Health inspection·July 22, 2022

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident #34's face sheet dated 07/21/2022 revealed Resident #34 to be an [AGE] year-old male admitted to the facility on [DATE] with a diagnoses of chronic obstructive pulmonary disease, high blood pressure, dementia and history of a traumatic brain injury (injury to the brain caused by an external force). Review of Resident #34's admission MDS assessment dated [DATE] revealed Resident #34 to have a BIMS score 6 to indicate severely impaired cognition. Resident #34 required extensive assistance by two or more people with ADL's. Resident #34 had no swallowing issues and did not require a therapeutic or mechanically altered diet. Review of Resident #34's care plan (undated) revealed Resident #34 had the potential for weight loss with interventions to include the dietitian following up at least quarterly, determine food preferences, monitor food intake and allow ample time to consume meals. Review of Resident #34's physician order dated 06/07/2022 revealed Resident #34 was ordered health shakes twice daily with meals for weight stabilization. An observation on 07/20/2022 at 1:03 PM revealed Resident #34 did not have a health shake with his meal. Review of Resident #34's meal ticket revealed Resident #34 was ordered a mighty shake. In an interview on 07/20/2022 at 1:05 PM, CNA A stated she did not know why Resident #31 did not have his health shake. She said she would get him one. She stated Resident #34 received her [SUPPLEMENT NAME] from the medication aide with her medications. She said she would get her a health shake to go with her meal. She said the meal ticket was unclear for Resident #31 because Resident #31 did not receive [SUPPLEMENT NAME] with her meals. She said Resident #31's ticket needed to be revised. In an observation on 07/20/2022 at 1:10 PM, Resident #34 received his health shake from CNA A and drank 100% of it. In a follow-up observation on 07/21/2022 at 7:40 AM, Resident #31 was not observed to have fortified cereal with her breakfast . Review of Resident #31's meal ticket dated 07/21/2022 for breakfast revealed Resident #31 had fortified cereal ordered as part of her breakfast. In an interview on 07/21/2022 at 7:45 AM CNA D stated Resident #31 did not eat the fortified cereal and they did not give it to her. She said Resident #31's meal ticket needed to be updated. She said she did not know why her meal ticket was not updated and the nurses notified the kitchen staff of changes needed to resident meal tickets. In an interview on 07/21/2022 at 10:07 AM, NTR DIR said when a resident had a changed or new diet order a nurse input the order into the resident's EMR and then completed a diet order communication change form. He said once the kitchen staff received the diet order communication change form, he or one of the assistant dietary managers will make the change to the resident's meal ticket information. He said he had not received any dietary changes for Resident #31 or Resident #34. He said what was on the resident's meal ticket was what should be on their tray. He said even if the resident was known to not eat fortified cereal, it should still be offered until it is discontinued from the meal (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675886 If continuation sheet Page 2 of 14 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 675886 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Coryell Health Rehabliving at the Meadows 110 Chicktown Rd Gatesville, TX 76528 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 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few ticket. He stated health shakes or mighty shakes should be brought with the meal as designated on the meal ticket from the kitchen. In an interview on 07/21/2022 at 10:20 AM, the ADON stated Resident #34 should have had his health shake with his meal and she did not know why staff did not serve it to him. She said the fortified cereal for Resident #31 needed to be discontinued if she did not want to eat it. She said she would reach out to the doctor for further orders for Resident #31. She stated the charge nurse should be checking each resident's meal ticket compared with the tray to ensure the resident received all of their food and supplements as ordered. She stated residents who did not receive their health shakes or supplements would be at risk for weight loss. In an interview on 07/21/2022 at 3:47 PM, the DON stated the resident's food on their tray should match their meal ticket and their meal ticket should match their physician orders. She said even if a resident was known to not eat the fortified cereal it should be offered or discontinued. She said she would check all resident physician orders with meal tickets on the locked unit to ensure consistency with what residents received on their trays. Review of Resident #31's Nutrition Update/Quarterly Review dated 05/27/2022 revealed Resident #31 required a regular diet with regular portions and [NUTRITION SUPPLEMENT] with medications. No additional supplement was noted for Resident #31. Review of Resident #34's Nutrition Update/Quarterly Review dated 05/27/2022 revealed Resident #34 required a regular diet with no documented nutrition supplement recommended. Review of Diet orders policy (undated) revealed the purpose of the policy was to ensure residents and patients are given an accurate meal. The policy noted physicians will be notified of the available diets in the facility and diets will be offered as ordered by the physician. The dietetics professional will be notified of any special diets not listed on the menu. Resident response to special and modified diets will be evaluated and ineffective or inappropriate diets (including texture modifications) will be referred to the physician for discontinuation or change to a more appropriate diet. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675886 If continuation sheet Page 3 of 14 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 675886 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Coryell Health Rehabliving at the Meadows 110 Chicktown Rd Gatesville, TX 76528 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview and record review the facility failed to ensure all drugs and biological medications were not past their expiration dates and had readable labels were labeled in accordance with professional principles for 1 of 4 medication aide carts (C-Hall medication cart) reviewed and also failed to ensure that drugs and biologicals used in the facility were secured properly for 1 of 4 nurse medication carts (E-Hall nurse medication cart) reviewed for label/store drug. The facility failed to ensure expired and/or discontinued medications were removed from the medication carts, and that all medication on the cart had readable labels. The facility further failed to ensure medication carts were not left unlocked and unsupervised. This failure could place residents at risk of not receiving the intended therapeutic benefits of their medications and could place all residents at risk for possible drug diversion. Findings include: Observation on 07/21/2022 at 3:00 PM revealed the facility's C-Hall medication cart with a bottle of cetirizine hydrochloride 10 mg expired on 06/2022. Further observation of the medication cart revealed a bottle of Benadryl 25 mg with a handwritten open date of 12/16/2021. The expiration date on the bottle was unreadable. The C-Hall medication cart also contained a bottle of melatonin 1mg with a label with no readable open date or readable expiration date. In an interview on 07/21/2022 at 3:05 PM MA B stated it was the responsibility of the medication aide to ensure medications on the cart are not expired. She stated she did not notice the medication cetirizine hydrochloride was expired or that the labels on the benadryl and melatonin were not readable. MA B stated the medication bottles should be checked when the medication is administered. MA B stated one resident was receiving the cetirizine hydrochloride daily. MA B further stated no residents had current orders for benadryl or melatonin. Observation on 07/21/2022 at 3:32 PM revealed an unlocked nurse medication cart on E-Hall in the hall next to the nurses station with drawers facing the patient hall where residents could access them. In an interview on 07/21/2022 at 3:39 PM LVN C stated the cart was open and should be locked. She stated she did not leave it open that the other LVN working on the unit did, but she was not currently on the unit. LVN C stated the cart should be locked to ensure no one is able to get into the cart and remove medications. In an interview on 07/21/2022 at 3:50 PM the DON stated the medication carts should be locked at all times to prevent unauthorized removal of medications from the carts and to protect the residents. The DON further stated that all medications on the carts should have readable labels and carts should be checked by the medication aides during the medication pass to ensure no expired medications are on the carts to ensure residents are not receiving expired medications to might have altered therapeutic effects. Review of the facility's policy Storage of medications dated 11/2020 reflected The facility stores (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675886 If continuation sheet Page 4 of 14 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 675886 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Coryell Health Rehabliving at the Meadows 110 Chicktown Rd Gatesville, TX 76528 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 0761 Level of Harm - Minimal harm or potential for actual harm all drugs and biologicals in a safe, secure, and orderly manner. Drugs and biologicals used in the facility are stored in locked compartments .Only persons authorized to prepare and administer medications have access to the locked medications. Drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling .discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed . Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675886 If continuation sheet Page 5 of 14 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 675886 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Coryell Health Rehabliving at the Meadows 110 Chicktown Rd Gatesville, TX 76528 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 designated to meet individual needs for 1 (Resident #12) of 8 residents reviewed for food to meet individual needs. The facility failed to provide Resident #12 with finger foods as ordered by the physician. This failure put residents at risk for poor oral intake, weight loss and malnutrition. Findings included: Review of Resident #12's face sheet dated 07/21/2022 revealed Resident #12 was an [AGE] year-old female admitted to the facility on [DATE] with a diagnosis of Alzheimer's disease (a cognitive disorder that causes decreased cognition and confusion), Type 2 Diabetes Mellitus, history of hip fracture and adult failure to thrive (decline seen in elderly adults related to multiple health conditions resulting in a downward spiral