Health inspection·January 24, 2024

F 0657 Level of Harm - Minimal harm or potential for actual harm * Interventions: Initiate BLS/CPR if Resident #33 is without heartbeat or not breathing. Notify EMS.; and Request for CPR to be initiated will be followed. During a joint interview on [DATE] at 09:25 AM LVN D and DON both said that Resident #33 was a DNR, and the form had just recently been completed and put into effect. Residents Affected - Few During an interview on [DATE] at 4:00 pm DON said that she was responsible for updating the care plans and that Resident # 33's care plan should have been updated within 7 days of his significant change MDS, which was completed on [DATE]. She said that this was due to a breakdown in communication between staff. She said that she was unsure who actually placed the signed form in his paper chart, but that they had done so without communication to staff and that is why the care plan had not been updated. She said that she had corrected the care plan now and she would try and ensure that it did not happen again. She said she would find out where the breakdown occurred and implement education to ensure proper communication between staff in the future. She acknowledged that this put residents at risk of not receiving proper care. During an interview on [DATE] at 9:30 am, Administrator said that going forward she would be doing lots of education regarding communication. Record review of a facility policy titled Care Plans, Comprehensive Person-Centered dated 2001 with revision date of [DATE] read .The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required MDS assessment (Admission, Annual, or Significant Change in Status) . and .The comprehensive, person-centered care plan: a.) includes measurable objectives and timeframes; b) describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including: (1) services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment . and .The interdisciplinary team reviews and updates the care plan: 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: 675729 If continuation sheet Page 2 of 16 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 01/24/2024 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the drug regimen review recommendations from the pharmacy consultant were acted upon for 7 of 16 residents (Residents #209, #40, #308, #10, #6, #44 and #208) reviewed for drug regimen review. -The Facility did not follow up on the pharmacy consultant's recommendations for Gradual Dose Reduction (GDR) dated 01/11/2023 for Resident #209, #40 and #308 until 05/03/2023, four months after original recommendation. -The Facility did not follow up on the pharmacy consultant's recommendations for Gradual Dose Reduction (GDR) dated 05/10/2023 and 05/11/2023 for Resident #10, #6, #44 and #208 until 07/10/2023 and 07/11/2023, two months after original recommendation. -The Facility did not develop policies and procedures to address the timeframes of the medication regimen review (MRR). These failures could place residents at risk for medication errors, unnecessary medications, and incorrect administration. Findings include: Record review of facility face sheet dated 01/24/24 indicated Resident #209 was a [AGE] year-old female admitted on [DATE] with diagnosis of depression (mental health disorder that affects mood). Record review of quarterly MDS assessment dated [DATE]/23 indicated Resident #209 had a BIMS of 9 indicating moderately impaired cognition and section N indicated she received an antidepressant. Record review of facility face sheet dated 01/24/24 indicated Resident #40 was a [AGE] year-old female admitted on [DATE] with depression (mental health disorder that affects mood) and weakness. Record review of quarterly MDS assessment dated [DATE] indicated Resident #40 had a BIMS of 12 indicating moderately impaired cognition and section N indicated she was taking an antidepressant. Record review of facility face sheet dated 01/24/24 indicated Resident #308 was a [AGE] year-old female admitted on [DATE] with diagnosis of anxiety (nervousness) and depression (mental health disorder that affects mood) and muscle wasting. Record review of quarterly MDS assessment dated [DATE] indicated Resident #308 had a BIMS of 12 indicating moderately impaired cognition and section N indicated she was taking an antianxiety medication and antidepressant. Record review of facility face sheet dated 01/24/2024 indicated Resident #10 was a 57 -year-old male admitted on [DATE] with diagnosis of depression (mental health disorder that affects mood) and insomnia (inability to sleep). