Inspection·October 5, 2023

F 0580 and allow time to calm down. Level of Harm - Immediate jeopardy to resident health or safety Record review of Resident #1's care plan, dated 06/20/23, indicated Resident #1 had a verbal behavioral symptoms directed at others such as urinating on the bed, being naked in the hallways and cussing at others. Interventions included respond in a calm voice, maintain eye contact. Remove from area if Resident #1 was abusive to others. Residents Affected - Few Record review of Resident #1's clinical file revealed there were no care plans available for review related to homicidal ideations. Record review of a clinical note dated 09/14/23, at 4:02 a.m., and completed by LVN A, indicated LVN A was walking down the hallway when she overheard Resident #1 tell CNA B I want to kill somebody so that I can go back to prison. I want to shoot or stab someone, probably both. The DON and administrator were notified. Q-15 minute monitoring set up for Resident #1. Resident #1 was lying in bed watching TV, no s/s of distress or mental status. Resident #1 appeared calm. Will continue to monitor Resident #1 and inform oncoming shift of behavior. There was no documentation of physician notification. Record review of a progress note, dated 09/18/23, completed by APRN L indicated she spoke with the nurse (she could not recall the name of the nurse) and the nurse indicated Resident #1 was being monitored after stating he wanted to stab his roommate. Resident #1 was lying in bed without acute distress. Resident #1 stated I don't want to hurt anyone. I just want to get out of here. I don't want to be here. Resident #1 said he did not have a plan to harm himself or anyone else. Resident #1 was in a pleasant mood without s/s of distress/anxiety/depression. APRN L included an order to refer for psychiatric services to evaluate Resident #1 for possible adjustment to medications. Resident #1 did not appear to be a harm to himself or anyone else. Record review of a psychiatric assessment, completed on 09/21/23, by FNP N, indicated Resident #1 was assessed due to agitation and expressing he wanted to hurt someone. Resident #1 refused to engage. Staff indicated Resident #1 was more agitated and said he wanted a knife to stab someone and to go back to prison. Resident #1 was uncooperative with the exam. Revisit in two weeks. Record review of a progress note, dated 09/25/23 completed by APRN L, indicated Resident #1 was lying in bed without acute distress. He was easy to wake. He said he did not want to hurt anyone. He wanted to get out of the facility. He did not want to be in the facility. He was instructed he could not make threats against others and verbalized understanding. He had no behaviors since last visit. Record review of clinical note dated 09/26/23 at 9:21 a.m., and completed by ADON C, indicated RP was notified regarding homicidal intentions and MD suggestions of sending to behavioral hospital to adjust medication and any possible treatment needed., RP agreed. Referral sent to behavior hospital. Record review of progress note, dated 09/26/23 at 10:31 p.m., completed by APRN L, indicated (late entry) spoke with nurse and Resident #1 was being monitored after stating he wanted to stab his roommate. Resident #1 was lying in bed without acute distress. Resident #1 stated I don't want to hurt anyone. I just want to get out of here. I don't want to be here. Resident #1 said he did not have a plan to harm himself or anyone else. Resident #1 was in a pleasant mood without s/s of distress/anxiety/depression. Order given to refer for psychiatric services to evaluate Resident #1 for possible adjustment to medications. Resident #1 did not appear to be a harm to himself or anyone else. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675338 If continuation sheet Page 2 of 29 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 10/05/2023 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 0580 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few During an interview on 09/26/23 at 4:55 a.m., LVN A said Resident #1 was on frequent monitoring with Q15 minute checks due to threats of harm to others. She said she overheard Resident #1 tell CNA B he wanted to kill someone, to shoot or stab them so he could go back to prison. She said she notified the DON and the administrator immediately. She said she did not notify the physician. She said she was not aware of Resident #1 making any previous threats to harm others. During an interview on 09/29/23 at 9:29 a.m., the DON said she was notified by LVN A on 09/14/23 of Resident #1's threat to shoot or stab someone. She said she did not remove him from the room or move his roommate because Resident #1 did not specify anyone he wanted to harm. She said he did not have an active plan. The DON said Resident #1 was mobile with a wheelchair. She said Resident #1 was placed on q15 minute checks. She said he was not placed on 1-1. She said the physician and psychiatric services were not notified at the time of the incident. During an interview on 09/29/23 at 10:00 a.m., the Administrator indicated she was not made aware of Resident #1's threats to harm others on 09/14/23. She said she was off due to her husband having surgery. She said Resident #1 was not placed on 1-1 and could have harmed his roommate or others. She said she would have placed Resident #1 on 1-1 until cleared by psychiatric services. She said she would have moved Resident #1 or his roommate. She said the police should have been notified. She said she did a counseling and coaching with the DON and LVN A on 09/26/23 related to notification and reporting. She said she notified MD K and completed an emergency QAPI on 09/26/23. She said staff were in-serviced on 09/26/23. During an interview on 09/29/23 at 1:56 p.m., APRN L said she was completing scheduled rounds in the facility on 09/21/23 and LVN A informed her of Resident #1's threat to harm his roommate. She said Resident #1 indicated he had no plan and no intention. She said she was not aware of any prior threats. APRN L said staff would continue to monitor Resident #1 until he was seen by psychiatric services. During an interview on 09/29/23 at 2:41 p.m., FNP N said she assessed Resident #1 on 09/21/23. She said he was not cooperative with the assessment. She said he made a threat to hurt someone with a knife so he could go to prison. She said she would have recommended Resident #1 be sent out to a behavioral unit if he was a threat. Record review of the facility's Physician Notification policy, updated March 2019, indicated The types of conditions which arise frequently are listed. This list is not inclusive. Altered Mental Status .It is the responsibility of the nursing staff to observe the change, make an assessment, and notify the physician as indicated based on the assessment. The physician; physician assistant; nurse practitioner; or clinical nurse specialist is to be promptly notified of the results of the radiology, lab and other diagnostic tests ordered. The nurse will: Recognize the condition change. Monitor the Patient and continue to assess the condition and changes. Notify the physician, patient and patient representative of any change in condition. This was determined to be an Immediate Jeopardy (IJ) on 09/29/23 at 3:22 p.m. The Administrator was notified. The Administrator was provided with the IJ template on 09/29/22 at 3:44 p.m. The following Plan of Removal submitted by the facility was accepted on 09/29/23 at 4:10 p.m. Immediate Action: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675338 If continuation sheet Page 3 of 29 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 10/05/2023 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 0580 Systematic Approach: Level of Harm - Immediate jeopardy to resident health or safety 1. Assessment Residents Affected - Few - Resident #1 with homicidal ideation on 9/14/23 was placed on one-on-one on 9/26/23 at 9:02 AM until he was discharged to a Behavioral hospital on 9/27/23 at 2:00 PM.-The Executive Director notified the facility Medical Director of the Immediate Jeopardy on 09/29/22 at 4:20 PM. -An emergency QAPI meeting was held on 9/26/2023. -All residents will have a psychosocial assessment updated by the Director of Nurses, Assistant Director of Nurses and/or Patient Care Coordinator on 9/29/2023 to identify any current patients that are at imminent risk homicidal/suicidal ideation. The psychosocial assessments were completed on 9/29/23 by 6:00 PM. After completion of psychosocial assessments, no other residents were found to be at imminent risk of homicidal/suicidal ideation. The assessment includes the following information: The assessment is to determine if a resident is an imminent/suicidal risk for psychiatric needs. Who will be responsible: Director of Nursing/Nurse Managers Who Will monitor: Executive Director and RDCS -Beginning 9/29/2023, psychosocial assessments will be completed upon admission, condition change, and quarterly by the charge nurse and/or nurse managers, and for any resident that triggers an imminent risk for homicidal/suicidal ideation, the facility will initiate one-on-one supervision until further direction is provided. The abuse/neglect policy will be implemented immediately. The physician will be notified immediately of any homicidal ideation of any resident. The ED and DON will monitor for compliance daily by running an audit of the psychosocial assessments. Audits will be completed weekly for 3 months until 12/29/2023 and then monthly on an ongoing basis. Who will be responsible: Director of Nursing/Nurse Managers Who Will monitor: Executive Director/RDCS -Beginning 9/29/23, any resident who triggers an imminent risk of homicidal/suicidal ideation, will be placed on one-on-one supervision and will have notification to the staff caring for the resident, the attending physician, and psychiatric services referral will be made by the nurse manager and monitored by clinical staff. -ED will call family, police and notify physician to confirm notification of resident homicidal/suicidal ideation. -ED will implement the abuse/neglect policy immediately. -Any staff that is aware of a resident with homicidal/suicidal ideation will immediately inform the ED. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675338 If continuation sheet Page 4 of 29 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 10/05/2023 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 0580 Level of Harm - Immediate jeopardy to resident health or safety -ED will notify HHSC of a homicidal/suicidal resident incident according to reporting protocols and following the abuse/neglect prohibition protocol. Who will be responsible: Director of Nursing/Nurse Managers Who Will monitor: Executive Director/RDCS Residents Affected - Few All staff were educated to notify the Executive Director, DON or RDCS immediately upon verbalization of a resident wanting to harm someone or themselves. This education was provided on 9/29/2023. This education was provided by the Executive Director, DON and RDCS. Staff will not be allowed to begin their shift until the education has been completed. Until alternative and or safe living arrangements are made the resident will be placed on one-on-one supervision with facility staff. Resident care plans will also be updated to include any verbalizations of wanting to harm others including homicidal/suicidal ideations. The ED and/or RDCS will monitor weekly for compliance by completing an audit of the psychosocial assessments. Audits will be completed weekly for 3 months until 12/29/2023 and then monthly on an ongoing basis. Who will be responsible: Director of Nursing/Nurse Managers Who Will monitor: Executive Director/RDCS 2. In-Services All staff were in-serviced on resident homicidal/suicidal ideation and the abuse/neglect policy by the ED/RDCS/Director of Nursing and/or Nurse Managers. All new staff will receive the education as part of the onboarding orientation process prior to being assigned and providing care to residents. No staff member will be allowed to work in the facility until the above required in-services are completed. The in-service with all staff will be completed by 9/29/2023. All staff were in-serviced by 8:00 PM on 9/29/2023. Who will be responsible: DON/Nurse Managers Who Will monitor: Executive Director/RDCS Shift to Shift reporting process will be as follows: -As part of shift to shift report the charge nurse will notify the oncoming nurse of the one-on-one and homicidal/suicidal ideation. All nurses and CNAs will be in-serviced on the shift-to-shift report process by the Executive Director, Director of Nursing or Assistant Director of Nursing by 9/30/23 at 8:00 a.m. Who will be responsible: DON/Nurse Managers Who Will monitor: Executive Director/RDCS Each employee completed a post-test after their education was completed to ensure staff were able to identify abuse/neglect and reporting requirements. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675338 If continuation sheet Page 5 of 29 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 10/05/2023 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 0580 If the employee did not pass the test with at least 90% correctly answered the staff member was re-educated and re-tested until at least 90% pass rate was met. Level of Harm - Immediate jeopardy to resident health or safety A staff roster was utilized to ensure 100% of licensed nursing staff were in-serviced and tested. Residents Affected - Few In-services were deemed to be effective by the in-services post-test scores and verbalization of understanding by all facility staff (clinical, non-clinical and ancillary). All nurses, Executive Director and nurse managers were in-serviced on abuse and neglect on 9/29/23 by 8:00 PM. The Executive Director, DON and ADON were in-serviced by the RDCS on 9/29/23 by 4:00 PM. Who will be responsible: DON/Nurse Managers Who Will monitor: Executive Director/RDCS 3. Monitoring Starting 9/29/23 the Executive Director, Director of nursing and/or Nurse Managers will review all psychosocial assessments for any psychosocial needs including homicidal/suicidal ideation. The Regional Director of Clinical Services will review the documentation each week for compliance and will review any needs for reporting allegations to the state agency. Monitoring of the POR included the following: During interviews on 09/30/23 from 1:00 p.m. through 4:00 p.m. with LVN A 10 p.m. - 6 a.m., RN S (weekend shifts) CNA Q (6 a.m. -6 p.m.), LVN R (prn all shifts), CNA T (all shifts), LVN U 2 p.m. -10 p.m., LVN W 10 p.m. -6 a.m., LVN X 6 a.m. - 2 p.m., LVN Y 6 a.m. 2 p.m., CNA D 6 p.m.-6 a.m. and the ADON indicated staff were able to identify the Abuse Coordinator as the administrator. Staff indicated they were to report allegations of abuse and neglect immediately to the charge nurse or administrator and were able to give example of physical, verbal, sexual abuse, and immediate intervention procedures. All staff indicated they were educated to notify the Executive Director, DON or RDCS immediately if a resident threatened to harm someone or themselves. All staff indicated they would ensure any resident who threatened harm to themselves or others would be placed on 1-1 until cleared by their physician. They indicated resident care plans would be reviewed and updated to include any verbalizations of wanting to harm others which included homicidal/suicidal ideations. All staff indicated they were trained on resident homicidal/suicidal ideation and the abuse/neglect policy. They were able to give examples of appropriate actions to take in different situations involving abuse or threats of harm. The ADON and LVNs indicated they were to notify the physician of resident's change of condition and were able to give examples. During an interview on 09/30/23 at 3:45 p.m., the Administrator said she was in-serviced on 09/29/23 by the RDCS. She was able to verbalize the facility abuse, and neglect policy and they would conduct a thorough investigation of all incidents of resident threats of self harm or harm to others. She understood she was required to report incidents according to regulatory compliance, and reporting incidents of abuse or neglect that result in serious bodily injury/death. She said the physician would be notified immediately of any homicidal ideation of any resident. She and the DON would monitor (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675338 If continuation sheet Page 6 of 29 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 10/05/2023 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 0580 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few for compliance daily by running an audit of the psychosocial assessments. She said this would be completed weekly for 3 months until 12/29/23 and then monthly on an ongoing basis. She said she and the DON would review the facility 24 Hour Report and Incident Reports in the morning clinical for any allegation or instances of abuse and/or neglect and physician notification. During an interview on 09/30/23 at 4:00 p.m., the DON said she was in-serviced on 09/29/23 by the RDCS. She was able to verbalize the facility abuse, and neglect policy and they would conduct a thorough investigation of all incidents of resident threats of self harm or harm to others. She understood she was required to report incidents according to regulatory compliance, and reporting incidents of abuse or neglect that resulted in serious bodily injury/death. The DON and Administrator would monitor for compliance daily by running an audit of the psychosocial assessments. The DON and Administrator would review the facility 24 Hour Report and Incident Reports in the morning clinical for any allegation or instances of abuse and/or neglect and physician notification. She said this would be completed weekly for 3 months until 12/29/23 and then monthly on an ongoing basis. Record review of all incidents from the previous 90 days indicated there were no additional incidents of threats of self harm or harm to others as of 09/30/23. Record review of resident abuse questionnaire, dated 09/29/23, indicated no residents were identified as reporting any abuse or being afraid of any residents or staff. Record review of training records indicated all staff (nursing and non-nursing) were in-serviced on 09/29/23 regarding the facility abuse and neglect policy, the procedure for reporting incidents of threats of harm with serious harm and/or death, suspected abuse/neglect, recognizing threats of harm (to self and others), and physician notification. Record review of quiz results, dated 09/29/23 and 09/30/23, indicated all staff passed the quiz regarding abuse, neglect, reporting, suicide threats, managing suicide ideations, comprehensive care plans, and physician notification. The Administrator and the DON were informed the Immediate Jeopardy was removed on 09/30/23 at 4:10 p.m. The facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm and with a scope identified as isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675338 If continuation sheet Page 7 of 29 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 10/05/2023 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 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to develop and implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property for 1 of 10 residents (Resident #1) reviewed for abuse and neglect. Residents Affected - Few 1. The facility failed to place Resident #1 on 1-1 or move him to a private room after he threatened to shoot or stab someone. 