of poor nutrition, weight loss, inactivity, depression and decreasing functional ability). Review of Resident #12's MDS significant change assessment dated [DATE] revealed Resident #12 had a BIMS score of zero to indicate severely impaired cognition. Resident #12 required extensive assistance by two or more staff members for ADL's. Resident #12 required a therapeutic diet. Review of Resident #12's care plan dated 06/25/2021 revealed Resident #12 required for eating staff assistance due to dementia and had a regular diet, thin liquids with fortified cereal. Resident #12 diet changed to finger foods. Interventions included break tasks up into smaller steps, prefers a quiet environment, assist by opening containers and cutting up food, giver verbal cues to prompt, allow adequate time to eat and offer foods she likes and finger foods. Review of Resident #12's physician orders dated 11/03/2021 revealed Resident #12's diet order was regular diet, finger food texture and thin liquids. An observation on 07/20/2022 at 12:40 PM revealed Resident #12 to have chicken cut-up on her plate with au gratin potatoes and stewed tomatoes and okra. Resident #12 took a bite of the chicken using her fingers. Resident #12 did not eat the au gratin potatoes or stewed tomatoes. Review of Resident #12 meal ticket dated 07/20/2022 for lunch meal revealed Resident #12 to have a diet of finger foods, regular texture with the meal choice of lemon pepper chicken cubes, scalloped potatoes and au gratin potatoes and okra & tomatoes. In an observation and interview on 07/20/2022 at 1:00 PM, CNA A placed a disposable bowl of tomato slices in front of Resident #12. Resident #12 picked up the tomato slices and ate them all. CNA A said Resident #12 loved tomatoes and they tried to bring them to her at lunch and dinner. She said this preference was not on Resident #12's meal ticket, but all of the staff knew Resident #12 liked tomatoes. She said she did not know Resident #12 had finger foods on her meal ticket. She said they gave Resident #12 the regular entrée and then add in the tomatoes. She said Resident #12 was not able to use utensils and ate with her fingers. She said she and other facility staff will attempt to feed her the entrée food that was not a finger food and she will not eat very much and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675886 If continuation sheet Page 6 of 14 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 675886 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Coryell Health Rehabliving at the Meadows 110 Chicktown Rd Gatesville, TX 76528 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 prefers to feed herself. She said the au gratin potatoes and tomato and okra were not finger foods. She said she did not know if there was a finger food substitution for the au gratin potatoes and the tomato and okra mix. In a follow-up observation on 07/21/2022 at 7:40 AM, Resident #12 had a cut-up hard fried egg on her plate. Review of Resident #12 meal ticket dated 07/21/2022 for breakfast meal Resident #12 had diet as finger food with regular texture. Resident #12 had selected a hard-boiled egg, sausage and danish for her meal. Resident #12 also had in the notes section of the ticket: fortified cereal. In an interview on 07/21/2022 at 7:45 AM, CNA E said Resident #12 preferred finger foods and liked to feed herself. She said Resident #12 could not eat the fortified cereal on her own and did not like to be fed, so they do not give it to her. She said her meal ticket needed to be updated. She said she was not sure why they gave her a hard fried egg and not the hardboiled egg on the her ticket. She said Resident #12 could eat a hard-boiled egg cut-up on her own. She said Resident #12 already ate her sausage and her danish. In an interview on 07/21/2022 at 10:07 AM, NTR DIR said when a resident has a changed or new diet order a nurse will put the order into the resident's EMR and then completed a diet order communication change form. He said once the kitchen staff received the diet order communication change form, he or one of the assistant dietary managers will make the change to the resident's meal ticket information. He stated he had not received a diet order communication change form for Resident #12 and was not aware that Resident #12 did not eat the fortified cereal. He stated they substitute finger foods in the main entrée for residents who have a finger food diet order. He stated for instance for potatoes they will substitute tater tots. He stated the au gratin potatoes and tomato, and okra mix were not finger foods and should not have been served to Resident #12. In an interview on 07/21/2022 at 10:20 AM, ADON stated Resident #12 should have received finger foods for all part of her entrée and a substitution should have been make for the au gratin potatoes and tomato and okra mix. She said she would speak with Resident #12's physician and have the fortified cereal discontinued since Resident #12 did not like it. She said Resident #12's weight was stable. She said she would update Resident #12's orders and send a dietary change communication form to have Resident #12's meal ticket updated. She said she was not sure why it had not been updated with her preferences until today. In an interview on 07/21/2022 at 1:00 PM, the RP for Resident #12 stated she was not aware of Resident #12's finger food diet order not being followed. She said it made sense that they did not give Resident #12 finger foods because when she visited Resident #12, she noticed Resident #12 was covered in