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675729 If continuation sheet Page 3 of 16 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 01/24/2024 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of quarterly MDS assessment dated [DATE] indicated Resident #10 had a BIMS of 15 indicating intact cognition and section N indicated he was receiving an antidepressant. Record review of facility face sheet dated 01/24/24 indicated Resident #6 was a [AGE] year-old male admitted on [DATE] with diagnosis of depression (mental health disorder that affects mood), history of falls and muscle weakness. Record review of quarterly MDS assessment dated [DATE] indicated Resident #6 had a BIMS of 11 of indicating moderately impaired cognition and section N indicated he was taking an antidepressant. Record review of facility face sheet dated 01/24/24 indicated Resident #44 was an 86 -year-old female admitted on [DATE] with diagnosis of depression (mental health disorder that affects mood) and muscle weakness. Record review of quarterly MDS assessment dated [DATE] indicated Resident #44 had a BIMS of 01 of indicating severely impaired cognition and section N indicated she was taking an anti-anxiety medication. Record review of facility face sheet dated 01/24/24 indicated Resident #208 was a [AGE] year-old male admitted on [DATE] with diagnosis of Insomnia (inability to sleep) and pain. Record review of quarterly MDS assessment dated [DATE] indicated Resident #208 had a BIMS of 15 indicating intact cognition and section N indicated he was taking a hypnotic. Record review of documents titled Consultant Pharmacist's Monthly Report for [Facility], dated January 2023 to December 2023 reflected the pharmacist had made medication regimen review recommendations for the residents' physician to review. The record review of pharmacy medication regimen review Note to Attending Physician/Prescriber revealed 7 of 16 residents reviewed had recommendations/ interventions that were not executed timely as indicated below: Resident #209 GDR recommendation dated 01/11/23 for Paxil 20 mg, decrease Paxil to 10mg. Resident #209 had been receiving Paxil (antidepressant) used to treat a depressed mood, since April 2022. Recommendation was received declined and signed on 05/03/23, four months after origination date. Resident #40 GDR recommendation dated 01/11/23 for Zoloft 150mg, decrease to Zoloft 125 mg. Resident #40 had been receiving Zoloft (antidepressant) used to treat a depressed mood for one year. Recommendation was received accepted and signed on 05/03/23, four months after origination date. Resident #308 GDR recommendation dated 01/11/23 for Remeron 15mg, decrease Remeron to 7.5mg. Resident #308 had been receiving Remeron (antidepressant) used to treat a depressed mood for one year. Recommendation was received declined and signed on 05/03/23, four months after origination date. Resident #10 GDR recommendation dated 05/10/23 for Trazodone 120 mg, decrease Trazadone to 50mg. Resident #10 had been receiving Trazodone (antidepressant) used to treat insomnia (unable to sleep) since April 2022. Recommendation was received accepted and signed on 07/11/23, two months after origination date. Resident #208 GDR recommendation dated 05/11/23 for Tylenol PM 500-25 mg two tablets at bedtime, decrease Tylenol PM to one tablet. Resident #208 had been receiving Tylenol PM used to treat insomnia (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675729 If continuation sheet Page 4 of 16 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 01/24/2024 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some (unable to sleep). GDR indicated there was no documentation of episodes of insomnia for resident #208. Recommendation was received accepted and signed in agreement on 07/11/23, two months after origination date. Resident #6 GDR recommendation dated 05/11/23 for Zoloft 50mg, decrease to Zoloft 25 mg. Resident #6 had been receiving Zoloft (antidepressant) used to treat a depressed mood for one year. Recommendation was received declined and signed on 07/11/23, two months after origination date. Resident #44 GDR recommendation dated 05/11/23 for Buspar 10 mg, decrease Buspar to 5mg. Resident #44 had been receiving Buspar (antidepressant) used to treat (depressed mood) since April 2022. Recommendation was received accepted and signed on 07/10/23, two months after origination date. During an interview on 01/23/24 at 12:00 p.m. the ADON said she had been in her position for just a few months. The ADON said the DON is responsible for sending the gradual dose reduction requests completed by the pharmacist and she completed them in the absence of the DON. She said that not following up on them timely could cause an adverse effect from unnecessary dosages but most of the time the physician declined the recommendations because they were already on a therapeutic dose and decreasing the dosages would cause more negative behaviors. During an interview on 01/23/24 at 3:30 p.m., the DON said she had worked at the facility since 4/17/2017 and was responsible for obtaining the completed pharmacy reviews for gradual dose reductions. The DON said not following up on recommendations timely could cause a delay in needed medication changes or other requested interventions. The DON said the recommendations made in January 2023 were not received signed until 5/3/23, four months later. The DON said the facility had a turnover of Medical Directors during that time period and she was having difficulty getting them executed. She said declinations or new orders were not obtained for the January recommendations until May of 2023, after the next pharmacy review was conducted and beyond the recommendation of 30 days. She said the problem had not been addressed during QAPI meetings. She said the GDR should be addressed before the next pharmacy review was conducted. During an interview on 01/23/24 10:00 a.m., The Administrator said she had been employed with facility for the past year and the DON was responsible for completion of the MMR Process including GDR. The Administrator said her expectation would be they are