Health inspection·November 15, 2023

F 0553 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few disease), muscle weakness, and unsteadiness on feet. Resident #2 had four (4) contacts listed including Resident #1 as spouse. None of the contacts listed for Resident #2 were listed as a representative of Resident #1. Record review of the MDS dated [DATE] indicated Resident #2 was usually understood by other and understood others. The MDS indicated Resident #2 had a BIMS of 11 and had moderate cognitive impairment. During an interview on 11/15/23 at 8:14 a.m. Resident #1's representative D (POA) said she had not been contacted to attend the initial comprehensive care plan conference for Resident #1 on 9/21/23. Representative D of Resident #1 said the representatives for Resident #2 (Resident #1's spouse) had been invited by the Social Worker and attended the initial care plan for Resident #1's conference by mistake and that was a violation of Resident #1's rights. Representative D stated she would like the matter investigated. During an interview on 11/15/23/10/23 at 2:00 p.m. the MDS Coordinator said she had only been in her position for a few weeks. The MDS Coordinator said she was responsible for ensuring care plans were completed. The MDS Coordinator said residents' representatives were routinely invited to care plan meetings. The MDS Coordinator said it was important to involve residents' representatives in care plan meetings because it was their loved one's care and an inter-departmental meeting that would inform residents and families of different services the facility had to offer they might not be aware of. During an interview on 11/15/23 at 2:18 p.m. the Administrator said care plans were performed on admission, quarterly, and with a change in condition. The Administrator said residents and their families/responsible parties were invited to care plan meetings. The Administrator said Resident #1's care plan meeting was scheduled by the Social Worker, but she failed to follow the correct procedure of notification. The Administrator said the representatives for Resident #2 had been invited and attended Residents #1's care plan conference by mistake. The Administrator said she was made aware of the incident by Resident #1's representative D. The Administrator said she investigated the incident. The Administrator said the Social Worker was no longer employed by the facility. The Administrator said it was important for residents, families, or designated representatives to attend care plan meetings to be able to voice their opinions and to be able to take part in their own care. Record review of the facility's policy Care Plans, Comprehensive-Centered dated December 2016 indicated, .1. The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident .3 The IDT includes .e. the resident's legal representative. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675729 If continuation sheet Page 2 of 5 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675729 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Stonecreek Nursing & Rehabilitation 451 S El Camino Crossing San Augustine, TX 75972 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 0602 Protect each resident from the wrongful use of the resident's belongings or money. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the right to be free from misappropriation of property was provided for 2 of 5 residents reviewed for misappropriation of property. (Resident #3 and Resident#4). Residents Affected - Some The facility failed to prevent a diversion (misappropriation ) of Resident #3's methocarbamol tablets (used to treat muscle spasms and pain) a total of 60 tablets in two blister packs filled 5/23/23. One blister pack of the two packs dated 5/23/23 was observed in custody at the Sheriff's department containing 22 of 30 tablets and Resident #4's bottle of amoxicillin capsules (used to treat infection) was observed in custody at the Sherriff's department on 11/15/23, after being turned in by complainant. This failure could place residents at risk for decreased quality of life, misappropriation of property, and dignity. Findings included: 1.Record review of Resident #3's face sheet, dated of 11/15/23, indicated he was [AGE] years old, admitted on [DATE], readmitted on [DATE]. He had diagnoses including history of fracture of the left femur (broken bone in the upper leg), low back pain and muscle weakness. Record review of Resident #3's quarterly MDS, dated [DATE], indicated he had adequate hearing and vision, could understand and was understood by others, and had intact cognition with a BIMS score of 15. Record review of Resident #3's care plan, with an admission date of 07/05/2023 and revision date of 11/05/2023 indicated Resident #3 was at risk for pain with a history of pain. Record review of Resident #3's order summary report dated 11/15/23, indicated active orders as of 11/15/23 included an order to administer methocarbamol oral tablet 500mg one tablet by mouth every 8 hours as needed for pain. Record review of Resident #3's MAR for May, June, July, August, September, and October indicated no administration of methocarbamol 500mg by mouth. MAR for the month of November, indicated he received methocarbamol 500mg one tablet by mouth, once on 11/12/23. 2. Record review of Resident #4's face sheet, dated of 11/15/23, indicated he was [AGE] years old, admitted on [DATE]. He had diagnoses including history of pneumonia (lung infection), weakness and pain. Record review of Resident #4's quarterly MDS, dated [DATE], indicated he had impaired hearing and vision, could rarely understand, and was usually understood by others, and had severe cognitive impairment. Record review of Resident #4's order summary history indicated no previous order for amoxicillin 500mg since admission to the facility. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675729 If continuation sheet Page 3 of 5 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675729 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Stonecreek Nursing & Rehabilitation 451 S El Camino Crossing San Augustine, TX 75972 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 0602 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a phone interview on 11/14/23 at 11:18 a.m. complainant said he had discovered medications in a closet at his home ( the complainant's home) on 9/29/23 and turned them into the Sheriff's department. The complainant said he had taken the medications to the Sheriff's department and made a report concerning the medications and LVN A. The complainant said he discovered a box of blister packaged medications (25 to 30 cards) in his closet at his home after LVN A had moved out of his home. The complainant expressed concern that LVN A was stealing medications from the nursing facility she was currently employed at or had taken medications from other nursing facilities she was previously employed in [NAME] and Huntington. During an interview on 11/14/23 at 2:00 p.m., Deputy B said he would meet with this investigator at the Sheriff's department on 11/15/23 to examine the medications in the evidence file turned in by the Complainant against LVN A. Deputy B said that he had not brought any formal charges against LVN A since there were no narcotics, only medications classified as dangerous drugs. Deputy B said LVN A had said she had worked for Home Health Agencies during the Covid (a severe acute respiratory virus) pandemic and had not destroyed these medications yet. Deputy B said LVN A said the agencies had told her she keep these medications since none were narcotics. Deputy B said he had been contacted by the Board of Nurse Examiners concerning this case but there were no charges filed against LVN A at this time. During an interview on 11/14/23 at 3:00 p.m. the Administrator said she had no reason to suspect LVN A had taken any medications from the facility. No residents had complaints of unrelieved pain and no staff had reported any cards missing of dangerous drugs. The Administrator said she would call LVN A and put her on suspension for this investigation. During an interview and observation at the Sherriff's department with Deputy B on 11/15/22 beginning at 10:00 a.m. The evidence file contained one blister pack card of Methocarbamol 500mg tablets containing 8 of 30 tablets, label indicated issue date 5/23/23 one of two cards total 60 tablets, label indicated prescribed for Resident #3, currently residing in the facility (label indicated Methocarbamol belonged to the facility). The evidence file contained one bottle of amoxicillin 500mg caplets dated 1/16/23 prescribed for Resident #4, currently residing at the facility. 1- vial of unlabeled Zofran 4 mg per 2 ml injectable, 2- vials of unlabeled Phenergan 25mg/ml for injection, 32 additional medication blister packs of po medications were observed dates of ranging from 2018 to 2022, none of the additional blister packs belonged to any resident that resides or had previously resided at the nursing facility being investigated. During an interview and observation with LVN H on 11/15/23 at 12:30 a.m. a new blister pack of Methocarbamol 500mg belonging to Resident #3 was observed in the medication cart with a fill date of November 23. One tablet was missing for dose administered on 11/12/23. LVN H said Resident #3 gets routine pain medication and rarely asks for PRN pain medications. LVN H said she had never given Resident #3 his Methocarbamol 500mg po prn for muscle spasms or pain. LVN H said if the Methocarbamol 500mg was filled with 60 tablets on 5/23/23, Resident #3 should still have the two blister packages left due to non-use, since there were no tablets signed as being administered on the MAR since it was filled in May. The Medication was refilled in November of 2023 with one tablet signed out as administered 11/12/23. During an interview with Resident #3 on 11/15/22 at 12:40 p.m., Resident #3 said his pain is controlled by his scheduled medications. Resident #3 said he was started on the Methocarbamol a long time ago after he fractured his leg. Resident #3 said he had muscle spasms in his thigh in the hospital due to the injury and he came back to the facility with orders to continue as needed. Resident #3 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675729 If continuation sheet Page 4 of 5 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675729 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Stonecreek Nursing & Rehabilitation 451 S El Camino Crossing San Augustine, TX 75972 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 0602 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some said he thinks it has been several months since he requested anything for muscle spasms or uncontrolled pain. During an interview with Resident #4's representative on 11/15/22 at 1:00 p.m., the representative said the prescription for amoxicillin had been provided to the facility when the resident admitted in January, after he had been in the hospital. The representative said Resident #4 did not take any of the amoxicillin because he went into the hospital for his infection. Resident #4's Representative said she had given the medication to the admitting nurse for documentation and destruction. Resident #4 said she didn't know how the bottle ended up at the Sheriff's office unless someone had taken it from the facility. During a phone interview on 11/15/23 at 1:30 p.m. LVN A said she had taken the medications now in custody of the Sherriff's department from various nursing facilities she had worked at. LVN A said she did not remember taking any medications belonging to Resident #3 and Resident #4 or any other residents at the facility she was currently employed. LVN A said she knows she should have not taken the drugs and knows she will lose her job. LVN A was crying and remorseful about taking residents medications. She said the board of nursing has already been in contact with her. During an interview on 11/15/23 at 2:00 p.m. the Administrator said she would be reporting LVN A to the board of nursing and will prepare papers for termination. The Administrator said she would not employee anyone that had a history of stealing and would be in servicing all staff on misappropriation. She said in servicing on facility policies regarding misappropriation, medication destruction and an audit of medication would be completed. Record review of the facility's Identifying Exploitation, Theft and Misappropriation of Resident Property policy with a date of April 2021 indicated, .4. Misappropriation of resident property means the deliberate misplacement, exploitation or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent. 5. Examples of misappropriation of resident property include: . f. drug diversion (taking the resident's medication) . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675729 If continuation sheet Page 5 of 5