Inspection·September 22, 2023

F 0602 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Housekeeper A stated Resident #1 asked me to go the store for her last week on 09/08/23 to purchase a 12 pack of big red and she gave me her direct express cared, and she gave me her pin # I bought this and brought the receipt back to her. The other time she asked me to buy Dr. Pepper (12 pack) and a pair of tights. Brought back the receipt as well to her. Interview with Resident #1's responsible party on 09/22/23 at 9:30am, revealed Resident #1's RP was notified of the incident. RP stated Resident #1 was at home and doing fine. RP stated that the facility stated they are going to reimburse Resident #1's $10 that the Housekeeper charged her for gas money. An interview with ADM on 09/21/23 at 4:00pm, revealed ADM stated that Housekeeper A went to pick up some items for Resident #1 without authorization on two occasions. ADM stated when she questioned Housekeeper A about the incident, she admitted to going shopping for the Resident #1 on two different occasions and charging Resident #1 $5 for gas for each trip. ADM stated that Housekeeper A was terminated as a result of exploiting Resident #1 and the facility is in the process of reimbursing Resident #1's $10. ADM stated the facility in- serviced staff on reporting abuse, neglect, and exploitation. The facility immediately had an emergency resident council meeting in order to ensure that the residents are aware of who can shop for them and who cannot. Resident were educated on being exploited. The facility did an exploitation safe survey on the residents in the facility. ADM also stated that the local police department was notified of the incident ADM stated if the situation was not identified then there could have been further exploitation of the residents at the facility. Record review of the facility's Abuse, Neglect and Exploitation Policy, dated 12/2017 revealed Our residents have the right to be free abuse/neglect/misappropriation of resident property/ corporal punishment and involuntary seclusion. Abuse Prevention Our facility is committed to protecting our residents from abuse by anyone including/but not necessarily limited to: employees/other residents/consultants/volunteers/and staff from other agencies providing services to our residents/family members/legal guardians/surrogates/residents responsible parties/friends/visitors, or any other individuals. Comprehensive policies and procedures have been developed to aid our facility in preventing abuse/neglect/mistreatment of our residents. Our abuse prevention program provides policies and procedures that govern/as a minimum: e. The development of investigative protocols governing alleged residents' abuse/theft/misappropriation of resident property and resident-to-resident abuse FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675251 If continuation sheet Page 2 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675251 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/22/2023 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents fed by enteral means received the appropriate treatment and services to prevent complications for 1 of 1 resident reviewed for enteral nutrition (Resident #2). LVN A failed to follow the physician orders for enteral feedings on 09/07/23 at 6:00pm (a form of nutrition that is delivered into the digestive system as a liquid form via the feeding tube) for Resident #2. This failure could affect residents receiving enteral nutrition and hydration by placing them at risk of health complications. Findings included: Record review of Resident #2 face sheet dated 09/21/23, documented a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that include cerebral infarction (disrupted blood flow to the brain due to problems with the blood vessels that supply it), cognitive communication deficit (difficulty with thinking and communicating) , dysphagia oropharyngeal phase (swallowing problems occurring in the mouth and/or the throat), peptic ulcer site (open sores that develop on the inside lining of your stomach and the upper portion of your small intestine), acute kidney failure (occurs when your kidneys suddenly become unable to filter waste products from your blood), chronic kidney disease (when your kidneys are damaged and can't filter blood the way they should), anxiety disorder (excessive nervousness, fear, apprehension and worry), enterocolitis due to clostridium difficile and bipolar disorder (mental illness that causes unusual shifts in a person's mood, energy, activity levels and concentration). Record review of Resident #2's quarterly MDS assessment dated [DATE], revealed the resident had a BIMS score of 99 indicting the resident was unable to complete the interview. The quarterly MDS also revealed Resident #2 required total dependence in various areas of activities of daily living such as transfer, dressing, eating, toilet use, and personal hygiene. Record review of Resident #2's physician order dated 08/21/23 indicated Resident #2 had an order for Glucerna 1.5 cal oral liquid (nutritional supplements) Give 360 ml via peg tube every 6 hours (12:00am, 6:00am, 12:00pm and 6:00pm) for diabetes with a start dated of 08/03/23. Resident #2's order for feedings every 6 hours indicates Resident #2 is receiving continuous feedings. Record review of Resident #2's care plan dated 08/08/23 indicated Resident #2 requires tube feeding related to dysphagia. The care plan interventions include Glucerna 1.5 cal oral liquid (nutritional supplements) Give 360 ml via peg tube every 6 hours for diabetes. Attempted numerous times to contact LVN A for an Interview. No answer but voicemails were left. An interview with ADON on 09/21/23 at 11:10 am, ADON stated she observed Resident #2's Glucerna bottle had the same amount from the previous feeding. ADON stated on 09/07/23 at 8:54pm she notified the administrator that Resident #2 had a documented feeding of Glucerna enteral feeding, but the amount left in the Glucerna bottle had not changed since the prior feeding. ADON stated that LVN A, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675251 If continuation sheet Page 3 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675251 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/22/2023 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few documented that she had administered the enteral feeding at 5:15pm, but the Glucerna amount was still at the permanent line marked earlier in the day (to document the ounces left since the last/prior feeding). The Glucerna container amount had not changed from the previous feeding, suggesting that the 5:15pm feeding had not actually been given to Resident #2. ADON stated LVN A was suspended pending investigation on 09/07/23 at 9:40pm. The patient did not have any adverse effects from the missed feeding. An order was obtained for an immediate feeding, and family and physician were notified. ADON stated that feeding was given 2 hours and 25 minutes outside of the residents feeding window. ADON stated she spoke with LVN A and LVN A stated she clicked the feeding button but without feeding the Resident #2. ADON stated she contacted the MD for an order for a one time dose of Glucerna 1.5 admin 180 mL via PEG tube. MD requested that resident blood sugars be monitored during the night. Resident FSBS was checked at 12:00am as ordered and was checked again at 3:00am. Resident received feeding and family was notified. ADON stated Resident #2 could develop wounds from lack of nutrition, dehydration, weight loss, and resident would feel hungry if feedings were missed. ADON stated Resident #2 cannot verbalize her wants or needs. An interview with ADM on 09/21/23 at 4:00pm, ADM stated that she was notified by the ADON of the missed feeding for Resident #2. ADM stated that LVN A was suspended on the day of the incident and terminated on 09/14/23. ADM stated that Resident #2 is the only resident that receives tube feeding. ADM stated the facility notified Resident #2's family, physician, and dietician of the incident. ADM stated that Resident #2 had no adverse effects from the missed feeding but the nurses should always follow the physician orders. ADM stated that Resident #2 could have been hungry, dehydrated, or had weight loss if the physician orders are not followed. ADM stated the facility referred to Lippincott Nursing Procedures for instructions on how provide care for tube feedings. Tube Feedings Gastric enteral feeding involves delivery of a liquid feeding formula directly to the stomach via an enteral tube. Its typically indicated for patients who can't eat normally because of dysphagia or oral esophageal obstruction or injury. Gastric feedings also may be given to unconscious or intubated patients or to those recovering from GI tract surgery who can't ingest food orally. Implementation Verify the practitioner's order including the patient's identifiers, prescribed route based on the enteral tube's rep location, enteral feeding device, prescribed enteral formula, administration method, volume and rate of administration, and type, volume, and frequency of water flushes. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675251 If continuation sheet Page 4 of 4