implemented before the next pharmacy review was conducted. The Administrator said that the resident could suffer an adverse effect if the responses were not followed up on timely. During an interview on 01/24/2024 at 9:54 a.m. the Contract Pharmacist said he had been consulting at the facility for 14 years. He said he visited the facility monthly to perform pharmacist duties including medication regimen reviews and recommendations. He stated within 7 days of his visit he uploads his notes and recommendations into the google drive file and emails the DON and Administrator the information. He stated that ideally the recommendation should be sent to the physician and returned within 14 days, but it is usually 30 days. He stated that if a physician does not respond to the pharmacy recommendation within 30 days he sends another recommendation asking for a response. He stated the resident could suffer an adverse effect if recommendations were not acted upon timely. Record review of facility policy revised July 2022 titled Tapering Medications and Gradual Drug Dose Reduction indicated, After medications are ordered for a resident, the staff and practitioner shall seek an appropriate dose and duration for each medication that also minimizes the risk of adverse consequences. 1. All medications shall be considered for possible tapering. Tapering that is (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675729 If continuation sheet Page 5 of 16 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 01/24/2024 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 0756 Level of Harm - Minimal harm or potential for actual harm applicable to psychotropic medications are referred to as gradual dose reductions. 2. Residents who use psychotropic medications shall receive gradual dose reductions and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs .Policy interpretation and implementation 5. The physician will review periodically whether current medications are still necessary in their current doses; for example, whether an individual's condition or risk factors are sufficiently prominent or Residents Affected - Some ensuring that they require medication therapy to continue in the current dose, or whether those conditions and risks could potentially be equally well managed or controlled without certain medications, or with a lower dose. The policy did not address time frames for the different steps in the process. Record review of an undated Consultant Pharmacist Reports policy, documentation and communication of consultant pharmacist recommendations policy indicated, The consultant pharmacist works with the facility to establish a system whereby the consultant pharmacist observations and recommendations regarding residents' medication therapy are communicated to those with authority and/or responsibility to implement the recommendations and responded to in an appropriate and timely fashion . C. Recommendations are acted upon and documented by the facility staff and /or the prescriber. If the prescriber does not respond to recommendation directed to him/her (within a reasonable time frame/within 30 days), a reminder may be used. If the prescriber does not respond to the recommendation after the reminder (within 60 days) the Director of Nursing and/or the consultant pharmacist may contact the Medical Director. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675729 If continuation sheet Page 6 of 16 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 01/24/2024 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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to provide food that was palatable and served at an appetizing temperature for 1 of 4 halls (D hall) reviewed for palatable food. Residents Affected - Some The facility failed to provide palatable food served at an appetizing temperature on 1/24/2024 to residents on D hall for the breakfast meal. This failure could place residents who ate food from the kitchen at risk of weight loss, altered nutritional status, and diminished quality of life. Findings include: During initial interviews on 1/22/2024 from 9:26 am to 10:28 am on D hall, residents who ate meals in their rooms voiced concerns about the food being served cold. During an observation on 1/24/2024 at 7:50 am a test tray was on a meal cart with D hall meals. All meal trays arrived on hall D at 7:51 AM. CNA B began passing meal trays at 7:54 AM and the final tray was passed out at 8:20 AM. During an observation on 1/24/2024 at 8:20 AM a test tray obtained from the same cart as the D hall meal trays after the resident trays were passed, and food temperatures were checked by the dietary manager with surveyor and administrator present. Food temperatures were: Oatmeal- 109 degrees F. Scrambled eggs- 108 degrees F., Sausage patty- 89 degrees F., Bread (wrapped in foil)- 106 degrees F. Acceptable parameters for food temperatures for hot foods should be 135 degrees F or higher. During an interview on 1/24/2024 at 8:40 AM , the administrator said that department supervisors usually assist with passing meal trays on D hall, but because they were doing other tasks related to the survey, they did not assist with the meal service this morning. During an interview on 1/24/2024 at 10:30 AM the dietary manager said that she has requested plate warmers in the past to help keep the food warm