Health inspection·September 28, 2023

F 0583 Reviewed document Resident rights that speaks to confidentiality and was signed by all staff upon employment. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675886 If continuation sheet Page 2 of 17 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 09/28/2023 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation and record review, the facility failed to ensure that a resident who needs respiratory care was provided such care, consistent with professional standards of practice for 4 of 6 residents (Resident #35, #16, #43, #210) reviewed for ventilator orders. Residents Affected - Some The facility failed to label and date O2 tubing and water concentrator bottles weekly, per physician's orders, for Resident #35, #16, #43, #210. This failure could result in residents receiving incorrect or inadequate ventilator support and could result in a decline in health. Findings include: Review of Resident #35's MDS dated [DATE] reflected a [AGE] year-old female who was admitted on [DATE] with diagnoses of Chronic Kidney Disease (loss of kidney function), A-Fib (irregular, rapid heart rhythm), Hypothyroidism (decreased production of thyroid hormones), Dehydration, CHF (heart disease that causes SoB), Dementia and Hyperlipidemia (elevated lipid levels). Review of Resident #35's Significant Change in Status MDS dated [DATE] reflected no coding for oxygen. Resident #35 had a BIMS score of 3. Review of Resident #35's Comprehensive Care Plan, dated 07/15/23, reflected the following: Monitor oxygen saturation level related to supplemental oxygen use as ordered by provider. Review of Resident #35's consolidated physician's orders reflected the following: 09/18/23 21:00:00 CDT, Monday, CHANGE Oxygen Tubing and Water every Monday night *** Ensure to Date and Inital *** During an observation on 09/25/23, around 11:00 AM, Resident #35 was observed in her room connected to an Oxygen concentrator. The connected tubing was dated 09/08/23 and the water concentrator bottle was dated 09/23/23. Review of Resident #16's MDS reflected an [AGE] year-old female who was admitted on [DATE] with diagnoses of Cerebral Infarction (stroke), GERD (reflux), COPD (lung disease causing obstructed airflow from the lungs), Anemia (red blood cell deficiency), Cardiac Arrhythmia (abnormal heart rhythm), Presence of Cardiac Pacemaker and Osteoarthritis. Resident #16 had a BIMS of 6 and Section O reflected the use of oxygen therapy. Review of Resident #16's Care Plan, initiated 08/30/2023, reflected the following: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675886 If continuation sheet Page 3 of 17 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 09/28/2023 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 0695 Intervention: Evaluate Effectiveness of O2 and Respiratory Level of Harm - Minimal harm or potential for actual harm Review of Resident #16's consolidated physician's orders reflected the following: - Residents Affected - Some 09/18/23: Monday, CHANGE Oxygen Tubing and Water every Monday night *** Ensure to Date and Initial *** 09/18/23: Oxygen Therapy TAR, BID, 1, Nasal Cannula, PRN, Apply 1 L via Nasal Cannula PRN for SoB or sats less than 90% During an observation on 09/25/23, around 11:00 AM, Resident #16's room was observed with an Oxygen concentrator at her bedside. The connected tubing was dated 09/08/23 and the water concentrator bottle was dated 09/10/23. Review of Resident #43's Quarterly MDS dated [DATE] reflected an [AGE] year-old female who was admitted on [DATE] with diagnoses of CHF (heart disease that causes SoB), A-Fib (irregular, rapid heart rhythm), Cognitive Impairment, and Hemiplegia Affecting Right Dominant Side. Resident #43's BIMS was not documented and Section O of the MDS reflected the use of oxygen. Review of Resident #43's Comprehensive Care Plan, dated 07/19/23, reflected the following: Monitor respiratory status related to supplemental oxygen therapy resident non-compliance Review of Resident #43's consolidated physician's orders reflected the following: 09/24/23: Sunday, CHANGE Nebulizer Setup every Sunday night *** Ensure to Date and Initial *** 09/18/23: Monday, CHANGE Oxygen Tubing and Water every Monday night *** Ensure to Date and Initial *** 06/27/23: Oxygen Therapy TAR, BID, 3, Nasal Cannula, 366 days; Continuous Supplemental Oxygen Therapy via Nasal Cannula @ 3.5 LPM 07/23/23: Oxygen Check TAR, every week, change resident oxygen tubing and cannister once weekly (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675886 If continuation sheet Page 4 of 17 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 09/28/2023 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Observation of Resident #43's room on 09/25/23, around 11:00 AM, revealed the presence of an oxygen concentrator. The connected tubing and water concentrator bottle were both undated. A nasal cannula was observed on the ground next to the oxygen concentrator. Observation on 09/25/23 at 3:03 PM revealed Resident #43 in her room and was connected to the oxygen concentrator, with the nasal cannula inserted into their nose. The tubing remained undated. Observation of Resident #43's room on 09/26/23 at 10:11 AM revealed the presence of an oxygen concentrator. The connected tubing was dated 09/08/23 and the water concentrator bottle was undated. The resident was not connected to the concentrator, but the nasal cannula was observed