2. The facility failed to implement their abuse policy when they failed to report allegations of abuse. An Immediate Jeopardy (IJ) situation was identified on 09/29/23 at 3:22 p.m. While the IJ was removed on 09/30/23 at 4:10 p.m., the facility remained out of compliance at a scope of isolated with a potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk of abuse, physical harm, mental anguish, and emotional distress. Findings include: Record review of Resident #1's face sheet, dated 09/27/23, indicated a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), cerebral infarction (stroke), metabolic encephalopathy (an alteration in consciousness caused due to brain dysfunction), major depressive disorder (persistent feeling of sadness and loss of interest ), impulsiveness (tendency to act without thinking), and anxiety (a feeling of fear, dread, and uneasiness.) Record review of an MDS assessment, dated 09/15/23, indicated Resident #1 was usually able to make himself understood and understand others, had severe cognitive impairment, indicated by a BIMS score of 7. He had verbal behavior directed at others every 1-3 days. His behaviors were worse. He was mobile with a cane or wheelchair. Record review of Resident #1's care plan, dated 04/18/22, indicated Resident #1 had a neurocognitive disorder without behavioral disturbance (dementia). Interventions included remove Resident #1 from settings that seem to upset or exacerbate behaviors and psychiatric consult as ordered. Record review of Resident #1's care plan, dated 04/18/22, indicted Resident #1 had a history of behavioral symptoms of impulsiveness and temper outbursts. Interventions included remove from situation and allow time to calm down. Record review of Resident #1's care plan, dated 06/20/23, indicated Resident #1 had a verbal behavioral symptom directed at others such as urinating on the bed, being naked in the hallways and cussing at others. Interventions included respond in a calm voice, maintain eye contact. Remove from area if Resident #1 was abusive to others. Record review of Resident #1's clinical record revealed there were no care plans available for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675338 If continuation sheet Page 8 of 29 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 10/05/2023 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 0607 review related to homicidal ideations. Level of Harm - Immediate jeopardy to resident health or safety Record review of a clinical note dated 09/14/23 at 4:02 a.m., and completed by LVN A, indicated LVN A was walking down the hallway when she overheard Resident #1 tell CNA B I want to kill somebody so that I can go back to prison. I want to shoot or stab someone, probably both. The DON and administrator were notified. Q-15 minute monitoring set up for Resident #1. Resident #1 was lying in bed watching TV, no s/s of distress or mental status. Resident #1 appeared calm. Will continue to monitor Resident #1 and inform oncoming shift of behavior. There was no documentation of physician notification. Residents Affected - Few Record review of a progress note, dated 09/18/23, completed by APRN L, indicated she spoke with the nurse (the nurse was not identified) and the nurse indicated Resident #1 was being monitored after stating he wanted to stab his roommate. Resident #1 was lying in bed without acute distress. Resident #1 stated I don't want to hurt anyone. I just want to get out of here. I don't want to be here. Resident #1 said he did not have a plan to harm himself or anyone else. Resident #1 was in a pleasant mood without s/s of distress/anxiety/depression. Order given to refer for psychiatric services to evaluate Resident #1 for possible adjustment to medications. Resident #1 did not appear to be a harm to himself or anyone else. Record review of a psychiatric assessment, completed on 09/21/23 by FNP N, indicated Resident #1 was assessed due to agitation and expressing he wanted to hurt someone. Resident #1 refused to engage. Staff indicated Resident #1 was more agitated and said he wanted a knife to stab someone and to go back to prison. Resident #1 was uncooperative with exam. Revisit in two weeks. Record review of a progress note, dated 09/25/23 completed by APRN L, indicated Resident #1 was lying in bed without acute distress. He was easy to wake. He said he did not want to hurt anyone. He wanted to get out of the facility. He did not want to be in the facility. He was instructed he could not make threats against others and verbalized understanding. He had no behaviors since last visit. Record review of clinical note, dated 09/26/23 at 9:21 a.m. and completed by ADON C, indicated RP was notified regarding homicidal intentions and MD suggestions of sending to the behavioral hospital to adjust medication and any possible treatment needed., RP agreed. Referral sent to behavior hospital. Record review of progress note, dated 09/26/23 at 10:31 p.m., completed by APRN L, indicated (late entry) spoke with nurse and Resident #1 was being monitored after stating he wanted to stab his roommate. Resident #1 was lying in bed without acute distress. Resident #1 stated I don't want to hurt anyone. I just want to get out of here. I don't want to be here. Resident #1 said he did not have a plan to harm himself or anyone else. Resident #1 was in a pleasant mood without s/s of distress/anxiety/depression. Order given to refer for psychiatric services to evaluate Resident #1 for possible adjustment to medications. Resident #1 did not appear to be a harm to himself or anyone else. Record review of Q-15 minute monitoring sheets indicated monitoring was completed from 09/14/23 through 09/26/23. Resident #1 was placed on 1-1 after the State Surveyor intervention (until Resident #1 was transferred to behavior hospital on [DATE]). During an observation on 09/26/23 at 4:50 a.m., Resident #1 was lying in bed watching TV in his room. Resident #1's roommate was asleep. Staff were assisting other residents with ADLS. There was no 1-1 staff or sitter observed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675338 If continuation sheet Page 9 of 29 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 10/05/2023 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 0607 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few During an interview on 09/26/23 at 4:55 a.m., LVN A said Resident #1 was on frequent monitoring with Q15 minute checks due to threats of harm to others. She said she overheard Resident #1 tell CNA B he wanted to kill someone, to shoot or stab them so he could go back to prison. She said she notified the DON and the Administrator immediately. She said she did not notify the physician. She said she was not aware of Resident #1 making any previous threats to harm others. During an interview on 09/29/23 at 9:29 a.m., the DON said she was notified by LVN A of Resident #1's threat to shoot or stab someone. She said she did not remove him from the room or move his roommate because Resident #1 did not specify anyone he wanted to harm. She said he did not have an active plan. She said the room was not searched for a gun or a knife. The DON said Resident #1 was mobile with a wheelchair. She said Resident #1 was placed on q15 minute checks after he made a threat to shoot or stab someone. She said he was not placed on 1-1. She said she did not remove him from the room or move his roommate because Resident #1 did not specify anyone he wanted to harm. She said he did not have an active plan. She said she did not call the police. She said she did not report the incident to the State Survey Agency. She did not know Resident #1 threatening to harm others was a reportable event. She said she was trained on abuse and neglect. She said she did not think of reporting Resident #1's threat to harm others. She said other residents and staff were at risk of harm due to Resident #1's threat. During an interview on 09/29/23 at 10:00 a.m., the Administrator indicated she was not made aware of Resident #1's threats to harm others on 09/14/23. She said she was off due to her husband having surgery. She said Resident #1 was not placed on 1-1 and could have harmed his roommate or others. She said the DON was the designee and responsible to ensure polices were followed. She said she would have placed Resident #1 on 1-1 until cleared by psychiatric services. She said she would have moved Resident #1 or his roommate. She said she was not aware the incident was a reportable incident. She said she reported the incident to the State Survey Agency after the State Surveyor questioned the clinical note. She said the police should have been notified. She said she did a counseling and coaching with the DON and LVN A. She said she notified MD K and completed an emergency QAPI. She said staff were inserviced on 09/26/23. During an interview on 09/29/23 at 2:41 p.m., FNP N said she assessed Resident #1 on 09/21/23. She said he was not cooperative with the assessment. She said he made a threat to hurt someone with a knife so he could go to prison. She said she would have recommended Resident #1 be sent out to a behavioral unit if he was a threat. During an interview on 10/05/23 at 2:19 p.m., ADON C said Resident #1 should have been on 1-1 and put in a private room after he made threats to hurt others. She said psychiatric should have been contacted to assess Resident #1. She said Resident #1's threat to harm others was noted on the 24 hour report and would have been reviewed during the morning meeting. She said she did not recall if it was reviewed. Record review of the facility's Abuse Protocol, dated April 2019, indicated . 10. The abuse Prevention Coordinator will: a. Immediately (within 2 hours) report to (state agency) and other appropriate authorities incidents of Patient Abuse . Record review of the facility's Suicide Threats policy, dated 2001 (revised December 2007), indicated Resident suicide threats shall be taken seriously and addressed appropriately. 1. Staff shall report any resident threats of suicide immediately to the Nurse Supervisor /Charge Nurse. 2. The Nurse Supervisor /Charge Nurse shall immediately assess the situation and shall notify the Charge (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675338 If continuation sheet Page 10 of 29 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 10/05/2023 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 0607 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Nurse/Supervisor and /or Director of Nursing Services of such threats. 3. A staff member shall remain with the resident until the Nurse Supervisor/Charge Nurse arrives to evaluate the resident. 4. After assessing the resident in more detail, the Nurse Supervisor/Charge Nurse shall notify the resident's Attending Physician and responsible party, and shall seek further direction from the physician. 5. All nursing personnel and other staff involved in caring for the resident shall be informed of the suicide threat and instructed to report changes in the resident's behavior immediately. 6. As indicated, a psychiatric consultation or transfer for emergency psychiatric evaluation may be initiated. 7. If the resident remains in the facility, staff will monitor the resident's mood and behavior and update care plans accordingly , until a physician has determined that a risk of suicide does not appear to be present. 8. Staff shall document details of the situation objectively in the resident's medical record. This was determined to be an Immediate Jeopardy (IJ) on 09/29/23 at 3:22 p.m. The Administrator was notified. The Administrator was provided with the IJ template on 09/29/22 at 3:44 p.m. The following Plan of Removal submitted by the facility was accepted on 09/29/23 at 4:10 p.m. Immediate Action: Systematic Approach: 1. Assessment - Resident #1 with homicidal ideation on 9/14/23 was placed on one-on-one on 9/26/23 at 9:02 AM until he was discharged to a Behavioral hospital on 9/27/23 at 2:00 PM.