for the residents that eat in their room. She said that she has gotten complaints in the past about the food being served cold to residents who dine in their rooms. She said that she makes sure that the food is hot when it is put on the cart but is unable to control how quickly the meals are served once the cart leaves the kitchen. She said that serving food cold could cause the residents not to eat and lose weight. During an interview on 1/24/2024 at 11:00AM, the administrator said that she was planning to interview residents that ate their meals in their rooms and determine if the temperature of the meals were a consistent problem. She said that she then planned to take any concerns and discuss them with the department heads in the morning meeting to come up with solutions that would address any problems. She said that she expected the meal trays to be served in a timely manner. She said that food not served at the proper temperatures could lead to food borne illnesses and malnutrition. Record review of policy titled Food and Nutrition Services, the policy statement is Each resident is provided with a nourishing, palatable, well-balanced diet . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675729 If continuation sheet Page 7 of 16 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 01/24/2024 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 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to prepare food in a form designed to meet the needs for 1 of 6 residents (Resident #27) reviewed. The facility failed to ensure that Resident #27 received nectar thickened liquids as ordered. These failures could place residents at risk for aspiration. Findings include: Record review of a face sheet dated 1/16/2024 indicated Resident #27 was a [AGE] year-old female with an original admission date of 11/16/2018. Diagnosis include Chronic Obstructive Pulmonary Disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs), History of transient ischemic attack (a temporary period of symptoms similar to those of a stroke), Osteoporosis (condition that causes bones to become weak and brittle), Alzheimer's Disease (changes in the brain that lead to deposits of certain proteins that causes the brain to shrink and brain cells to die). Record review of MDS assessment dated [DATE] indicated Resident #27 requires set up assistance with eating and moderate assistance with all other activities of daily living. Resident #27 has a BIMS score of 04, which indicates severely impaired cognition. Resident #27 is incontinent of bowel and bladder. Record review of hospital discharge record dated 1/10/2024 indicated that patient was released from the hospital after treatment for a urinary tract infection and healthcare acquired pneumonia. Record review of physician orders for Resident #27 had a diet order of regular diet pureed texture, nectar consistency dated 1/18/2024. Record review of speech therapy evaluation dated 1/18/2024. Reason for referral was related to decline in speech-language. Swallowing abilities require minimal close supervision, label closure mild, oral phase mild, and oral clearance mild. During observation on 1/22/2024 at 10:00 AM, Resident #27 was sitting in the dining room for activities and drinking coffee. No thickening agent was used in the coffee, and it was thin consistency. During an observation on 1 /23/2024 at 8:30 AM a water pitcher with water and ice, no thickener added on bedside table of Resident #27. During an interview on1/23/2024 at 8:35 AM with CNA A. CNA A said that if there is a change in a resident's diet, the nurses communicate the changes to the CNA staff. She said that there are no identifiers in the resident's room or outside the room to indicate of resident is on a therapeutic diet. CNA A correctly identified resident #27 as having an order for a therapeutic diet. She said that the water at the bedside was an accident and that the resident does not drink without assistance. She said that the resident could aspirate if the therapeutic diet was not followed. During an interview on 1/23/2024 at 8:45 AM with LVN C, LVN C said that any new orders including (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675729 If continuation sheet Page 8 of 16 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 01/24/2024 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 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few diet changes were verbally communicated to the CNA's and that it was placed on the 24 hour report to communicate between shifts. She stated that the department managers reviewed the 24-hour report in the morning meeting. She stated that if a nurse was off for several days, then the nurse would review the 24-hour reports and the chart for any new orders. LVN C stated that she was aware of the residents on her hall with therapeutic diets. She stated that the family member of Resident #27's roommate would place items on Resident #27's side of the room. She stated that if a resident was given regular liquids when they were ordered nectar consistency then there would be an increased risk of aspiration. During an interview on 1/23/2024 at 9:00 AM with Activity Director, the activities director said that she is told in the morning meeting when a resident has a change in diet and that she accommodates those needs during activities that have food or drink. She