Inspection·August 9, 2023

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few into her room and slapped her because she did not have her oxygen ready. He said the local Police Department was called and they interviewed resident as well. He said he did not see any injuries to the resident initially but reported the abuse allegation immediately to the ADM. In an interview on 8/9/2023 at 8:25 a.m., the SW said the LD reported to her on 6/8/2023 that Resident #103 told him she was slapped in the face by a black clerical worker last night. She said the LD, ADON and herself interviewed the resident. She said Resident #103 alleged a big black lady came into her room and slapped her in her face last night because she did not have her oxygen ready. She said the resident did not know the perpetrator. She said she contacted the local Police Department, and they came out and interviewed resident as well. SW and ADON reviewed schedule from previous evening and night shift and no one working met the description provided by the resident. Record review of clinical progress notes indicated on 6/8/2023 at 4:30 p.m., SW entry reveals resident told LD that she had been slapped in the face by a black clerical worker. LD notified ED and SW. SW, ADON, LD and resident met so that the resident could tell us what happened. Resident said that she was in her room and a black clerical worker came in and slapped her because she did not have her oxygen ready. Resident was laughing and smiling during interview and seemed to be in good spirits. Local police department notified and investigated. MD & RP notified of incident. Record review of clinical progress notes indicated on 6/8/2023 at 5:08 p.m. ADON entry reveals patient reported to LD that someone came in her room last night and slapped her across the face, assessment done no bruises or injuries noted. In an interview on 08/9/23 at 3:00 p.m., the ADM said she was the acting Abuse Coordinator (AC). She said on 6/8/2023 she was out of town for the day when the LD called her to report the abuse allegation made by Resident #103. She said she directed the LD to notify the SW and ADON, which he did. She said the SW and ADON interviewed the resident, contacted the police department, and initiated the investigation. She said that ADON & SW contacted her and updated her frequently with findings. The ADM acknowledged she did not send nor delegate anyone to report the allegation of abuse to the State Agency. She said she went to the facility the next day on 6/9/2023 and reported the incident to HHS, the State Agency around 9:00am on 6/9/2023. The administrator said the abuse allegation was not reported to HHS in the 2-hour time frame as required. She said she knew all allegations of abuse were to be reported to the State Agency within 2 hours regardless of if there was serious bodily harm or not. She said the negative outcome would be that this would put the residents at risk for abuse. Record review of the facility Abuse Protocol Revision dated April 2019 in part revealed: Fundamental Information: (Protection) 10. The Abuse Prevention Coordinator will: a. Immediately (within 2 hours) report to the Department of Aging and Disability Services (DADS) and other appropriate authorities' incidents of Patient Abuse as required under applicable regulations and regulatory guidance. Report events that cause reasonable suspicion of serious bodily injury immediately (within 2 hours) after forming the suspicion to THE Department of Aging and Disability (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675338 If continuation sheet Page 2 of 13 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 675338 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mill Creek 1105 W Hwy 418 Silsbee, TX 77656 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 Services (DADS) and other appropriate authorities as required under applicable regulations and regulatory guidance. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675338 If continuation sheet Page 3 of 13 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 675338 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mill Creek 1105 W Hwy 418 Silsbee, TX 77656 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 0645 PASARR screening for Mental disorders or Intellectual Disabilities 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 each resident in a nursing facility is screened for a mental disorder (MD) prior to admission and that individuals identified with MD are evaluated and receive care and services in the most integrated setting appropriate to their needs for 1 of 13 residents reviewed for PASRR Assessments. (Residents #8) Residents Affected - Few The facility failed to ensure Resident's #8's pre-admission screening and resident review (PASRR) Level l screening indicated a diagnosis of mental illness, although diagnosis was present upon admission. Thisese failures could place all residents who had a mental illness at risk for not receiving needed assessment, care, and specialized services to meet their needs. Findings included: Record review of a face sheet dated 8/9/23 indicated Resident #8 was a [AGE] year-old that was admitted on [DATE], was [AGE] years old with diagnoses including bipolar (a mental health condition that causes extreme mood swings) and dementia (loss of cognitive function). Record review of a PL 1 (PASRR Level 1) screening dated 09/09/21 indicated Resident #8 was negative for mental illness. Record review of the most recent comprehensive MDS annual assessment dated [DATE] Indicated Resident #8 had a