-The Executive Director notified the facility Medical Director of the Immediate Jeopardy on 09/29/22 at 4:20 PM. -An emergency QAPI meeting was held on 9/26/2023. -All residents will have a psychosocial assessment updated by the Director of Nurses, Assistant Director of Nurses and/or Patient Care Coordinator on 9/29/2023 to identify any current patients that are at imminent risk homicidal/suicidal ideation. The psychosocial assessments were completed on 9/29/23 by 6:00 PM. After completion of psychosocial assessments, no other residents were found to be at imminent risk of homicidal/suicidal ideation. The assessment includes the following information: The assessment is to determine if a resident is an imminent/suicidal risk for psychiatric needs. Who will be responsible: Director of Nursing/Nurse Managers Who Will monitor: Executive Director and RDCS -Beginning 9/29/2023, psychosocial assessments will be completed upon admission, condition change, and quarterly by the charge nurse and/or nurse managers, and for any resident that triggers an imminent risk for homicidal/suicidal ideation, the facility will initiate one-on-one supervision until further direction is provided. The abuse/neglect policy will be implemented immediately. The physician will be notified immediately of any homicidal ideation of any resident. The ED and DON will monitor (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675338 If continuation sheet Page 11 of 29 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 10/05/2023 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 0607 Level of Harm - Immediate jeopardy to resident health or safety for compliance daily by running an audit of the psychosocial assessments. Audits will be completed weekly for 3 months until 12/29/2023 and then monthly on an ongoing basis. Who will be responsible: Director of Nursing/Nurse Managers Who Will monitor: Executive Director/RDCS Residents Affected - Few -Beginning 9/29/23, any resident who triggers an imminent risk of homicidal/suicidal ideation, will be placed on one-on-one supervision and will have notification to the staff caring for the resident, the attending physician, and psychiatric services referral will be made by the nurse manager and monitored by clinical staff. -ED will call family, police and notify physician to confirm notification of resident homicidal/suicidal ideation. -ED will implement the abuse/neglect policy immediately. -Any staff that is aware of a resident with homicidal/suicidal ideation will immediately inform the ED. -ED will notify HHSC of a homicidal/suicidal resident incident according to reporting protocols and following the abuse/neglect prohibition protocol. Who will be responsible: Director of Nursing/Nurse Managers Who Will monitor: Executive Director/RDCS All staff were educated to notify the Executive Director, DON or RDCS immediately upon verbalization of a resident wanting to harm someone or themselves. This education was provided on 9/29/2023. This education was provided by the Executive Director, DON and RDCS. Staff will not be allowed to begin their shift until the education has been completed. Until alternative and or safe living arrangements are made the resident will be placed on one-on-one supervision with facility staff. Resident care plans will also be updated to include any verbalizations of wanting to harm others including homicidal/suicidal ideations. The ED and/or RDCS will monitor weekly for compliance by completing an audit of the psychosocial assessments. Audits will be completed weekly for 3 months until 12/29/2023 and then monthly on an ongoing basis. Who will be responsible: Director of Nursing/Nurse Managers Who Will monitor: Executive Director/RDCS 2. In-Services All staff were in-serviced on resident homicidal/suicidal ideation and the abuse/neglect policy by the ED/RDCS/Director of Nursing and/or Nurse Managers. All new staff will receive the education as part of the onboarding orientation process prior to being assigned and providing care to residents. No staff member will be allowed to work in the facility until the above required in-services are completed. The in-service with all staff will be completed by 9/29/2023. All staff were in-serviced by (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675338 If continuation sheet Page 12 of 29 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 10/05/2023 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 0607 8:00 PM on 9/29/2023. Level of Harm - Immediate jeopardy to resident health or safety Who will be responsible: DON/Nurse Managers Residents Affected - Few Shift to Shift reporting process will be as follows: Who Will monitor: Executive Director/RDCS -As part of shift to shift report the charge nurse will notify the oncoming nurse of the one-on-one and homicidal/suicidal ideation. All nurses and CNAs will be in-serviced on the shift-to-shift report process by the Executive Director, Director of Nursing or Assistant Director of Nursing by 9/30/23 at 8:00 a.m. Who will be responsible: DON/Nurse Managers Who Will monitor: Executive Director/RDCS Each employee completed a post-test after their education was completed to ensure staff were able to identify abuse/neglect and reporting requirements. If the employee did not pass the test with at least 90% correctly answered the staff member was re-educated and re-tested until at least 90% pass rate was met. A staff roster was utilized to ensure 100% of licensed nursing staff were in-serviced and tested. In-services were deemed to be effective by the in-services post-test scores and verbalization of understanding by all facility staff (clinical, non-clinical and ancillary). All nurses, Executive Director and nurse managers were in-serviced on abuse and neglect on 9/29/23 by 8:00 PM. The Executive Director, DON and ADON were in-serviced by the RDCS on 9/29/23 by 4:00 PM. Who will be responsible: DON/Nurse Managers Who Will monitor: Executive Director/RDCS 3. Monitoring Starting 9/29/23 the Executive Director, Director of nursing and/or Nurse Managers will review all psychosocial assessments for any psychosocial needs including homicidal/suicidal ideation. The Regional Director of Clinical Services will review the documentation each week for compliance and will review any needs for reporting allegations to the state agency. Monitoring of the POR included the following: During interviews on 09/30/23 from 1:00 p.m. through 4:00 p.m. with LVN A 10 p.m. - 6 a.m., RN S (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675338 If continuation sheet Page 13 of 29 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 10/05/2023 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 0607 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few (weekend shifts) CNA Q 6 a.m. -6 p.m.), LVN R (prn all shifts), CNA T (all shifts), LVN U 2 p.m. -10 p.m., LVN W 10 p.m. -6 a.m., LVN X 6 a.m. - 2 p.m., LVN Y 6 a.m. 2 p.m., CNA D 6 p.m.-6 a.m. and the ADON indicated staff were able to identify the Abuse Coordinator as the administrator. Staff indicated they were to report allegations of abuse and neglect immediately to the charge nurse or administrator and were able to give example of physical, verbal, sexual abuse, and immediate intervention procedures. All staff indicated they were educated to notify the Executive Director, DON or RDCS immediately if a resident threatened to harm someone or themselves. All staff indicated they would ensure any resident who threatened harm to themselves or others would be placed on 1-1 until cleared by their physician. They indicated resident care plans would be reviewed and updated to include any verbalizations of wanting to harm others which included homicidal/suicidal ideations. All staff indicated they were trained on resident homicidal/suicidal ideation and the abuse/neglect policy. They were able to give examples of appropriate actions to take in different situations involving abuse or threats of harm. The ADON and LVNs indicated they were to notify the physician of resident's change of condition and were able to give examples. Interviews conducted with three alert residents on 09/30/23 from 1:00 p.m. through 4:00 p.m. indicated they would report abuse to the administrator or the DON. They were not afraid of any residents. During an interview on 09/30/23 at 3:45 p.m., the Administrator said she was in-serviced on 09/29/23 by the RDCS. She was able to verbalize the facility abuse, and neglect policy and they would conduct a thorough investigation of all incidents of resident threats of self harm or harm to others. She understood she was required to report incidents according to regulatory compliance, and reporting incidents of abuse or neglect that result in serious bodily injury/death. She said the physician would be notified immediately of any homicidal ideation of any resident. She and the DON would monitor for compliance daily by running an audit of the psychosocial assessments. She said this would be completed weekly for 3 months until 12/29/23 and then monthly on an ongoing basis. She said she and the DON would review the facility 24 Hour Report and Incident Reports in the morning clinical for any allegation or instances of abuse and/or neglect and physician notification. During an interview on 09/30/23 at 4:00 p.m., the DON said she was in-serviced on 09/29/23 by the RDCS. She was able to verbalize the facility abuse, and neglect policy and they would conduct a thorough investigation of all incidents of resident threats of self harm or harm to others. She understood she was required to report incidents according to regulatory compliance, and reporting incidents of abuse or neglect that resulted in serious bodily injury/death. The DON and Administrator would monitor for compliance daily by running an audit of the psychosocial assessments. The DON and Administrator would review the facility 24 Hour Report and Incident Reports in the morning clinical for any allegation or instances of abuse and/or neglect and physician notification. She said this would be completed weekly for 3 months until 12/29/23 and then monthly on an ongoing basis. Record review of all incidents from the previous 90 days indicated there were no additional incidents of threats of self harm or harm to others as of 09/30/23. Record review of resident abuse questionnaire, dated 09/29/23, indicated no residents were identified as reporting any abuse or being afraid of any residents or staff. Record review of training records indicated all staff (nursing and non-nursing) were in-serviced on 09/29/23 regarding the facility abuse and neglect policy, the procedure for reporting incidents of threats of harm with serious harm and/or death, suspected abuse/neglect, recognizing threats of harm (to self and others), and physician notification. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675338 If continuation sheet Page 14 of 29 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 10/05/2023 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 0607 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Record review of quiz results, dated 09/29/23 and 09/30/23, indicated all staff passed the quiz regarding abuse, neglect, reporting, suicide threats, managing suicide ideations, comprehensive care plans, and physician notification. The Administrator and the DON were informed the Immediate Jeopardy was removed on 09/30/23 at 4:10 p.m. The facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm and with a scope identified as isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. Event ID: Facility ID: 675338 If continuation sheet Page 15 of 29 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 10/05/2023 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure all alleged violations involving abuse, neglect, exploitation or mistreatment, which included injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, to the administrator of the facility and to other officials, including the State Survey Agency, in accordance with State law through established procedures for 1 of 10 residents (Resident #1) reviewed for abuse and neglect. The facility failed to ensure the abuse coordinator and/or designee reported immediately to HHSC after Resident #1 threatened to shoot or stab someone. This failure could place residents at risk of abuse, physical harm, mental anguish, and emotional distress. Findings include: Record review of Resident #1's face sheet, dated 09/27/23, indicated a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), cerebral infarction (stroke), metabolic encephalopathy (an alteration in consciousness caused due to brain dysfunction), major depressive disorder (persistent feeling of sadness and loss of interest ), impulsiveness (tendency to act without thinking), and anxiety (a feeling of fear, dread, and uneasiness.) Record review of an MDS assessment, dated 09/15/23, indicated Resident #1 was usually able to make himself understood and understand others, had severe cognitive impairment, indicated by a BIMS score of 7. He had verbal behavior directed at others every 1-3 days. His behaviors were worse. He was mobile with a cane or wheelchair. Record review of Resident #1's care plan, dated 04/18/22, indicated Resident #1 had a neurocognitive disorder without behavioral disturbance (dementia). Interventions included remove Resident #1 from settings that seem to upset or exacerbate behaviors and psychiatric consult as ordered. Record review of Resident #1's care plan, dated 04/18/22, indicted Resident #1 had a history of behavioral symptoms of impulsiveness and temper outbursts. Interventions included remove from situation and all time to calm down. Record review of Resident #1's care plan, dated 06/20/23, indicated Resident #1 had a verbal behavioral symptom directed at others such as urinating on the bed, being naked in the hallways and cussing at others. Interventions included respond in a calm voice, maintain eye contact. Remove from area if Resident #1 was abusive to others. Record review of Resident #1's clinical record revealed there were no care plans available for review related to homicidal ideations. Record review of a clinical note dated 09/14/23 at 4:02 a.m., and completed by LVN A, indicated LVN (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675338 If continuation sheet Page 16 of 29 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 10/05/2023 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 Level of Harm - Minimal harm or potential for actual harm A was walking down the hallway when she overheard Resident #1 tell CNA B I want to kill somebody so that I can go back to prison. I want to shoot or stab someone, probably both. The DON and administrator were notified. Q-15 minute monitoring set up for Resident #1. Resident #1 was lying in bed watching TV, no s/s of distress or mental status. Resident #1 appeared calm. Will continue to monitor Resident #1 and inform oncoming shift of behavior. There was no documentation of physician notification. Residents Affected - Few Record review of a progress note, dated 09/18/23, completed by APRN L, indicated she spoke with the nurse and the nurse indicated Resident #1 was being monitored after stating he wanted to stab his roommate. Resident #1 was lying in bed without acute distress. Resident #1 stated I don't want to hurt anyone. I just want to get out of here. I don't want to be here. Resident #1 said he did not have a plan to harm himself or anyone else. Resident #1 was in a pleasant mood without s/s of distress/anxiety/depression. Order given to refer for psychiatric services to evaluate Resident #1 for possible adjustment to medications. Resident #1 did not appear to be a harm to himself or anyone else. Record review of a psychiatric assessment, completed on 09/21/23 by FNP N, indicated Resident #1 was assessed due to agitation and expressing he wanted to hurt someone. Resident #1 refused to engage. Staff indicated Resident #1 was more agitated and said he wanted a knife to stab someone and to go back to prison. Resident #1 was uncooperative with exam. Revisit in two weeks. Record review of a progress note, dated 09/25/23 completed by APRN L, indicated Resident #1 was lying in bed without acute distress. He was easy to wake. He said he did not want to hurt anyone. He wanted to get out of the facility. He did not want to be in the facility. He was instructed he could not make threats against others and verbalized understanding. He had no behaviors since last visit. Record review of clinical note, dated 09/26/23 at 9:21 a.m. and completed by ADON C, indicated RP was notified regarding homicidal intentions and MD suggestions of sending to the behavioral hospital to adjust medication and any possible treatment needed., RP agreed. Referral sent to behavior hospital. Record review of progress note, dated 09/26/23 at 10:31 p.m., completed by APRN L, indicated (late entry) spoke with nurse and Resident #1 was being monitored after stating he wanted to stab his roommate. Resident #1 was lying in bed without acute distress. Resident #1 stated I don't want to hurt anyone. I just want to get out of here. I don't want to be here. Resident #1 said he did not have a plan to harm himself or anyone else. Resident #1 was in a pleasant mood without s/s of distress/anxiety/depression. Order given to refer for psychiatric services to evaluate Resident #1 for possible adjustment to medications. Resident #1 did not appear to be a harm to himself or anyone else. Record review of Q-15 minute monitoring sheets indicated monitoring was completed from 09/14/23 through 09/26/23. Resident #1 was placed on 1-1 after the State Surveyor intervention (until Resident #1 was transferred to behavior hospital on [DATE]). During an observation on 09/26/23 at 4:50 a.m., Resident #1 was lying in bed watching TV in his room. Resident #1's roommate was asleep. Staff were assisting other residents with ADLS. During an interview on 09/26/23 at 4:55 a.m., LVN A said Resident #1 was on frequent monitoring with Q15 minute checks due to threats of harm to others. She said she overheard Resident #1 tell CNA B he wanted to kill someone, to shoot or stab them so he could go back to prison. She said she notified the DON and the administrator immediately. She said she did not notify the physician. She said she (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675338 If continuation sheet Page 17 of 29 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 10/05/2023 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 was not aware of Resident #1 making any previous threats to harm others. Level of Harm - Minimal harm or potential for actual harm During an interview on 09/29/23 at 9:29 a.m., the DON said she was notified by LVN A of Resident #1's threat to shoot or stab someone. She did not know Resident #1 threatening to harm others was a reportable event. She said she was trained on abuse and neglect. She said she did not think of reporting Resident #1's threat to harm others. She said other residents and staff were at risk of harm due to Resident #1's threat. Residents Affected - Few During an interview on 09/29/23 at 10:00 a.m., the Administrator indicated she was not made aware of Resident #1's threats to harm others on 09/14/23. She said she was off due to her husband having surgery. She said she was not aware the incident was a reportable incident. She said she reported the incident to the State Survey Agency on 09/26/23 after the State Surveyor questioned the clinical note. She said the police should have been notified. She said she did a counseling and coaching with the DON and LVN A. She said she notified MD K and completed an emergency QAPI. She said staff were in-serviced on 09/26/23. During an interview on 09/29/23 at 1:56 p.m., APRN L said she completed scheduled rounds in the facility on 09/21/23 and LVN A informed her of Resident #1's threat to harm his roommate. She said Resident #1 indicated he had no plan and no intention. She said she was not aware of any prior threats. APRN L said staff would continue to monitor Resident #1 until he was seen by psychiatric services. During an interview on 09/29/23 at 2:41 p.m., FNP N said she assessed Resident #1 on 09/21/23. She said he was not cooperative with the assessment. She said he made a threat to hurt someone with a knife so he could go to prison. She said she would have recommended Resident #1 be sent out to a behavioral unit if he was a threat. During an interview on 10/05/23 at 2:19 p.m., ADON C said she was not aware the incident was reportable to the State Survey Agency. She said she was trained on abuse prevention and reporting. Record review of the facility's Abuse Protocol, dated April 2019, indicated . 10. The abuse Prevention Coordinator will: a. Immediately (within 2 hours) report to (state agency) and other appropriate authorities incidents of Patient Abuse . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675338 If continuation sheet Page 18 of 29 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 10/05/2023 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 each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 10 residents (Resident #1) reviewed for care plans. The facility failed to ensure Resident #1's care plan included supervision and interventions after he made threats of harm to others. This failure could place residents at risk of accidents, injuries, and death due to lack of appropriate interventions in place. Findings included: Record review of a face sheet dated 09/27/23 indicated Resident #1 was a [AGE] year old male, admitted on [DATE], and his diagnoses included dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), cerebral infarction (stroke), metabolic encephalopathy (an alteration in consciousness caused due to brain dysfunction), major depressive disorder (persistent feeling of sadness and loss of interest ), impulsiveness (tendency to act without thinking), and anxiety (a feeling of fear, dread, and uneasiness). Record review of an MDS assessment dated [DATE] indicated Resident #1 was usually able to make himself understood and understand others, had severe cognitive impairment (BIMS score of 7). He had verbal behavior directed at others every 1-3 days. His behaviors were worse. He was mobile with a cane or wheelchair. Record review of a care plan dated 04/18/22 indicated Resident #1 had a neurocognitive disorder without behavioral disturbance (dementia). Interventions included remove Resident #1 from settings that seem to upset or exacerbate behaviors and psychiatric consult as ordered. Record review of a care plan dated 04/18/22 indicted Resident #1 had a history of behavioral symptoms of impulsiveness and temper outbursts. Interventions include remove from situation and all time to calm down. Record review of a care plan dated 06/20/23 indicated Resident #1 had a verbal behavioral symptoms directed at others such as urinating on the bed, being naked in the hallways and cussing at others. Interventions included respond in a calm voice, maintain eye contact. Remove from area if Resident #1 is abusive to others. There was no care plan available for review related to homicide ideations. Record review of a clinical note dated 09/14/23 at 4:02 a.m. and completed by LVN A, indicated LVN A was walking down the hallway when she overheard Resident #1 tell CNA B I want to kill somebody so that I can go back to prison. I want to shoot or stab someone, probably both. The DON and administrator were notified. Q-15 minute monitoring set up for Resident #1. Resident #1 was lying in bed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675338 If continuation sheet Page 19 of 29 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 10/05/2023 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 watching TV, no s/s of distress or mental status. Resident #1 appeared calm. Will continue to monitor Resident #1 and inform oncoming shift of behavior. There was no documentation of physician notification. Record review of a progress note dated 09/18/23 completed by APRN L indicated she spoke with the nurse and the nurse indicated Resident #1 was being monitored after stating he wanted to stab his roommate. Resident #1 was lying in bed without acute distress. Resident #1 stated I don't want to hurt anyone. I just want to get out of here. I don't want to be here. Resident #1 said he did not have a plan to harm himself or anyone else. Resident #1 was in a pleasant mood without s/s of distress/anxiety/depression. Order given to refer for psychiatric services to evaluate Resident #1 for possible adjustment to medications. Resident #1 does not appear to be a harm to himself or anyone else. Record review of a psychiatric assessment completed on 09/21/23 by FNP N indicated Resident #1 was assessed due to agitation and expressing he wanted to hurt someone. Resident #1 refused to engage. Staff indicated Resident #1 was more agitated and said he wanted a knife to stab someone and go back to prison. Resident #1 was uncooperative with exam. Revisit in two weeks. Record review of a progress note, dated 09/25/23 completed by APRN L, indicated Resident #1 was lying in bed without acute distress. He was easy to wake. He said he did not want to hurt anyone. He wanted to get out of the facility. He did not want to be in the facility. He was instructed he could not make threats against others and verbalized understanding. He had no behaviors since last visit. Record review of clinical note dated 09/26/23 at 9:21 a.m. and completed by ADON C indicated RP was notified regarding homicidal intentions and MD suggestions of sending to behavioral hospital to adjust medication and any possible treatment needed., RP agreed. Referral sent to behavior hospital. Record review of progress note dated 09/26/23 at 10:31 p.m., completed by APRN L indicated (late entry) spoke with nurse and Resident #1 was being monitored after stating he wanted to stab his roommate. Resident #1 was lying in bed without acute distress. Resident #1 stated I don't want to hurt anyone. I just want to get out of here. I don't want to be here. Resident #1 said he did not have a plan to harm himself or anyone else. Resident #1 was in a pleasant mood without s/s of distress/anxiety/depression. Order give to refer for psychiatric services to evaluate Resident #1 for possible adjustment to medications. Resident #1 does not appear to be a harm to himself or anyone else. Record review of Q-15 minute monitoring sheets indicated monitoring was completed from 09/14/23 through 09/26/23. Resident #1 was placed on 1-1 after the surveyor intervention (until Resident #1 was transferred to behavior hospital on [DATE]). The surveyor requested the incident report for 09/14/23. The administrator indicated there was no incident report completed for Resident #1's threat to harm others. During an observation on 09/26/23 at 4:50 a.m., Resident #1 was lying in bed watching TV in his room. Resident #1's roommate was asleep. Staff were assisting other residents with ADLS. During an interview on 09/26/23 at 4:55 a.m., LVN A said Resident #1 was on frequent monitoring with Q15 minute checks due to threats of harm to others. She said she overheard Resident #1 tell CNA B he wanted to kill someone, to shoot or stab them so he could go back to prison. She said she notified the DON and the administrator immediately. She said she did not notify the physician. She said she was not aware of Resident #1 making any previous threats to harm others. She said she was not aware (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675338 If continuation sheet Page 20 of 29 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 10/05/2023 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 of care plan interventions in place. Level of Harm - Minimal harm or potential for actual harm During an interview on 09/29/23 at 9:29 a.m., the DON said she was notified by LVN A of Resident #1's threat to shoot or stab someone. She said he was put on Q15 minute checks. She said she was not aware of care plan or interventions in place. Residents Affected - Few During an interview on 09/29/23 at 10:00 a.m., the administrator indicated she was not made aware of Resident #1's threats to harm others on 09/14/23. She said she was off due to her husband having surgery. She said there was no care plan or interventions in place to ensure resident safety . Record review of the facility's Comprehensive care plan policy, dated 2001 (revised September 2010), indicated An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident.2. The comprehensive care plan is based on a thorough assessment that includes, but is not limited to, the MDS. 3. Each resident's comprehensive care plan is designed to: a. Incorporate identified problem areas; b. Incorporate risk factors associated with identified problems; c. Build on the resident's strengths; d. Reflect the resident's expressed wishes regarding care and treatment goals; e. Reflect treatment goals, timetables and objectives in measurable outcomes; f. Identify the professional services that are responsible for each element of care; g. Aid in preventing or reducing declines in the resident's functional status and/or functional levels; h. Enhance the optimal functioning of the resident by focusing on a rehabilitative program; and i. Reflect currently recognized standards of practice for problem areas and conditions.9. The Care Planning/Interdisciplinary Team is responsible for the review and updating of care plans: a. When there has been a significant change in the resident's condition; . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675338 If continuation sheet Page 21 of 29 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 10/05/2023 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 - Immediate jeopardy to resident health or safety Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 10 residents (Resident #1) reviewed for accidents and supervision. The facility failed to place Resident #1 on 1-1 supervision or move him to a private room after he threatened he wanted to shoot or stab someone. An Immediate Jeopardy (IJ) situation was identified on 09/29/23 at 3:22 p.m. While the IJ was removed on 09/30/23 at 4:10 p.m., the facility remained out of compliance at a scope of isolated with the potential for more than minimal harm due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk of abuse, physical harm, mental anguish, and emotional distress. Findings included: Record review of Resident #1's face sheet, dated 09/27/23, indicated a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), cerebral infarction (stroke), metabolic encephalopathy (an alteration in consciousness caused due to brain dysfunction), major depressive disorder (persistent feeling of sadness and loss of interest ), impulsiveness (tendency to act without thinking), and anxiety (a feeling of fear, dread, and uneasiness.) Record review of an MDS assessment, dated 09/15/23, indicated Resident #1 was usually able to make himself understood and understand others, had severe cognitive impairment, indicated by a BIMS score of 7. He had verbal behavior directed at others every 1-3 days. His behaviors were worse. He was mobile with a cane or wheelchair. Record review of Resident #1's care plan, dated 04/18/22, indicated Resident #1 had a neurocognitive disorder without behavioral disturbance (dementia). Interventions included remove Resident #1 from settings that seem to upset or exacerbate behaviors and psychiatric consult as ordered. Record review of Resident #1's care plan, dated 04/18/22, indicted Resident #1 had a history of behavioral symptoms of impulsiveness and temper outbursts. Interventions included remove from situation and allow time to calm down. Record review of Resident #1's care plan, dated 06/20/23, indicated Resident #1 had a verbal behavioral symptom directed at others such as urinating on the bed, being naked in the hallways and cussing at others. Interventions included respond in a calm voice, maintain eye contact. Remove from area if Resident #1 was abusive to others. Record review of Resident #1's clinical record revealed there were no care plans available for review related to homicidal ideations. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675338 If continuation sheet Page 22 of 29 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 10/05/2023 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 - Immediate jeopardy to resident health or safety Record review of a clinical note dated 09/14/23 at 4:02 a.m., and completed by LVN A, indicated LVN A was walking down the hallway when she overheard Resident #1 tell CNA B I want to kill somebody so that I can go back to prison. I want to shoot or stab someone, probably both. The DON and administrator were notified. Q-15 minute monitoring set up for Resident #1. Resident #1 was lying in bed watching TV, no s/s of distress or mental status. Resident #1 appeared calm. Will continue to monitor Resident #1 and inform oncoming shift of behavior. There was no documentation of physician notification. Residents Affected - Few Record review of a progress note, dated 09/18/23, completed by APRN L, indicated she spoke with the nurse (the nurse was not identified) and the nurse indicated Resident #1 was being monitored after stating he wanted to stab his roommate. Resident #1 was lying in bed without acute distress. Resident #1 stated I don't want to hurt anyone. I just want to get out of here. I don't want to be here. Resident #1 said he did not have a plan to harm himself or anyone else. Resident #1 was in a pleasant mood without s/s of distress/anxiety/depression. Order given to refer for psychiatric services to evaluate Resident #1 for possible adjustment to medications. Resident #1 did not appear to be a harm to himself or anyone else. Record review of a psychiatric assessment, completed on 09/21/23 by FNP N, indicated Resident #1 was assessed due to agitation and expressing he wanted to hurt someone. Resident #1 refused to engage. Staff indicated Resident #1 was more agitated and said he wanted a knife to stab someone and to go back to prison. Resident #1 was uncooperative with exam. Revisit in two weeks. Record review of a progress note, dated 09/25/23 completed by APRN L, indicated Resident #1 was lying in bed without acute distress. He was easy to wake. He said he did not want to hurt anyone. He wanted to get out of the facility. He did not want to be in the facility. He was instructed he could not make threats against others and verbalized understanding. He had no behaviors since last visit. Record review of clinical note, dated 09/26/23 at 9:21 a.m. and completed by ADON C, indicated RP was notified regarding homicidal intentions and MD suggestions of sending to the behavioral hospital to adjust medication and any possible treatment needed., RP agreed. Referral sent to behavior hospital. Record review of progress note, dated 09/26/23 at 10:31 p.m., completed by APRN L, indicated (late entry) spoke with nurse and Resident #1 was being monitored after stating he wanted to stab his roommate. Resident #1 was lying in bed without acute distress. Resident #1 stated I don't want to hurt anyone. I just want to get out of here. I don't want to be here. Resident #1 said he did not have a plan to harm himself or anyone else. Resident #1 was in a pleasant mood without s/s of distress/anxiety/depression. Order given to refer for psychiatric services to evaluate Resident #1 for possible adjustment to medications. Resident #1 did not appear to be a harm to himself or anyone else. Record review of Q-15 minute monitoring sheets indicated monitoring was completed from 09/14/23 through 09/26/23. Resident #1 was placed on 1-1 after the State Surveyor intervention (until Resident #1 was transferred to behavior hospital on [DATE]). During an observation on 09/26/23 at 4:50 a.m., Resident #1 was lying in bed watching TV in his room. Resident #1's roommate was asleep. Staff were assisting other residents with ADLS. There was no 1-1 staff or sitter observed. During an interview on 09/26/23 at 4:55 a.m., LVN A said Resident #1 was on frequent monitoring (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675338 If continuation sheet Page 23 of 29 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 10/05/2023 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 - Immediate jeopardy to resident health or safety Residents Affected - Few with Q15 minute checks due to threats of harm to others. She said she overheard Resident #1 tell CNA B he wanted to kill someone, to shoot or stab them so he could go back to prison. She said she notified the DON and the Administrator immediately. She said she did not notify the physician. She said she was not aware of Resident #1 making any previous threats to harm others. During an interview on 09/29/23 at 9:29 a.m., the DON said she was notified by LVN A of Resident #1's threat to shoot or stab someone. She said she did not remove him from the room or move his roommate because Resident #1 did not specify anyone he wanted to harm. She said he did not have an active plan. She said the room was not searched for a gun or a knife. The DON said Resident #1 was mobile with a wheelchair. She said Resident #1 was placed on q15 minute checks. She said he was not placed on 1-1. She said she did not call the police. She said she did not report the incident to the state. She did not know Resident #1 threatening to harm others was a reportable event. She said she was trained on abuse and neglect. She said she did not think of reporting Resident #2's threat to harm others. She said other residents and staff were at risk of harm due to Resident #2's threat. She said Resident #1's care plan was not reviewed and updated to include threats of harm to others. During an interview on 09/29/23 at 4:39 p.m., APRN L said she was in the process of completing scheduled rounds in the facility on 09/21/23 and LVN A informed her of Resident #1's threat to harm his roommate. She said Resident #1 indicated he had no plan and no intention. She said she was not aware of any prior threats. APRN L said staff would continue to monitor Resident #1 until he was seen by psychiatric services. During an interview on 09/29/23 at 4:50 p.m., FNP N said she assessed Resident #1 on 09/21/23. She said he was not cooperative with assessment. She said he made a threat to hurt someone with a knife so he could go to prison. She said she would have recommended Resident #1 be sent out to a behavioral unit if he was a threat. During an interview on 09/29/23 at 10:00 a.m., the Administrator indicated she was not made aware of Resident #1's threats to harm others on 09/14/23. She said she was off due to her husband having surgery. She said Resident #1 was not placed on 1-1 and could have harmed his roommate or others. She said she would have placed Resident #1 on 1-1 until cleared by psychiatric services. She said she would have moved Resident #1 or his roommate. She said she was not aware the incident was a reportable incident. She said she reported the incident to the State Survey Agency after the State Surveyor questioned the clinical note. She said the police should have been notified. She said she did a counseling and coaching with the DON and LVN A. She said she notified MD K and completed an emergency QAPI. She said staff were inserviced on 09/26/23. During an interview on 10/05/23 at 2:19 p.m., ADON C said Resident #1 should have been on 1-1 and put in a private room after he made threats to hurt others. She said psychiatric should have been contacted to assess Resident #1. She said Resident #1's threat to harm others was noted on the 24 hour report and would have been reviewed during the morning meeting. She said she did not recall if it was reviewed. Record review of the facility's Safety and Supervision of Residents, dated 2001 (revised July 2017), indicated Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities . 2. Resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment. 3. The type and frequency of resident supervision may vary among residents (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675338 If continuation sheet Page 24 of 29 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 10/05/2023 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 - Immediate jeopardy to resident health or safety and over time for the same resident. For example, resident supervision may need to be increased when there are temporary hazards in the environment (such as construction) or if there is a change in the resident's condition. This was determined to be an Immediate Jeopardy (IJ) on 09/29/23 at 3:22 p.m. The Administrator was notified. The Administrator was provided with the IJ template on 09/29/22 at 3:44 p.m. Residents Affected - Few The following Plan of Removal submitted by the facility was accepted on 09/29/23 at 4:10 p.m. Immediate Action: Systematic Approach: 1. Assessment - Resident #1 with homicidal ideation on 9/14/23 was placed on one-on-one on 9/26/23 at 9:02 AM until he was discharged to a Behavioral hospital on 9/27/23 at 2:00 PM.