food all the time. In an interview on 07/21/2022 at 3:35 PM, LVN F stated she was not aware of meal tickets and what was served to residents being inaccurate. She said during meal service she checked the resident's trays to ensure they match the meal ticket. She said if a food was not available, they make a substitution. She said for Resident #12 she did not know about the finger food diet order. She said when they received a new or updated diet order from the resident's physician, she put it into the resident's EMR. She then completed a dietary change form and gave it to the kitchen staff to change in their system. She said the NTR DIR required a copy of the physician order if it was physician directed change. She said the dietitian can make some changes like adding preferences or health shakes. She said (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675886 If continuation sheet Page 7 of 14 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 675886 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Coryell Health Rehabliving at the Meadows 110 Chicktown Rd Gatesville, TX 76528 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 the dietitian changes were communicated with dietary change form too. Level of Harm - Minimal harm or potential for actual harm In an interview on 07/21/2022 at 3:47 PM, the DON stated the resident's food on their tray should match their meal ticket and their meal ticket should match their physician orders. She was not aware of Resident #12 not receiving finger foods at meals. She would not consider au gratin potatoes and tomato and okra mix a finger food. She said she was not aware of Resident #12 not liking the fortified cereal and the physician would need to discontinue the order and they would remove it from her meal ticket. She said Resident #12's preference for fresh sliced tomatoes at lunch and dinner would need to be added. She said the nurse should check the meal tickets and confirm the food served was what on the meal ticket. She said not having the correct food for residents could result in decreased intake and weight loss. Residents Affected - Few Review of Resident #12 Nutrition Quarterly Review dated 07/06/2022 and written by RD revealed Resident #12 diet order was finger food and regular portion size. Resident #12 was to receive snacks as needed and health shakes if intake of meal was less than 50%. Resident #12 noted with stable weight and meal intake was greater than 75% for most meals. Review of Diet orders policy (undated) revealed the purpose of the policy was to ensure residents and patients are given an accurate meal. The policy noted physicians will be notified of the available diets in the facility and diets will be offered as ordered by the physician. The dietetics professional will be notified of any special diets not listed on the menu. Resident response to special and modified diets will be evaluated and ineffective or inappropriate diets (including texture modifications) will be referred to the physician for discontinuation or change to a more appropriate diet. Review of System for Recording Food Preferences Policy (undated) revealed food preferences will be kept on file for each resident. The policy further revealed disliked foods should be noted on the form and update resident information on a daily basis or as needed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675886 If continuation sheet Page 8 of 14 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 675886 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Coryell Health Rehabliving at the Meadows 110 Chicktown Rd Gatesville, TX 76528 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 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to ensure each resident received food that accommodates resident preferences for 1 of 8 (Residents #2) residents reviewed for food preferences. The facility failed to provide Resident #2 a lactose free diet as designated in her physician orders and on her meal ticket. This failure could place residents at risk for reactions to foods not tolerated, gastrointestinal complications and decreased oral intake. Findings included: Review of Resident #2 face sheet dated 07/21/2022 revealed Resident #2 was an [AGE] year-old female admitted to the facility on [DATE] with a diagnosis of pneumonia, multiple sclerosis (disease in which the immune system eats away at the protective covering of the nerves), dementia (disorder that causes impairments in thinking, memory and behavior), major depressive disorder and history of a stroke. Review of Resident #2 annual MDS assessment dated [DATE] revealed Resident #2 had a BIMS score of six to indicate severe impairment in cognition. Resident #2 required extensive assistance by two or more staff members for ADL's. Resident #2 required supervision and set-up help for eating. Resident #2 was noted to have difficulty or pain when swallowing but did not require a therapeutic or mechanically altered diet. Review of Resident #2 care plan dated 07/21/2022 revealed Resident #2 was noted to have allergies to eggs and lactose with an intervention to not give medications or offer eggs or food items with lactose present. Resident #2 had potential for weight loss due to new admission added as a problem on 06/27/2019. An intervention included was Resident #2 had a regular diet with thin liquids and lactose free milk only. Review of Resident #2 physician orders dated 01/18/2021 revealed Resident #2 had a diet order for regular diet, regular texture, thin liquids with intolerance to milk and no eggs