negative PL 1 screening and was negative for serious mental illness, intellectual disabilities, and developmental disabilities. The MDS indicated Resident #8 had mild impairment with cognition, diagnoses including psychotic disordered and dementia and received antipsychotic medication for 7 of 7 days. Record review of a care plan revised 2/24/22 indicated Resident #8 received psychotropic medication Seroquel related to diagnoses of bipolar. Record review of physician orders dated August 2023 indicated Resident #8 was receiving Seroquel (anti-psychotic) 50mg given at bedtime for hallucinations, delusions related to bi-polar with start date of 5/9/23. During an interview on 08/09/23 at 2:25 p.m., the SW said she was responsible for Preadmission PASRR screening on new admits and said she just started working in 2023. She said maybe the ADM. would know who completed Resident #8 PL1. During an interview on 08/09/23 at 2:30 p.m., the ADM said the PASRR for Resident #8 was incorrect. She said if the PASRR was not correctly completed, the resident might not get the care and services as needed. The administrator said his her expectation was for all PL1 to be completed correctly, put in the portal correctly and her and the DON would be monitoring. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675338 If continuation sheet Page 4 of 13 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 675338 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mill Creek 1105 W Hwy 418 Silsbee, TX 77656 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for 1 of 13 residents reviewed for care plans. (Resident #4) The facility did not develop and implement a hospice care plan for Resident #4. This failure could place the residents at risk of not receiving the appropriate care and services to maintain their highest level of well-being. Findings included: Record review of the physician orders dated July 2023 indicated Resident #4, admitted [DATE], was [AGE] years old with a diagnosis of chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe). The orders indicated the resident received hospice services beginning 06/05/23. Record review of the most recent significant change MDS dated [DATE] indicated Resident #4 received hospice services. Record review of a care plan dated 09/16/21 to present [08/09/23] did not indicate Resident #4 received hospice services. During observation and interview on 08/07/23 at 12:25 p.m., several family members were present in Resident #4's room. Resident #4 was unresponsive with slight labored breathing noted. One of the family members said the resident was on hospice services and was in the process of actively dying. The family denied concerns related to the hospice services. During an interview on 08/07/23 at 1:18 p.m., LVN A said Resident #4 was placed on hospice services on 06/05/23. She said the resident recently began declining due to Alzheimer's (a progressive disease that destroys memory and other mental functions) with increased confusion. The LVN said she was not responsible for completing the care plans. During an interview on 08/09/23 at 2:22 p.m., the DON said there was not a hospice care plan for Resident #4. She said the resident was on hospice services and should have a care plan in place for hospice. She said her expectations were for outside services to be care planned so everyone was aware of the interventions and protocol for each resident. She said there could be a breakdown in communication between the care team and the resident could not receive the appropriate care if a care plan was not completed. She said LVN C was responsible for completing the care plan but was no longer an employee of the facility. During an interview on 08/09/23 at 2:31 p.m., the ADM said LVN C, who was responsible for completing the care plans on 6/5/23, no longer worked at the facility. She said the facility had not hired another MDS nurse and the corporate MDS nurse was filling in for the position. She said her expectations were for the resident's care plans to be complete and correct. An attempt was made on 08/09/23 at 2:33 p.m. to contact LVN C, who was responsible for completing (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675338 If continuation sheet Page 5 of 13 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 675338 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mill Creek 1105 W Hwy 418 Silsbee, TX 77656 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 the care plans on 06/05/23, with no answer to the phone. A message was left for call back without success. Level of Harm - Minimal harm or potential for actual harm Record review of a Patient Care Management System 12 policy dated November 2017 indicated: . Each Care Plan must be reviewed and updated by the interdisciplinary Care Plan team quarterly, upon each change in condition and upon re-admission. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675338 If continuation sheet Page 6 of 13 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 675338 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mill Creek 1105 W Hwy 418 Silsbee, TX 77656 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure that the resident environment remained as free of accident hazards as was possible for 1 of 19 Residents (Resident #17), who resided on Hall 200 and 1 of 2 halls (Hall 200) reviewed for accidents and hazards. The facility failed to ensure Resident #17 did not keep isopropyl alcohol (disinfectant) in her room. The facility failed to ensure residents' environment remained free from accident hazards as possible by securing chemicals on Hall 200. These failures could place residents at risk of harm or injury and contribute to avoidable accidents. Findings included: 1. Record review of Resident #17's face sheet dated 8/9/23, indicated she was an [AGE] year-old female admitted to the facility on [DATE], with diagnoses that included high blood pressure and schizophrenia (disorder that affects a person's ability to think, feel or behave clearly). Record review of the physician orders dated August 2023 indicated Resident #17 had no orders for isopropyl alcohol for a treatment to her legs. Record review of Resident #17's most recent quarterly MDS assessment, dated 05/12/23 indicated the resident was cognitively intact for daily decision-making skills and received oxygen therapy. During an observation on 08/07/23 at 9:17 a.m., Resident #17 was in bed and was receiving oxygen. There was a 16-ounce bottle which was 3/4 full. The label indicated 70% isopropyl alcohol and keep out of reach of children on Resident #17's nightstand beside her bed. The label indicated Flammable .use only in a well-ventilated area-fumes may be toxic. During an interview on 08/07/23 at 9:20 a.m., Resident #17 said she rubbed the alcohol on her legs when they hurt and said she did not know who had given it to her. During an observation and interview on 08/07/23 at 9:25 a.m., the ADON said the residents should not have isopropyl alcohol at bedside as she removed the bottle from Resident #17's room. The ADON said I will call her doctor and get a treatment for her legs and said maybe her family had brought it to the resident. 2. During an observation on 08/07/23 at 10:32 a.m., there was a bottle on top of a housekeeping cart labeled peroxide multiple surface cleaner/disinfectant. There was a nurse down the hall however, she was turned towards a medication cart and was giving medications and going into a resident's room. During an interview on 08/07/23 at 10:34 a.m., LVN E denied that she observed the bottle of disinfectant on the housekeeping cart and denied watching it for the housekeeper. She said all chemicals (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675338 If continuation sheet Page 7 of 13 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 675338 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mill Creek 1105 W Hwy 418 Silsbee, TX 77656 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 need to be locked up. Level of Harm - Minimal harm or potential for actual harm During an interview on 08/07/23 at 10:37 a.m., Housekeeping Staff F said she should have locked the chemicals up when she finished using it. She said she was trained on hire how to secure chemicals when not in use. Residents Affected - Few During an observation on 08/07/23 at 10:39 a.m., there was a full bottle of peroxide multiple surface cleaner/disinfectant in resident room [ROOM NUMBER] on the dresser, the door was open, and the resident was not in the room. During an interview on 08/07/23 at 10:42 a.m., the Housekeeping Director said the chemicals must be secured when not in use or the residents could hurt themselves. She said all the housekeeping staff were trained when hired on keeping the chemicals secured on their housekeeping carts when not in use. She said the housekeepers were responsible and must had forgotten to lock the chemicals up. Record review of the material safety data sheet (MSDS) for the peroxide multi-purpose solution dated 09/23/10 provided by the facility indicated . direct contact with eyes can cause irreversible damage .slightly irritating to skin slightly irritating to respiratory system. Record review of the policy dated 2017 titled Hazardous Areas, Devices and Equipment indicated Policy Statement All hazardous areas, devices and equipment in the facility will be identified and addressed appropriately to ensure resident safety and mitigate accident hazards to the extent possible. Policy Interpretation and Implementation 1. As part of the facility's overall safety and accident prevention program, hazardous areas and objects in the resident environment will be identified and addressed by the safety committee. Record review of a MSDS sheet obtained from an internet site rsc.aux.eng.ufl.edu on 08/15/23 indicated . Isopropyl alcohol was flammable liquid. Causes eye irritation. May cause skin irritation. Ingestion: Give conscious victims . milk or water. If breathing difficulty give oxygen and get medical attention quickly. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675338 If continuation sheet Page 8 of 13 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 675338 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mill Creek 1105 W Hwy 418 Silsbee, TX 77656 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 0695 Provide safe and appropriate respiratory care for a resident when needed. 