said that she was not aware that Resident #27 had a therapeutic diet. She stated that she had been off work the previous week when the change had occurred and was not aware of it. She said that the resident #27 was drinking regular consistency coffee as observed. She said that she did not have a list of residents with therapeutic diets and that if she was not told in the morning meeting, she was not aware of diet changes. She said that a resident could aspirate and get sick if a therapeutic diet was not followed. During an interview on 1/24/2024 at 10:00 AM with Speech Therapist, the Speech therapist said that she was currently treating Resident #27. She said that the Assistant Director of Nurses referred the patient to speech therapy after observing resident coughing during a meal while assisting resident. The speech therapist said that she recommended the change in the resident's diet from regular consistency to pureed texture and nectar thick liquids and the doctor approved the order. She said that the patient would return to a regular consistency because she was not exhibiting any signs of swallowing problems and that during evaluation and therapy the therapist noted the muscles used for swallowing to be strong. She said that the diet change was a precautionary measure and was allowing staff to observe the resident. She said that the resident did not need a medical swallow study to be performed at this time due to resident not meeting the criteria needed for the study. The speech therapist said that the resident returned from the hospital with health care related pneumonia and that the diagnosis could be the reason for Resident #27's occasional cough. She said that when she receives an order to change a resident's diet, she communicates the change to the charge nurse and/or director of nursing. She said that if the correct diet is not followed then a resident is at risk for aspiration. During an interview on 1/24/2024 at 11:30 AM with ADON, she said that she made the request for speech therapy to evaluate Resident #27. She said that she was assisting the resident during lunch and that the resident began to cough after drinking some fluids. She said that since the resident had been hospitalized and has had a decline she requested the evaluation. She said that she was aware that the resident was recovering from pneumonia but wanted to make sure that Resident #27 was not having any swallowing issues. During an interview on 1/24/2024 at 1:00 PM with DON. The DON said that when a resident has a diet change, the order is put into electronic charting system. A communication sheet is completed and given to the dietary staff. She said that during the morning meeting all new orders and changes are discussed with the department heads. The activities director is part of the morning meeting. She said that the activities director has access to the electronic charting system and is able to review any new orders. She stated that if the activities director is not at work, then the activities director is responsible for identifying any changes in orders and updating diet changes. She said that moving forward the facility will come up with a process where written communication will be done. She said (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675729 If continuation sheet Page 9 of 16 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 01/24/2024 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 0805 that residents are at risk for aspiration and choking if diet is not followed. Level of Harm - Minimal harm or potential for actual harm Review of Therapeutic Diets policy dated October 2017 noted Snacks will be compatible with the therapeutic diet. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675729 If continuation sheet Page 10 of 16 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 01/24/2024 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 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions in the facility's only kitchen. Residents Affected - Many The facility did not label or date a bag of unknown substance in the freezer, whipped topping, and diced peppers, did not dispose of cheesecake, lettuce, chicken wings and shrimp, and did not cover drinks stored in walk in cooler. These failures could place residents at risk for food-borne illnesses. Findings included: During an observation on 01/22/2024 at 9:00 AM in the kitchen, In the upright refrigerator a container labeled cheesecake dated 1-6-2024. A zipper top bag with unknown substance in freezer with no label or date. The walk-in cooler contained a bag of shredded lettuce dated 1-16-2024, brown in appearance and a closed bag of whipped topping with no date. A cart with drinks in plastic glasses were uncovered. In walk in freezer, a closed container of diced peppers with no date. A zipper bag of chicken wings and shrimp with severe frost bite. In pantry, a zipper bag of spaghetti noodles dated 11/19/23 open and zipper seal open to air. The bag of whipped topping package directions state that it is good for 2 weeks once defrosted. During an interview on 1/22/2024 at 9:45 AM , the dietary manager said everyone who worked in the kitchen was responsible for ensuring foods were labeled and dated properly. She stated that she does not always know where to find the expiration dates on items. She states that items are to be labeled with contents and date that item is placed in refrigerator or freezer with a used by date. Use by date is 72 hours after opening item. Dietary manager states that any expired items or items that are not labeled are to be discarded. Dietary manager states that residents could become ill if they consume items that have expired. 