-The Executive Director notified the facility Medical Director of the Immediate Jeopardy on 09/29/22 at 4:20 PM. -An emergency QAPI meeting was held on 9/26/2023. -All residents will have a psychosocial assessment updated by the Director of Nurses, Assistant Director of Nurses and/or Patient Care Coordinator on 9/29/2023 to identify any current patients that are at imminent risk homicidal/suicidal ideation. The psychosocial assessments were completed on 9/29/23 by 6:00 PM. After completion of psychosocial assessments, no other residents were found to be at imminent risk of homicidal/suicidal ideation. The assessment includes the following information: The assessment is to determine if a resident is an imminent/suicidal risk for psychiatric needs. Who will be responsible: Director of Nursing/Nurse Managers Who Will monitor: Executive Director and RDCS -Beginning 9/29/2023, psychosocial assessments will be completed upon admission, condition change, and quarterly by the charge nurse and/or nurse managers, and for any resident that triggers an imminent risk for homicidal/suicidal ideation, the facility will initiate one-on-one supervision until further direction is provided. The abuse/neglect policy will be implemented immediately. The physician will be notified immediately of any homicidal ideation of any resident. The ED and DON will monitor for compliance daily by running an audit of the psychosocial assessments. Audits will be completed weekly for 3 months until 12/29/2023 and then monthly on an ongoing basis. Who will be responsible: Director of Nursing/Nurse Managers Who Will monitor: Executive Director/RDCS -Beginning 9/29/23, any resident who triggers an imminent risk of homicidal/suicidal ideation, will (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675338 If continuation sheet Page 25 of 29 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 10/05/2023 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 - Immediate jeopardy to resident health or safety Residents Affected - Few be placed on one-on-one supervision and will have notification to the staff caring for the resident, the attending physician, and psychiatric services referral will be made by the nurse manager and monitored by clinical staff. -ED will call family, police and notify physician to confirm notification of resident homicidal/suicidal ideation. -ED will implement the abuse/neglect policy immediately. -Any staff that is aware of a resident with homicidal/suicidal ideation will immediately inform the ED. -ED will notify HHSC of a homicidal/suicidal resident incident according to reporting protocols and following the abuse/neglect prohibition protocol. Who will be responsible: Director of Nursing/Nurse Managers Who Will monitor: Executive Director/RDCS All staff were educated to notify the Executive Director, DON or RDCS immediately upon verbalization of a resident wanting to harm someone or themselves. This education was provided on 9/29/2023. This education was provided by the Executive Director, DON and RDCS. Staff will not be allowed to begin their shift until the education has been completed. Until alternative and or safe living arrangements are made the resident will be placed on one-on-one supervision with facility staff. Resident care plans will also be updated to include any verbalizations of wanting to harm others including homicidal/suicidal ideations. The ED and/or RDCS will monitor weekly for compliance by completing an audit of the psychosocial assessments. Audits will be completed weekly for 3 months until 12/29/2023 and then monthly on an ongoing basis. Who will be responsible: Director of Nursing/Nurse Managers Who Will monitor: Executive Director/RDCS 2. In-Services All staff were in-serviced on resident homicidal/suicidal ideation and the abuse/neglect policy by the ED/RDCS/Director of Nursing and/or Nurse Managers. All new staff will receive the education as part of the onboarding orientation process prior to being assigned and providing care to residents. No staff member will be allowed to work in the facility until the above required in-services are completed. The in-service with all staff will be completed by 9/29/2023. All staff were in-serviced by 8:00 PM on 9/29/2023. Who will be responsible: DON/Nurse Managers Who Will monitor: Executive Director/RDCS Shift to Shift reporting process will be as follows: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675338 If continuation sheet Page 26 of 29 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 10/05/2023 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 -As part of shift to shift report the charge nurse will notify the oncoming nurse of the one-on-one and homicidal/suicidal ideation. Level of Harm - Immediate jeopardy to resident health or safety All nurses and CNAs will be in-serviced on the shift-to-shift report process by the Executive Director, Director of Nursing or Assistant Director of Nursing by 9/30/23 at 8:00 a.m. Residents Affected - Few Who will be responsible: DON/Nurse Managers Who Will monitor: Executive Director/RDCS Each employee completed a post-test after their education was completed to ensure staff were able to identify abuse/neglect and reporting requirements. If the employee did not pass the test with at least 90% correctly answered the staff member was re-educated and re-tested until at least 90% pass rate was met. A staff roster was utilized to ensure 100% of licensed nursing staff were in-serviced and tested. In-services were deemed to be effective by the in-services post-test scores and verbalization of understanding by all facility staff (clinical, non-clinical and ancillary). All nurses, Executive Director and nurse managers were in-serviced on abuse and neglect on 9/29/23 by 8:00 PM. The Executive Director, DON and ADON were in-serviced by the RDCS on 9/29/23 by 4:00 PM. Who will be responsible: DON/Nurse Managers Who Will monitor: Executive Director/RDCS 3. Monitoring Starting 9/29/23 the Executive Director, Director of nursing and/or Nurse Managers will review all psychosocial assessments for any psychosocial needs including homicidal/suicidal ideation. The Regional Director of Clinical Services will review the documentation each week for compliance and will review any needs for reporting allegations to the state agency. Monitoring of the POR included the following: During interviews on 09/30/23 from 1:00 p.m. through 4:00 p.m. with LVN A 10 p.m. - 6 a.m., RN S (weekend shifts) CNA Q 6 a.m. -6 p.m.), LVN R (prn all shifts), CNA T (all shifts), LVN U 2 p.m. -10 p.m., LVN W 10 p.m. -6 a.m., LVN X 6 a.m. - 2 p.m., LVN Y 6 a.m. 2 p.m., CNA D 6 p.m.-6 a.m. and the ADON indicated staff were able to identify the Abuse Coordinator as the administrator. Staff indicated they were to report allegations of abuse and neglect immediately to the charge nurse or administrator and were able to give example of physical, verbal, sexual abuse, and immediate intervention procedures. All staff indicated they were educated to notify the Executive Director, DON or RDCS immediately if a resident threatened to harm someone or themselves. All staff indicated they would ensure any resident who threatened harm to themselves or others would be placed on 1-1 until cleared by (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675338 If continuation sheet Page 27 of 29 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 10/05/2023 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 - Immediate jeopardy to resident health or safety their physician. They indicated resident care plans would be reviewed and updated to include any verbalizations of wanting to harm others which included homicidal/suicidal ideations. All staff indicated they were trained on resident homicidal/suicidal ideation and the abuse/neglect policy. They were able to give examples of appropriate actions to take in different situations involving abuse or threats of harm. The ADON and LVNs indicated they were to notify the physician of resident's change of condition and were able to give examples. Residents Affected - Few Interviews conducted with three alert residents on 09/30/23 from 1:00 p.m. through 4:00 p.m. indicated they would report abuse to the administrator or the DON. They were not afraid of any residents. During an interview on 09/30/23 at 3:45 p.m., the Administrator said she was in-serviced on 09/29/23 by the RDCS. She was able to verbalize the facility abuse, and neglect policy and they would conduct a thorough investigation of all incidents of resident threats of self harm or harm to others. She understood she was required to report incidents according to regulatory compliance, and reporting incidents of abuse or neglect that result in serious bodily injury/death. She said the physician would be notified immediately of any homicidal ideation of any resident. She and the DON would monitor for compliance daily by running an audit of the psychosocial assessments. She said this would be completed weekly for 3 months until 12/29/23 and then monthly on an ongoing basis. She said she and the DON would review the facility 24 Hour Report and Incident Reports in the morning clinical for any allegation or instances of abuse and/or neglect and physician notification. During an interview on 09/30/23 at 4:00 p.m., the DON said she was in-serviced on 09/29/23 by the RDCS. She was able to verbalize the facility abuse, and neglect policy and they would conduct a thorough investigation of all incidents of resident threats of self harm or harm to others. She understood she was required to report incidents according to regulatory compliance, and reporting incidents of abuse or neglect that resulted in serious bodily injury/death. The DON and Administrator would monitor for compliance daily by running an audit of the psychosocial assessments. The DON and Administrator would review the facility 24 Hour Report and Incident Reports in the morning clinical for any allegation or instances of abuse and/or neglect and physician notification. She said this would be completed weekly for 3 months until 12/29/23 and then monthly on an ongoing basis. Record review of all incidents from the previous 90 days indicated there were no additional incidents of threats of self harm or harm to others as of 09/30/23. Record review of resident abuse questionnaire, dated 09/29/23, indicated no residents were identified as reporting any abuse or being afraid of any residents or staff. Record review of training records indicated all staff (nursing and non-nursing) were in-serviced on 09/29/23 regarding the facility abuse and neglect policy, the procedure for reporting incidents of threats of harm with serious harm and/or death, suspected abuse/neglect, recognizing threats of harm (to self and others), and physician notification. Record review of quiz results, dated 09/29/23 and 09/30/23, indicated all staff passed the quiz regarding abuse, neglect, reporting, suicide threats, managing suicide ideations, comprehensive care plans, and physician notification. The Administrator and the DON were informed the Immediate Jeopardy was removed on 09/30/23 at 4:10 p.m. The facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm and with a scope identified as isolated due to the facility's need to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675338 If continuation sheet Page 28 of 29 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 10/05/2023 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 evaluate the effectiveness of the corrective systems that were put into place. Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675338 If continuation sheet Page 29 of 29