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 that a resident who needed respiratory care was provided such care, consistent with professional standards of practice and the comprehensive person-centered care plan for 3 of 13 residents reviewed for oxygen therapy. (Residents #4,18 and 28) Residents Affected - Some *The facility did not administer Resident #4 and #18's oxygen as ordered, and the residents' tubing was not changed weekly as ordered. *The facility did not change Resident #28's oxygen tubing weekly as ordered. These failures could place the residents at risk of not receiving the care and services to maintain their highest practicable physical, mental, and psychosocial well-being. Findings included: 1. Record review of the physician orders dated July 2023 indicated Resident #4, admitted [DATE], was [AGE] years old with diagnoses of chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe) and anxiety. The orders indicated the resident received oxygen 2L NC continuously and the oxygen tubing changed and dated weekly on the 10 p.m. to 6 a.m. shift. Record review of the most recent significant change MDS dated [DATE] indicated Resident #4 received oxygen therapy. Record review of a care plan dated 09/16/21 to present indicated Resident #4 receive oxygen at 2L/minute continuous. During the following observations, Resident #4's oxygen tubing was dated 07/23/23 and the resident had oxygen in progress at 4L NC: * on 08/07/23 at 9:13 a.m.; * on 08/07/23 at 1:39 p.m.; * on 08/08/23 at 9:33 a.m.; and * on 08/09/23 at 8:23 a.m. During observation, interview, and record review on 08/09/23 at 8:23 a.m., LVN A entered the room to check Resident #4's oxygen settings. LVN A said the oxygen tubing was dated 07/23/23. She said the tubing had not been changed as ordered every week. She said the oxygen tubing was supposed to be changed every Sunday on the night shift. LVN A said the possible negative outcome of not changing the tubing as ordered could be bacterial build up in tubing. She said Resident #4's oxygen was set on 4 liters nasal cannula. LVN A said she would have to check the electronic record to see if the oxygen dose was set correctly. After checking the electronic record, she said the order indicated the resident's oxygen was supposed to be set at 2 liters and the resident received the incorrect dose. She said it was her responsibility during her initial round assessments to ensure the residents received (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675338 If continuation sheet Page 9 of 13 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 675338 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mill Creek 1105 W Hwy 418 Silsbee, TX 77656 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some the correct dose of oxygen and the tubing was changed as ordered. She said not administering the correct dose of oxygen to the residents could cause increased dependence on oxygen. 2. Record review of the physician orders dated July 2023 indicated Resident #18, admitted [DATE], was [AGE] years old with diagnoses of congestive heart failure (a chronic condition in which the heart cannot pump blood efficiently) and chronic obstructive pulmonary disease. The orders indicated the resident received oxygen 2L NC continuously and the oxygen tubing changed and dated weekly on the 10 p.m. to 6 a.m. shift. Record review of the most recent quarterly MDS assessment dated [DATE] indicated Resident #18 received oxygen therapy. Record review of a care plan dated 06/18/17 to present [08/09/23] indicated Resident #18 had episodes of shortness of breath and was at risk for respiratory distress/failure. The resident received oxygen at 2 liters via nasal cannula continuously. During the following observations, Resident #18's oxygen tubing was dated 07/23/23 and the oxygen was in progress at 3L NC: * on 08/07/23 at 9:59 a.m.; * on 08/08/23 at 9:30 a.m.; and * on 08/09/23 at 8:36 a.m. During observations, interview, and record review on 08/09/23 at 8:36 a.m., LVN A entered the room to check Resident #18's oxygen settings. She said the oxygen was set at 3 liters nasal cannula and the oxygen tubing was dated 07/23/23. LVN A said the tubing had not been changed as ordered every week. She said the oxygen tubing was supposed to be changed every Sunday on the night shift. She said she would have to check the resident's electronic records for the correct oxygen dose. After checking the resident's electronic record, she said the order indicated the resident was ordered oxygen at 2 liters nasal cannula and she received the incorrect dose. LVN A said the possible negative outcome of not changing the tubing as ordered could be bacterial build up in tubing. She said it was her responsibility during her initial round assessments to ensure the residents received the correct dose of oxygen and the tubing was changed as ordered. 3. Record review of the physician orders dated August 2023 indicated Resident #28, admitted [DATE], was [AGE] years old with diagnosis of chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe) and anxiety. The orders indicated he was to receive oxygen 2L NC continuously and the oxygen tubing changed and dated weekly on the 10p.m. to 6 a.m. shift. Record review of a care plan dated 10/11/22 to present indicated Resident #28 was to receive oxygen at 2L/minute. Record review of a quarterly MDS dated [DATE] indicated Resident #28 received oxygen therapy. During the following observations, Resident #28's oxygen tubing was dated 07/23/23: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675338 If continuation sheet Page 10 of 13 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 675338 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mill Creek 1105 W Hwy 418 Silsbee, TX 77656 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 0695 * 08/07/23 at 1:06 p.m. Level of Harm - Minimal harm or potential for actual harm * 08/08/23 at 9:25 a.m. * 08/09/23 at 8:23 a.m. Residents Affected - Some During observation, interview, and record review on 08/09/23 at 8:15 a.m., LVN A entered Resident #28's room to check oxygen tubing. LVN A said the tubing was dated 07/23/23 and initialed by LVN B. LVN A then viewed the TAR for Resident #28 and it indicated the oxygen tubing was last changed 08/06/23 by LVN B. LVN A said the