an observation on 06/26/2023 at 8:25 a.m., revealed an ice machine with a brown residue on the interior part of the machine. The ice scoop holder had a green/black thick mold like substance with a chalk crystalized white powder dried to the insides on all four sides of the scoop holder. During an interview on 06/28/2023 at 9:57 a.m., Dietary Aide E stated all staff were responsible for labeling and dating. Dietary Aide E stated whoever puts up the groceries was responsible for ensuring dented cans are not left on the shelf. Dietary Aide E stated all staff were responsible for making sure the ice machine was cleaned. Dietary Aide E stated she was not aware until surveyor intervention bleach should not be used in the sanitation bucket or in the kitchen. Dietary Aide E stated the sanitizer from the 3-compartment sink should be used instead of the bleach to clean the workstation, prep, and common areas. Dietary Aide E stated these failures could put residents at risk for food borne illness and cross contamination. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675251 If continuation sheet Page 25 of 34 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 06/28/2023 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 06/28/2023 at 12:55 p.m., [NAME] D stated all staff were responsible for labeling, dating, and cleaning the ice machine. [NAME] D stated the ice machine should be cleaned daily and as needed. [NAME] D stated the primary person who received the delivery of food was responsible for checking for dented cans. [NAME] D stated she was not aware until surveyor intervention bleach should not be used at all in the kitchen. [NAME] D stated these failures could potentially put residents at risk for food borne illness and cross contamination. During an interview on 06/28/2023 at 1:10 p.m., the Food Service Supervisor stated due to the facility not having a dietary manager since 06/26/2023 she was here until further notice to provide assistance to the dietary staff to ensure they have the policy and procedures to follow. The Food Service Supervisor stated the Dietary Manager was responsible for making sure the kitchen was cleaned appropriately. The Food Service Supervisor stated all food should be labeled and dated with the date it was received, expiration date and the date it was opened. The Food Service Supervisor stated the entire staff was responsible for labeling/dating. The Food Service Supervisor stated the primary person who received the delivery was responsible for checking for dented cans. The Food Service Supervisor stated bleach should never be used in the kitchen. The Food Service Supervisor stated the staff should clean the workstation, prep areas and common areas with soap and water first and then used the sanitizer from the 3 compartments sink to follow. The Food Service Supervisor stated the dietary staff were responsible for cleaning the ice machine daily and as needed. The Food Service Supervisor stated these failures could potentially put residents at risk for food borne illness and cross contamination. Record review of the Ice Machine policy, dated 10/01/2018, indicated .the facility will maintain the ice machine, scoop, and storage container in a sanitary manner to minimize the risk of food hazards. The ice machine will be cleaned once per month or more often as needed. The scoop and storage container will be cleaned once each day Record review of the Food Deliveries policy, dated 10/01/2018, indicated . 2c. All cans must be in good condition and not dented. Record review of the Food Storage policy, last revised on 06/01/2019, indicated 1g. Use the first-in, first out rotation method. Date packages and place new items behind existing supplies, so that the older items are used first Record review of the General Kitchen Sanitation policy, dated 10/01/2018, indicated .the facility recognizes that food-borne illness has the potential to harm elderly and frail residents. All nutrition and food service employees will maintain clean, sanitary kitchen facilities in accordance with the state and US Food Codes in order to minimize the risk of infection and food borne illness . 9. Clean and rinse immediately prior to use, moist cloths used for wiping food spills on kitchenware and food-contact surfaces of equipment. Clean frequently during use in a sanitizing solution and do not use for any other purpose. When not in use, hold in a sanitizing solution of the proper concentration. 10. Clean and rinse in a sanitizing solution, moist cloths used for cleaning non-food-contact surfaces of equipment such as counters, dining tabletops and shelves and do not use for any other purpose. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675251 If continuation sheet Page 26 of 34 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 06/28/2023 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 0868 Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to maintain a quality assessment and assurance committee consisting at a minimum the required committee members for 5 of 7 meetings (June 2023, April 2023, March 2023, January 2023, and December 2022) reviewed for QAPI. Residents Affected - Some The facility did not ensure the Infection Control Representative attended their QAPI meetings in June 2023, April 2023, and December 2022. The facility did not ensure the Medical Director attended their QAPI meetings in March 2023 and January 2023. This failure could place residents at risk for quality deficiencies being unidentified, no appropriate plans of action developed and implemented, and no appropriate guidance developed. Findings included: Record review of the facility's Infection Control Representative Committee sign-in-sheets indicated the Infection Control Representative did not sign in for their meetings in June 2023, April 2023, and December 2022. The Medical Director did not sign in for their QAPI meetings in March 2023 and January 2023. During an interview on 6/28/23 at 8:15 AM, the Medical Director stated QAPI meetings were held every 2nd Wednesday of the month. The