or cheese. An observation on 07/20/2022 at 1:00 PM revealed Resident #2 to have a piece of cheesecake with her lunch. In an interview on 07/20/2022 at 1:02 PM, Resident #2 shook her head yes when asked if she would eat the cheesecake since she was lactose intolerant. Review Resident #2 meal ticket dated 07/20/2022 for lunch revealed Resident #2 had a regular diet, regular texture with intolerance to milk and no eggs or cheese. In an interview on 07/20/2022 at 1:10 PM, CNA E stated Resident #2 liked dairy foods and they would give her small portions when she asked for them for the past few months. She said Resident #2 did not experience symptoms such as diarrhea, nausea and vomiting when given dairy foods in small amounts. She said at breakfast Resident #2 will ask for milk or eggs and they gave her a small cup of milk (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675886 If continuation sheet Page 9 of 14 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 675886 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Coryell Health Rehabliving at the Meadows 110 Chicktown Rd Gatesville, TX 76528 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 0806 or a small portion of eggs. Level of Harm - Minimal harm or potential for actual harm In an interview on 07/20/2022 at 1:15 PM, ASST DM stated Resident #2 should have been given the alternate dessert of cake instead of the cheesecake. She stated Resident #2 had a history of lactose intolerance and cheesecake could cause her to have symptoms of lactose intolerance including nausea, vomiting and or diarrhea. She said staff should have checked Resident #2's meal card prior to serving Resident #2 the cheesecake and they would have known she could not have the cheesecake. Residents Affected - Few In an interview on 07/21/2022 at 10:07 AM, NTR DIR said when a resident has a changed or new diet order a nurse will put the order into the resident's EMR and then completed a diet order communication change form. He said once the kitchen staff received the diet order communication change form, he or one of the assistant dietary managers will make the change to the resident's meal ticket information. He said food allergies or intolerances were on the meal ticket and should be followed as ordered by the physician. He stated Resident #2 should not have been given the cheesecake for dessert as her meal ticket noted her to be lactose intolerant and said no milk, cheese or eggs. In an interview on 07/21/2022 at 10:20 AM, the ADON stated Resident #2 had mild lactose intolerance and the doctor ordered lactaid in April 2022 so Resident #2 could have small amounts of dairy products without side effects. She stated Resident #2 did not experience side effects of dairy products if given in small amounts. She said if Resident #2 had too much dairy products she had diarrhea. She said Resident #2's meal ticket needed to be updated to say small amounts of dairy were okay after a physician order was received to change Resident #2's meal ticket . She said the staff were giving her small amounts of dairy products because Resident #2 liked milk and eggs and would become upset if she was not allowed to have it. In an interview on 07/21/2022 at 3:47 PM, the DON stated Resident #2's meal ticket needed to be updated to reflect that Resident #2 could have small amounts of dairy products. She stated Resident #2's family did not want her to have dairy products but Resident #2's preference was to have small amounts. She stated Resident #2 did not experience side effects such as diarrhea if given dairy products in small amounts. She stated Resident #2 became upset if not given milk or eggs when she asked, and they wanted to honor her food preferences when they could. She stated the ADON was in the process of obtaining a new physician order to change Resident #2's meal ticket. She said Resident #2 should not have been given the cheesecake with lunch. Review of Resident #2 Nutrition update/quarterly review dated 11/29/2021 revealed Resident #2 had a diet order of regular lactose free, no dairy, coffee, yogurt or eggs. Review of Diet orders policy (undated) revealed the purpose of the policy was to ensure residents and patients are given an accurate meal. The policy noted physicians will be notified of the available diets in the facility and diets will be offered as ordered by the physician. The dietetics professional will be notified of any special diets not listed on the menu. Resident response to special and modified diets will be evaluated and ineffective or inappropriate diets (including texture modifications) will be referred to the physician for discontinuation or change to a more appropriate diet. Review of System for Recording Food Preferences Policy (undated) revealed food preferences will be kept on file for each resident. The policy further revealed disliked foods should be noted on the form and update resident information on a daily basis or as needed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675886 If continuation sheet Page 10 of 14 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 675886 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Coryell Health Rehabliving at the Meadows 110 Chicktown Rd Gatesville, TX 76528 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 0808 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to follow the therapeutic diet as ordered by the physician for 1 of 8 (Resident #4) residents reviewed for therapeutic diets. The facility failed to provide the physician ordered mechanical soft diet for Resident #4. This failure could contribute to meal dissatisfaction, poor food intake, and the potential for weight loss. Findings included: Review of Resident #4 face sheet dated 07/21/2022 revealed Resident #4 was an [AGE] year-old female admitted to the facility 10/24/2016 with a diagnoses of bacterial pneumonia (bacterial infection of the lungs), dementia (disorder that causes impairments in thinking, memory and behavior), major depressive disorder, hypothyroidism (low thyroid hormone disorder), high blood pressure, endometriosis (condition in which tissue that usually grows in uterus, grows outside of the uterus) and atrial fibrillation (irregular heart caused by the heart chambers beating out of sync). Review of Resident #4 annual MDS assessment dated [DATE] revealed Resident #4 had a BIMS score of zero to indicate Resident #4 had severely impaired cognition. Resident #4 required extensive assistance by two or more staff for ADL's. Resident #4 required one person assistance with eating. Resident #4 was not noted to have a swallowing disorder but did require a mechanically altered diet. Review of Resident #4 care plan dated 09/22/2020 revealed Resident #4 nutritional care area triggered related to swallowing issues, low/high BMI, mechanically altered diet and therapeutic diet to manage high blood pressure, diabetes mellitus, renal failure (condition in which the kidneys do not fully function to clean a patient's blood) and dysphagia (difficulty swallowing). The care plan goal was resident will maintain current weight and consume at least 50% of all meals for the next 90 days. Interventions included assess fluid intake and hydration status, finger foods so she can walk and eat, mechanical soft diet, encourage good nutritional intake, two calorie health shake twice daily, monitor assistance needed with nutritional intake and notify physician of changes. Additionally, the staff should offer food alternatives when appropriate for any meal. Review of Resident #4's physician orders dated 03/02/2021 revealed Resident #4's diet order was regular diet, mechanical soft finger foods and thin liquids. In an observation on 07/20/2022 at 12:45 PM, Resident #4 had pureed foods on her plate and was assisted by CNA A. Review of Resident #4 meal ticket dated 07/20/2022 for the lunch meal, Resident #4 had a regular diet, mechanical soft texture and thin liquids. Pureed was hand-written at the bottom of the ticket. In an interview on 07/20/2022 at 12:48 PM, CNA A stated Resident #4 was recently changed to a pureed diet and her meal ticket had not been updated in the dietary system. She said Resident #4 had been chewing her food for extended amounts of time and did not eat as much as a result so the nurse downgraded her to pureed . She said Resident #4 ate the pureed food well. She said she was not sure who (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675886 If continuation sheet Page 11 of 14 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 675886 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Coryell Health Rehabliving at the Meadows 110 Chicktown Rd Gatesville, TX 76528 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 0808 Level of Harm - Minimal harm or potential for actual harm wrote pureed on the ticket. When asked how an unfamiliar staff member to Resident #4 would know she needed a pureed diet if someone did not write pureed on the ticket, she said she did not know. In a follow-up observation on 07/21/2022 at 8:15 AM, Resident #4 was served pureed foods and was assisted by CNA E. Residents Affected - Few Review of Resident #4 meal ticket dated 07/21/2022 for the breakfast meal, Resident #4 had a regular diet, mechanical soft texture and thin liquids. Pureed was hand-written at the bottom of the ticket. In an interview on 07/21/2022 at 8:20 AM, CNA E stated Resident #4 was recently changed to pureed maybe last Friday 07/15/2022. She said Resident #4 kept chewing and chewing her food and then would spit it out and the nurse downgraded Resident #4's diet to pureed. She stated Resident #4 ate the pureed foods well. She said she did not know who wrote pureed on the ticket. When asked how an unfamiliar staff member to Resident #4 would know she needed a pureed diet if someone did not write pureed on the ticket, she said she did not know. In an interview on 07/21/2022 at 10:07 AM, NTR DIR said when a resident has a changed or new diet order a nurse will put the order into the resident's EMR and then completed a diet order communication change form. He said once the kitchen staff received the diet order communication change form, he or one of the assistant dietary managers will make the change to the resident's meal ticket information. He had not received a diet order communication change form for Resident #4. For Resident #4 the kitchen did not receive a diet order communication change from nursing staff and were unaware of the pureed diet order change. He stated unfamiliar staff to Resident #4 would not have known from her meal ticket that Resident #4 required pureed texture and not mechanical soft as it says on her meal ticket. NTR DIR said they did not change diet orders on the meal ticket without a physician order. He stated he did not know who wrote pureed on Resident #4's ticket. In an interview on 07/21/2022 at 10:20 AM, the ADON stated Resident #4's physician signed off on the diet order change to pureed texture. She said nursing staff have been trialing pureed texture with Resident #4 due to her chewing the mechanical soft food and not swallowing it. She said she made