Resident's tubing was not dated for 08/06/23 as the TAR indicated and the tubing should have been dated when LVN B changed it. LVN A said oxygen tubing should be changed weekly on the night shift. During an interview on 08/09/23 at 8:43 a.m., the DON said her expectations were for the oxygen to be set at the correct liters as ordered and for the nurses to be checking the oxygen during their assessment of the residents. She said depending on the oxygen dose ordered, the possible negative outcome of not administering the oxygen as ordered would be the resident could either be hyperventilated or desaturation could occur. The DON said all oxygen tubing was to be changed weekly. She said documentation of the weekly change was on the resident's TAR. She said possible negative outcome of not changing tubing weekly could be water/humidity building up in the old tubing and causing resident illness/infection. Three attempts were made on 08/09/23 to contact night nurse LVN B, who was responsible for changing the tubing on 08/06/23, without success. A message was left for callback without success. Record review of a Protocol for Oxygen Administration updated March 2019 indicated : Oxygen tubing, cannulas, nebulizer tubing's, and face masks will be changed weekly and as needed. Record review of a Physician Orders policy dated February 2010 indicated: . GUIDELINES: o Obtain order from physician authorized/designee. o Read order back to physician/designee to verify and/or clarify. o Fill out telephone order form completely. o Orders to be carried out as stated by physician. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675338 If continuation sheet Page 11 of 13 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 675338 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mill Creek 1105 W Hwy 418 Silsbee, TX 77656 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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. 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 food that was palatable and attractive to 1 of 13 residents reviewed for food palatability. (Resident #28) Residents Affected - Few The facility did not serve mashed potatoes that were palatable to Resident #28. This failure could place residents who ate food from the kitchen at risk of weight loss, alternate nutritional status, and diminished quality of life. Findings included: Record review of physician orders and face sheet dated August 2023 for Resident #28 indicated he was a [AGE] year-old male admitted to the facility on [DATE]. His diagnosis included chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make breathing difficult) and anxiety disorder. The orders indicated he was to receive a mechanically altered regular diet. Record review of a care plan with effective date of 10/07/22 for Resident #28 indicated he was receiving a mechanically altered regular diet and had 3 natural teeth on the bottom, none on the top. Record review of the quarterly MDS dated [DATE] indicated Resident #28 was cognitively intact. During an observation and interview on 08/07/23 at 12:12 p.m., Resident #28 was in his room eating lunch. He had a meat patty, mashed potatoes, and cooked carrots. Resident #28 used his fork and pulled brownish/black colored pea size lumps out of his mashed potatoes. He said he was not going to eat whatever these were. He then tried to mash the lumps with his fork, but they did not mash easily. During an observation and interview on 08/07/23 at 12:15 p.m. the DM and the dietician came to Resident #28's room. They viewed the lumps pulled from the potatoes and said they did not know what they were. During an observation and interview on 08/07/23 at 12:18 p.m., the dietician and the DM went to the kitchen and viewed a bag of uncooked mashed potatoes. Black spots were visible throughout the bag. Bag ingredients listed potatoes, ingredient to hold color, and spices. The DM and [NAME] C said they thought the black spots were pepper and never noticed the size of them. During an observation and interview on 08/08/23 at 12:15 p.m., Resident #28 was eating lunch in his room and did not receive mashed potatoes. When asked if he ever told anyone about the lumps in the potatoes, he said he told everyone, and nobody listened or did anything about it. He said he could not recall who he had told. During an observation on 08/08/23 at 3:15 p.m., the DM said the facility had been serving those same mashed potatoes in a bag for at least 2 years and no one had ever complained about brown lumps. She said after seeing more lumps in the potatoes today at lunch service the facility did not serve them. She said the facility would no longer use bagged potatoes. The facility would find an alternative. During an interview on 08/09/23 at 11:25 a.m., the Administrator said she expected the kitchen to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675338 If continuation sheet Page 12 of 13 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 675338 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mill Creek 1105 W Hwy 418 Silsbee, TX 77656 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 0804 serve palatable pleasing food to all residents. Level of Harm - Minimal harm or potential for actual harm Record review of the facility policy, Purpose and Objectives of the Dietary Department dated November 2004, stated in part: The purpose of the Dietary Department is to provide high quality, nutritious, palatable and attractive meals in a sanitary manner. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675338 If continuation sheet Page 13 of 13