Medical Director stated he could not remember if he attended the meetings on June 2023, April 2023, and December 2022. The Medical Director stated he was often late to the meetings, and he might have missed the sign in sheets that were passed around. The Medical Director stated he was expected to attend all the QAPI meetings and sign the sign-in sheets that he had attended. The Medical Director stated if he was not present for the meeting, then he would make sure he reviewed the meeting later. The Medical Director stated the importance of attending the meetings was to discuss infection control and evaluate wounds. During an interview on 6/28/23 at 10:18 AM, the ADON (Infection Control Representative) stated she could not remember if she had attended the meetings in June 2023, April 2023, and December 2022.The ADON stated she had been working night shift and if she was not able to attend the meetings, then the DON would review the meetings with her the next day. The ADON stated she was expected to be present for the QAPI meetings and sign the sign-in sheets that she had attended. The ADON stated the importance of attending QAPI meeting was to review everything as an interdisciplinary team and make sure nothing important was missed. During an interview on 6/28/23 at 11:17 AM, the Administrator stated the ADON was probably working on the floor the night prior to the QAPI meeting and not able to attend. The Administrator stated the DON was responsible for reviewing the QAPI meetings with the ADON the following day and the ADON should have signed the attendance form at that time. The Administrator stated the importance of attending the QAPI meetings was to oversee everything going on in the building, discuss improvements, and make sure everyone was aware of what needed to be fixed. The Administrator stated that if staff members were not present for the meetings, then resident care might not be fully met, because staff members would not be on the same page. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675251 If continuation sheet Page 27 of 34 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 06/28/2023 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 0868 Level of Harm - Minimal harm or potential for actual harm Record review of the facility's policy Quality Assessment and Assurance Committee, implemented on 10/24/22, indicated the committee will be composed of, at a minimum: the Director of Nursing, The Medical Director, at least three other facility staff members, one of which will be the Administrator, owner, a board member or other individual in a leadership role and the Infection Preventionist. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675251 If continuation sheet Page 28 of 34 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 06/28/2023 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 5 staff (LVN A, CNA B, CNA C) reviewed for infection control. Residents Affected - Few The facility failed to ensure CNA B and CNA C appropriately collected soiled linen after removing them from Resident #9's bed. The facility failed to ensure LVN A changed gloves and performed hand hygiene while providing wound care to Resident #9. These failures could place residents and staff at risk for cross-contamination and the spread of infection. Findings included: During an observation on 06/26/2023 starting at 2:41 PM, CNA B and CNA C walked out of Resident #9's room after providing incontinent care. Dirty sheets observed on the floor. LVN A entered the room to set up to provide wound care to Resident #9. LVN A walked around the dirty sheets and she entered and exited the room to gather all her wound care supplies. LVN A did not perform hand hygiene prior to beginning wound care on Resident #9. LVN A applied gloves and removed the dirty dressing. LVN A did not change gloves or perform hand hygiene after removing the dirty dressing. LVN A used the dirty gloves and cleaned Resident #9's wound with normal saline, patted it dry, applied anapest gel (ointment used for wounds) and collagen powder, covered with calcium alginate, and applied a clean dressing to the wound. Using the same dirty gloves LVN A repositioned resident and covered him with his sheets. After this, LVN A removed the dirty gloves and performed hand hygiene. CNA C returned to collect the dirty sheets on the floor, bagged them, and took them out of the room. During an interview on 06/26/2023 at 2:51 PM, LVN A said she should have changed gloves and performed hand hygiene after removing the dirty dressing from Resident #9's wound. LVN A said gloves should be changed anytime when switching from anything dirty to clean. LVN A said hand hygiene should be performed after glove changes and before and after care. LVN A said she did not do this because she was nervous. LVN A said it was important to perform glove changes and hand hygiene to not transmit any bacteria or germs and to not cause an infection. During an interview on 06/26/2023 at 2:58 PM, CNA B said CNA C and her were in a hurry, and that was why they left the dirty sheets on the floor in Resident #9's room after providing incontinent care and changing the linens on his bed. CNA B said the dirty sheets should not have been placed on the floor. CNA B said dirty linens go in a plastic bag after removing them from the residents' beds. CNA B said it was important to place the dirty sheets in a bag because of contamination and infection control. During an interview on 06/26/2023 at 3:00 PM, CNA C said dirty linens should not be placed on the floor. CNA C said, Usually we put them in a plastic bag, but we were in a rush and did not grab enough trash bags. CNA C said CNA B and her had performed incontinent care and removed the dirty sheets from Resident #9's bed and placed them on the floor. CNA C said it was important to place the dirty sheets in a bag after removing them from the residents' beds to decrease contamination and keep the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675251 If continuation sheet Page 29 of 34 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 