the change in Resident #4's EMR and would complete the dietary change communication form for the kitchen staff to make the change on Resident #4's meal ticket. She stated the nurses on this unit were aware of Resident #4 being trialed on pureed foods but did not know how an unfamiliar staff member would know Resident #4 required a pureed texture. She said Resident #4 was not changed to pureed due to a swallowing, choking or safety issue, but changed to pureed to see if it would increase her intake. In an interview on 07/21/2022 at 3:47 PM, the DON stated Resident #4 was changed to pureed due to chewing her food a long time and spitting it out. She said she was changed in the EMR and the dietary system today after they received the physician order . She said she did not know how staff unfamiliar to Resident #4 would know she was being trialed on the pureed diet if it was not written on the meal ticket. She said the physician order and dietary system should have been updated sooner to reflect the change. In an interview on 07/22/22 at 11:35 AM ST said was notified last week by nursing staff of Resident #4 needing a pureed diet texture due to increased chewing times and less intake. She did not do an evaluation since it was not related to safety but would if needed if it was related to dysphagia, ie coughing while eating or choking episode. She said Resident #4 had a steady decline in cognition (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675886 If continuation sheet Page 12 of 14 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 675886 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Coryell Health Rehabliving at the Meadows 110 Chicktown Rd Gatesville, TX 76528 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 0808 recently related to her medical conditions and therefore the need for pureed is not surprising. Level of Harm - Minimal harm or potential for actual harm In an interview on 07/22/2022 at 11:47 AM, RD stated she was not involved in the decision to change Resident #4 to pureed diet texture and was not notified she was having issues with mechanical soft diet texture. She said speech therapy would likely be the specialty that would downgrade a diet texture. Residents Affected - Few Review of Resident #4 Nutrition Update/Quarterly Review dated 07/01/2022 revealed Resident #4 diet order as mechanical soft, finger food and standard size portions. Resident # 4 had no change in dentition or oral health and was noted to have generally good intake with many meals documented at 75-100%. There were no new recommendations by the dietitian. Review of Diet orders policy (undated) revealed the purpose of the policy was to ensure residents and patients are given an accurate meal. The policy noted physicians will be notified of the available diets in the facility and diets will be offered as ordered by the physician. The dietetics professional will be notified of any special diets not listed on the menu. Resident response to special and modified diets will be evaluated and ineffective or inappropriate diets (including texture modifications) will be referred to the physician for discontinuation or change to a more appropriate diet. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675886 If continuation sheet Page 13 of 14 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 675886 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Coryell Health Rehabliving at the Meadows 110 Chicktown Rd Gatesville, TX 76528 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 refrigerator, walk-in cooler and freezer. Residents Affected - Few The facility failed to label and date open foods stored in the facility's stand-alone refrigerator, walk-in cooler, and stand-alone freezer. These failures could place residents who ate food from the kitchen at risk for consumption of expired or outdated leftover food and food borne illness. Findings included: An observation on 07/20/2022 at 10:20 AM revealed a container of frozen strawberries in a plastic container with no label or date in stand-alone freezer #1. An observation on 07/20/2022 at 10:25 AM revealed in the walk-in cooler multiple black containers with clear lids containing cut-up vegetables, shredded cheese and sour cream with no label or date. Two packages of sliced cheese were open with no date of opening. An observation on 07/20/2022 at 10:30 AM revealed in refrigerator #2 multiple black containers with clear lids containing cut up vegetables with no label or date. In an interview on 07/20/2022 at 10:35 AM, ASST DM stated all the foods should have had a label and date so staff know when to throw the food away. She stated in the walk-in cooler they usually cover the whole rack with the containers with a plastic cover and date it but due to the recent remodeling the cook did not have his routine rack. She said he should have labeled each shelf with the date the food was put into the containers. She said the frozen strawberries should have had a label the date they were frozen so they would know when to use them by or throw them out. She said serving foods past their use by date could expose residents to food borne illness. Review of Food Storage Policy (undated) revealed food is stored, prepared and transported at an appropriate temperature and by methods designed to prevent contamination. Food items will be stored on shelves, labeled/dated (label must contain name, item date prepared and the date it must be used or thrown out by). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675886 If continuation sheet Page 14 of 14