01/24/24 9:00AM interview with Cook. The [NAME] said all items placed in the refrigerator or freezer should be placed in a zipper bag, labeled with contents and date that item was opened or prepared. [NAME] stated that any items that are not dated should be thrown away and any items not used in a 72-hour period should not be used and thrown away. [NAME] states that residents could get sick if they eat food that is old. 01/24/24 9:15 AM Interview with Dietary Aide. The Dietary Aide said items that are stored in the refrigerator and freezer are placed in a zipper bag or in a container with a lid. She states that a label with the contents, date and use by date are placed on the container or bag. Dietary aide states that if items are not labeled properly then the residents could receive food that will make them sick. 01/24/2024 10:00 AM interview with the administrator. Administrator states that all items in the refrigerator and freezer should be labeled as stated in the policy. She states that items that are not labeled or have expired should be thrown out. The administrator states that her expectations are that the kitchen staff labels all items in the kitchen according to the policy and that the staff remove any items that are out of date and that the items be checked on a routine basis. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675729 If continuation sheet Page 11 of 16 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 01/24/2024 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 0812 Level of Harm - Minimal harm or potential for actual harm Review of the facility's undated Leftover storage policy states, Leftovers are properly stored immediately .labeled and dated as to use by and are dated as to a four-day use by date, adding four days to the present date. Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675729 If continuation sheet Page 12 of 16 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 01/24/2024 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 6 residents (Resident # 28) reviewed for infection control. Residents Affected - Few CNA A failed to perform proper hand hygiene while providing incontinent care to Resident #28 on 01/23/2024. This failure could place residents at risk of exposure to communicable diseases and infections. Findings: Record review of a facility face sheet indicated Resident #28 admitted to the facility on [DATE] with diagnosis of heart failure. Record review of a quarterly MDS assessment dated [DATE] indicated Resident #28 had a BIMS of 11 indicating moderately impaired cognition, required moderate assistance with toileting hygiene and was always incontinent of bowel and bladder. Record review of comprehensive care plan dated 01/03/2024 indicated Resident #28 had an ADL self-care deficit and bowel and bladder incontinence and to perform incontinent care. During an observation on 01/23/24 at 10:33 am CNA A provided incontinent care to Resident # 28. During incontinent care CNA A did not wash or sanitize her hands in between glove changes and upon completion of incontinent care. CNA A repositioned Resident #28 and made the bed without performing hand hygiene following incontinent care. During an interview on 01/23/24 at 10:43 am CNA A stated she had been a CNA for 7 years and employed at the facility a year. She stated she was trained on hire and again in December 2023 on infection control measures including handwashing and incontinent care. She stated she should have washed or sanitized her hands with each glove change and after care was given and by not doing so could lead to infections. During an interview on 01/23/24 at 11:58 am, the ADON stated she completed the skills checkoff for CNA A on 12/14/2023 and she was competent on proper infection control measures and handwashing at that time. She stated the CNA's were trained to wash or sanitize their hands before and after glove changes and before completing any other task to prevent infections. During an interview on 01/23/24 at 12:00 pm, the DON stated she and the ADON were responsible for training CNA's on incontinent care and infection control. She stated the CNA should have washed or sanitized their hands between glove changes and before performing task with the resident to prevent infections. She stated she expected infection control measures were followed. During an interview on 01/24/2024 at 10:05 am, the administrator stated the ADON was responsible for oversight and training of the CNA's regarding infection control and hand hygiene. She stated overall she and the DON were responsible for ensuring the policies and procedures were followed daily. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675729 If continuation sheet Page 13 of 16 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 01/24/2024 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 0880 Level of Harm - Minimal harm or potential for actual harm She stated she expected all staff to follow infection control and hand hygiene measures with every task to prevent the spread of infections. Record review of a facility policy titled Perineal Care dated February 2018 indicated, .10. remove gloves, 11. wash and dry hands, 12. reposition the bed covers . Residents Affected - Few Record review of a facility policy titled Handwashing/Hand Hygiene dated August 2019 indicated, .7. use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap and water for the following situations: m. after removing gloves, 8. Hand hygiene is the final step after removing and disposing of personal protective equipment . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675729 If continuation sheet Page 14 of 16 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 01/24/2024 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 0919 Make sure that a working call system is available in each resident's bathroom and bathing area. 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 be equipped to allow residents to call for staff through a communication system which relays the call directly to a centralized staff work area for 2 of 5 residents reviewed for call lights. (Resident #41 & #49). Residents Affected - Some The facility failed to ensure Resident #41 and #49's emergency call light in the bathroom would reach the floor. The call light cords were gathered and secured with a rubber band. This failure could place residents at risk of injury, pain, hospitalization, and a diminished quality of life. Findings include: Record review of a facility face sheet for Resident # 41 indicated that he was a [AGE] year-old male admitted to the facility on [DATE] with diagnosis of Alzheimer's disease. Record review of a Quarterly MDS assessment for Resident # 41 dated 1/13/24 indicated that he had a BIMS score of 2 which indicated severe cognitive impairment. Section GG indicated that he was independent in transferring on and off the toilet. Section H indicated that he was always continent of bowel and bladder. Record review of a Care Plan dated 10/10/22 for Resident # 41 indicated that he was at risk for falls with an intervention included to be sure the resident's call light is within reach. Record review of a facility face sheet dated 1/23/24 for Resident # 49 indicated that he was a [AGE] year-old male admitted to the facility on [DATE] with subsequent readmission on [DATE] with diagnosis of dementia. Record review of a Comprehensive MDS assessment dated [DATE] for Resident #49 indicated that he had a BIMS score of 0 which indicates that he had severe cognitive impairment. Section GG indicated that he was independent with transferring on and off the toilet. Section H indicated that he was always continent of bowel and bladder. Record review of a Care Plan dated 4/30/23 for Resident # 49 indicated that he had the following intervention: Toileting: Provide education on call light use, safety and proper body mechanics. During an observation and interview on 1/22/24 at 9:33 am the bathroom call light in Resident #41's room was observed to be too short. The string appeared to be new and gathered and secured with a rubber band. It was approximately 3 to 4 inches in length and was not reachable from the floor. Resident #41 said that he did use the restroom by himself but could not remember if he had ever needed to use the light. During an observation and interview on 1/22/24 at 9:53 am the bathroom call light in Resident #49's room was observed to be too short. The string appeared to be new and gathered and secured with a rubber band. It was approximately 3 to 4 inches in length and was not reachable from the floor. Resident #49 said that he was independent and did use the restroom by himself. He denied having suffered any falls and says he has not needed to use the light. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675729 If continuation sheet Page 15 of 16 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 01/24/2024 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 0919 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an observation and interview on 1/22/24 at 2:50 pm, CNA E said that it could be a problem if a resident fell. He fixed the strings in the restrooms during our observation in both resident's rooms. He said that both residents do go to the bathroom independently. He said that Resident #41 needs assistance, but sometimes he does go by himself. During an interview on 1/22/24 at 3:00 pm Administrator said that if a resident were to fall, they would not be able to reach the call light. She said that the call lights were recently replaced on the unit, and it was possible that some of them had not been unwrapped upon installation. During an interview on 1/23/24 at 12:02 pm Maintenance Director said that he had been employed there since May of 2023 and said that the call light system in the unit was replaced sometime around September of 2023 and some strings may have been missed and not been unraveled. He said that he had checked the rest of the call lights in bathrooms on the unit, but that CNA D had already fixed them. Record review of a facility policy titled Answering the Call Light dated 2001 with a revision date of March 2021 read .Explain to the resident that a call system is also located in his/her bathroom .and .be sure the call light is within easy reach of the resident . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675729 If continuation sheet Page 16 of 16