06/28/2023 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 0880 place clean. CNA C said placing the residents' dirty linens on the floor could result in cross contamination. Level of Harm - Minimal harm or potential for actual harm During an interview on 06/28/2023 at 3:30 PM, the DON said dirty linens should not be placed on the floor. The DON said the charge nurses should be making sure the CNAs bag the dirty linens. The DON said she tried to observe incontinent care and make sure the CNAs were bagging items appropriately weekly. The DON said she had noticed the CNAs placing the dirty linens on the floor, and she had addressed it with the CNAs when she observed it. The DON said it was important for the dirty linens to be bagged appropriately because it was an infection control issue. The DON said placing the dirty linens on the floor could lead to staff tracking it all over the facility and placed the residents at risk of making them sick. The DON said the ADON and herself were responsible for ensuring the nurses changed gloves and performed hand hygiene while performing wound care. The DON said this was monitored by the annual competencies. The DON said hand hygiene should be performed in between glove changes and at the start and finish of the wound care. The DON said gloves should be changed after and hand hygiene performed after removing the dirty dressing from a wound. The DON said it was important to perform hand hygiene and glove changes while providing wound care to prevent infection to the wound. The DON said not performing hand hygiene and glove changes could make the residents sick and prolong the healing process of the wound. Residents Affected - Few During an interview on 06/28/2023 at 3:49 PM, the ADON said while providing wound care the dressing is considered dirty. The ADON said after removing the dirty dressing it should be discarded and gloves changed and hand hygiene performed. The ADON said hand hygiene should be performed between glove changes. The ADON said gloves should be changed when going from dirty to clean. The ADON said it was important to perform hand hygiene and glove changes while providing wound care so nothing would be introduced into the wound that should not be. The ADON said not performing hand hygiene and glove changes could cause an infection. The ADON said dirty linens should not be placed on the floor, they were supposed to be bagged. The ADON said the charge nurses were responsible for making sure the CNAs did this. The ADON said it was important to bag dirty linen appropriately because bacteria could be carried around on the staffs' feet and it could cause the rooms to smell. During an interview on 06/28/2023 at 4:32 PM, LVN A said she had occasionally seen the CNAs leave dirty linens on the floor. LVN A said she should be making sure the CNAs bagged the dirty linens and did not place them on the floor. LVN A said it was important to bag the dirty linens appropriately to keep from transferring germs from place to place. LVN A said not bagging the dirty linens appropriately could result in an unclean environment and the residents being exposed to things they should not be. During an interview on 06/28/2023 at 4:37 PM, the Administrator said the ADON and DON were responsible for making sure wound care was provided properly. The Administrator said she expected for the staff to perform adequate hand hygiene and glove changes. The Administrator said not performed hand hygiene and glove changes placed the resident at risk for infection. The Administrator said the charge nurses were responsible for ensuring the CNAs did not place dirty linens on the floor in the residents' rooms and that they were bagging them appropriately. The Administrator said it was important to bag the dirty linens appropriately for cleanliness and the resident's dignity. The Administrator said not bagging the dirty linens appropriately could make the residents feel embarrassed and could harbor insects. Record review of the facility's policy titled, Infection Prevention and Control Program, implemented on 05/13/2023, indicated, . soiled linen shall be collected at bedside and placed in a bag. When (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675251 If continuation sheet Page 30 of 34 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 06/28/2023 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the task is complete, the bag shall be closed securely and placed in the soled utility room/laundry barrel. Soiled linen shall not be kept in the resident's room or bathroom . Record review of the facility's policy titled, Hand Hygiene, implemented on 10/24/2022, indicated, All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility . staff will perform hand hygiene when indicated, using proper techniques consistent with accepted standards of practice . the use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves . During an interview with the DON on 06/28/2023 at 3:40 PM, a policy regarding performing wound care was requested and not provided prior to exit of the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675251 If continuation sheet Page 31 of 34 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 06/28/2023 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 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an effective pest control program to keep the facility free from pests in 1 of 5 halls, 1 of 1 dining room, 1 of 1 kitchen, and 2 of 13 (Resident #23 and Resident #27) residents reviewed for pest control. Residents Affected - Some The facility did not maintain an effective pest control program to ensure the facility was free of flies. This failure could place residents at risk for an unsanitary environment and a decreased quality of life. Findings included: 1. Record review of a face sheet dated 06/30/2023, indicated Resident #23 was an [AGE] year-old male initially admitted to the facility on [DATE] with diagnoses which included hypertensive heart disease with heart failure (complications of high blood pressure that affect the heart), Alzheimer's disease (progressive disease that destroys memory and other important mental functions), and transient cerebral ischemic attack (temporary blockage of blood flow to the brain). Record review of the Quarterly MDS assessment dated [DATE], indicated Resident #23 was usually able to make self-understood and sometimes understood others. The MDS assessment indicated Resident #23 had a BIMS score of 3, which indicated he had severe cognitive impairment. The MDS assessment indicated Resident #23 required extensive assistance with bed mobility, transfer, dressing, toilet use and personal hygiene. Record review of Resident #23's care plan with date initiated 11/23/2022 did not indicate to provide an environment free of pests. 2. Record review of a face sheet dated 03/09/2023 indicated, Resident #27 was a [AGE] year old female initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs), schizophrenia (mental disorder characterized by delusions, hallucinations, disorganized thoughts, speech and behavior), and intellectual disabilities (a condition that develops in childhood and affects your capacity to learn and retain new information, and it also affects everyday behavior). Record review of the Quarterly MDS assessment dated [DATE] indicated Resident #27 rarely/never understood others and sometimes made herself understood. The MDS assessment indicated Resident #27 had a short-term and long-term memory problem. The MDS assessment indicated Resident #27's cognitive skills were severely impaired. The MDS assessment indicated Resident #27 required extensive assistance with transferring, dressing and personal hygiene. Record review of Resident #27's care plan last revised 06/11/2023 did not indicate to provide an environment free of pests. During an observation on 06/26/2023 at 8:09 AM, multiple flies were observed in the kitchen. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675251 If continuation sheet Page 32 of 34 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 06/28/2023 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 0925 Level of Harm - Minimal harm or potential for actual harm During an observation on 06/26/2023 at 8:16 AM, Resident #23 had a fly swatter in his room. Resident #23 had multiple flies in his room. Resident #23 was non-interviewable. During an observation on 06/26/2023 at 10:58 AM, Resident #27 had multiple flies in her room. Resident #27 was in bed and the flies were crawling on both of her legs. Resident #27 was non-interviewable. Residents Affected - Some During an observation of the lunch meal on 06/26/3023 at 11:50 AM, multiple flies observed in the dining area while the residents were eating their meals. During an observation of the breakfast meal on 06/27/2023 at 7:55 AM, observed several residents and staff swatting away multiple flies with their hands in the dining room area. During an observation on 06/27/2023 at 9:02 AM, multiple flies observed down Hall A. Resident #27 had multiple flies in her room, and she kept swatting them away from her ears. During an observation on 06/27/2023 at 11:30 AM, [NAME] D was swatting away multiple flies in the kitchen while doing food temperatures. During an observation on 06/28/2023 at 10:41 AM, multiple flies observed down Hall A and in Resident #23's and Resident #27's rooms. During an interview on 06/28/2023 at 11:10 AM, the Maintenance Director said he had not notified the exterminator to see if he could do something about the excess flies because it had not been reported to him. The Maintenance Director said all the staff were responsible for making sure there was a clean, safe environment for everyone. The Maintenance Director said it was important to keep the environment free of pests, including flies, because it was their home and it needed to be clean and for a safe environment. During an interview on 06/28/2023 at 3:20 PM, the DON said she had noticed the flies in the halls, dining area, and Resident #23 and Resident #27's rooms. The DON said the Maintenance Director was responsible for notifying the pest control company. The DON said it was important to prevent the residents from getting bites and infections could be spread from the flies. The DON said the residents could ingest the flies, and the flies could aggravate the residents. During an interview on 06/28/2023 at 4:26 PM, LVN A said she had noticed the flies in A hall and in Resident #23's and Resident #27's rooms. LVN A said she had let multiple office management staff know and they said they would all pest control. LVN A said it was important to have an environment free of flies because the flies could lay eggs on the residents and cause infection, and it was unsanitary to have flies in the facility. During an interview on 06/28/2023 at 4:56 PM, the Administrator said she had noticed the flies in the facility. The Administrator said the Maintenance Director was responsible for the facility being free of pests. The Administrator said it was important to have an environment free of pests because they could get on the food and harbor infection. The Administrator said the pests could affect the residents' dignity. Record review of the service reports indicated visits on: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675251 If continuation sheet Page 33 of 34 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 06/28/2023 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 0925 01/20/2023- Fly Program insect light trap maintenance Level of Harm - Minimal harm or potential for actual harm 02/03/2023- Fly Program insect light trap maintenance 03/01/2023- Fly Program insect light trap maintenance Residents Affected - Some 04/30/2023- no indication of treatment for flies 05/22/2023- Fly Program insect light trap maintenance 06/26/2023- Fly Program insect light trap maintenance. Record review of the facility's undated policy titled, Pest Program Specifications, did not address maintaining an effective pest control program. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675251 If continuation sheet Page 34 of 34