on the floor. An observation on 09/27/23 of Resident #43 revealed she was sitting in her room in her recliner chair, reading a book. Oxygen concentrator was in her room. Nasal cannula was observed positioned on the oxygen machine. During an observation and interview on 09/27/23 at 11:42 AM, Resident #43 revealed she can place her nasal cannula in her nose on her own. She stated, I guess I should put this on. Resident was observed grabbing her nasal cannula and appropriately placing it on her nose. She stated when she leaves her room, she can remove the cannula herself. Review of Resident #210's MDS dated [DATE] reflected an [AGE] year-old female who was admitted on [DATE] with diagnoses of CHF (heart disease that causes SoB), Chronic A-Fib (irregular, rapid heart rhythm), HTN (high blood pressure), Osteoarthritis, Obstructive Sleep Apnea (stopping breathing during sleep), Dementia, and Anxiety. Resident #210 had a BIMS score of 8 and oxygen was not coded in the MDS. Review of Resident #210's Comprehensive Care Plan, dated 07/19/23, reflected the following: Encourage resident to keep nasal cannula in place for supplemental oxygen therapy related to non compliance. Review of Resident #210's consolidated physician's orders reflected the following: 09/18/23: Monday, CHANGE Oxygen Tubing and Water every Monday night *** Ensure to Date and Initial *** 09/19/23: Oxygen Therapy TAR, Daily, 2, Nasal Cannula, PRN, Apply 2L of o2 via Nasal Cannula as needed for SoB or saturation level (stats) less than 90% During an observation on 09/25/23 at 11:05 AM, Resident #210 was observed in bed, with O2 Concentrator on and nasal cannula was in the resident's nose. The connected tubing was undated. During an interview on 09/27/23 at 11:45 AM, LVN A stated the nurses have been trained and were (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675886 If continuation sheet Page 5 of 17 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 09/28/2023 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some responsible for changing and ensuring the tubing on oxygen concentrators weekly and are up to date. She stated there were residents at the facility who may remove their nasal cannulas on their own, but they provide education on infection control for those residents who were capable to do so. LVN A stated the risks of not changing the tubing weekly could pose the risk of infection. Interview on 09/27/23 at 2:14 PM with LVN B revealed nurses were responsible for changing the tubing on oxygen concentrators. She stated when they were changed, the tubing should have a label with the date it was changed; she stated the water bottle should also be labeled and dated. She stated this information (orders) can be found on the computer; with the new software, the facility has begun to put orders to change the tubing and bottle weekly. During an interview on 09/28/23 at 10:00 AM, the DON stated the expectation for changing oxygen tubing was that it should be changed at least every (7) days to avoid complications including infection to the resident. She stated this should be reflected in residents MAR. During an interview on 09/28/23 at approximately 12:00 PM, the ADM stated regarding labeling and dating oxygen tubes and water concentrator bottles, she would expect staff to follow their policy. She stated the risks of not ensuring oxygen concentrator equipment was not labeled and dated per physician's orders was that there is a risk of infection which could cause harm to the resident. Review of a facility policy titled Oxygen Administration, last revised October 2021, reflected the following: Purpose: 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675886 If continuation sheet Page 6 of 17 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 09/28/2023 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 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure each residents drug regimen was free from unnecessary drugs by having an indication for use for 3 (Residents #40,19 and 38) of 3 residents reviewed for unecessary drugs. Residents Affected - Few The facility failed to have adequate indications for routine medications for Residents #40, 19 and 38. This failure could potentially affect all residents that receive routine medications from receiving unnecessary medications. Findings include Review of Resident # 40's face sheet dated 07/14/2023 revealed an [AGE] year-old female admitted on [DATE]. Her diagnoses included hypertension (elevated blood pressure), septicemia( infection of the blood stream), wound infection (infection to open wound), hyperlipidemia( High level of fat particles in the blood), thyroid disorder( disfunction of thyroid), and non-Alzheimer's dementia ( a group of thinking and social symptoms that interfere with daily function not related to Alzheimer's). Review of Resident # 40's MDS dated [DATE] revealed a BIMS score of 4 (0-7 indicates severe cognitive impairment). Review of Resident # 40's Physician's orders revealed the following medications with no indications for use : Ascorbic Acid 500 mg 1-tab po BID Calcium -vitamin D (Calcium500+D) 1-tab po daily Cholecalciferol 25 mcg po daily Levothyroxine 100 Mcg po daily Melatonin-pyridoxine 1 tab every night at bedtime MiraLAX 17 g po daily K-Tab 10 mEq po daily Pravastatin 20 mg I tab po every night at bedtime Senna 8.6 mg 1-tab po daily Zinc Sulfate 50 mg po daily Arginaide 1 packet po daily (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675886 If continuation sheet Page 7 of 17 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 09/28/2023 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 0757 Prostat 30 ml po daily Level of Harm - Minimal harm or potential for actual harm Aspirin 81 mg po daily Remeron 15 mg po every night at bedtime Residents Affected - Few Review of Resident # 40's Medication administration record dated 9/28/2023 revealed the following medications where received by the resident. Ascorbic Acid 500 mg 1-tab po BID Calcium -vitamin D (Calcium500+D) 1-tab po daily Cholecalciferol 25 mcg po daily Levothyroxine 100 Mcg po daily Melatonin-pyridoxine 1 tab every night at bedtime MiraLAX 17 g po daily K-Tab 10 mEq po daily Pravastatin 20 mg I tab po every night at bedtime Senna 8.6 mg 1-tab po daily Zinc Sulfate 50 mg po daily Arginaide 1 packet po daily Prostat 30 ml po daily Aspirin 81 mg po daily Remeron 15 mg po every night at bedtime Review of Resident # 19's face sheet dated 5/26/2023 revealed an [AGE] year-old male with diagnoses that included Clostridium difficile colitis( inflammation of the colon caused by the bacteria Difficile), essential hypertension ( elevated blood pressure), acute myocardial infarction( heart attack), chronic obstructive pulmonary disease( a group of lung diseases that block air flow and make it difficult to breath), Dementia( group of thinking and social symptom that interfere with daily function), history of traumatic brain injury( brain dysfunction caused by an outside force), and psychotic disturbance( a mental disorder characterized by a disconnection from reality). Review of Resident # 19's MDS revealed a BIMS score of 03 (0-7 indicated severe cognitive impairment). Review of Resident # 19's Physician's orders revealed the following medications with no indications (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675886 If continuation sheet Page 8 of 17 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 09/28/2023 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 0757 for use: Level of Harm - Minimal harm or potential for actual harm Eliquis 5 mg 1 tab BID Vitamin D3 2,000 units po daily Residents Affected - Few Cardizem LA 180 mg po daily (hold parameters in place) Nexium 20 mg tab 1 po daily Tramadol 50 mg 1 tab bid Potassium Chloride 20 [NAME] tab- ER po bid Florastor 250 mg cap po daily Review of Resident # 19's Medication Administration record dated 9/28/2023 indicated the resident received the following medications. Eliquis 5 mg 1 tab BID Vitamin D3 2,000 units po daily Cardizem LA 180 mg po daily (hold parameters in place) Nexium 20 mg tab 1 po daily Tramadol 50 mg 1 tab bid Potassium Chloride 20 [NAME] tab- ER po bid Florastor 250 mg cap po daily Review of Resident # 38's face sheet dated 9/28/23 revealed a [AGE] year old female admitted on [DATE] with diagnoses that included obstructive sleep apnea ( intermittent airflow blockage during sleep), Major depressive disorder ( persistently low of depressed mood causing significate disruption in daily life), gastroesophageal reflux disease( a digestive disease in which stomach acid irritates the food pipe lining), Diabetes Mellitus, type 2 ( a chronic condition is which the body processes blood sugar) atrial fibrillation( an irregular usually fast heart rate), and chronic kidney disease( a condition where the kidney had trouble filtering the blood) Review of Resident # 38's MDS shows a BIMS score of 09 (8-12 suggest moderate cognitive impairment). Review of Resident # 38's Physician's orders revealed the following medications with no indication for use. Fluoxetine 20 mg 1 tab daily (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675886 If continuation sheet Page 9 of 17 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 09/28/2023 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 0757 Entresto 24 mg-26 mg 1-tab po bid Level of Harm - Minimal harm or potential for actual harm Vitamin D3 2000 mg daily po Jardiance 10 mg 1-tab po daily Residents Affected - Few Zetia 10mg 1-tab po daily Ferrous Sulfate 325 mg 1-tab po tid Flonase 50 mcg spray 2 sprays into each nostril daily Furosemide 20 mg 1-tab po daily Gabapentin 200 mg po 1 cap daily Levothyroxine 50 mcg 1-tab po daily Metoprolol Succinate ER 25 mg I tab po daily (parameter in place with no indication for use) Crestor 10 mg 1-tab po daily Humalog 10 units subcutaneous injection with meals and bedtime Pantoprazole 40 mg 1-tab po daily Voltarin 1 app topical bid Aspirin 81 mg 1 daily po Levemir 24 units subcutaneous bid with meals Review of Resident # 38's Medication Administration Record dated 9/28/2023 indicated that the resident received the following medications Fluoxetine 20 mg 1 tab daily Entresto 24 mg-26 mg 1-tab po bid Vitamin D3 2000 mg daily po Jardiance 10 mg 1-tab po daily Zetia 10mg 1-tab po daily Ferrous Sulfate 325 mg 1-tab po tid Flonase 50 mcg spray 2 sprays into each nostril daily (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675886 If continuation sheet Page 10 of 17 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 09/28/2023 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 0757 Furosemide 20 mg 1-tab po daily Level of Harm - Minimal harm or potential for actual harm Gabapentin 200 mg po 1 cap daily Levothyroxine 50 mcg 1-tab po daily Residents Affected - Few Metoprolol Succinate ER 25 mg I tab po daily (parameter in place with no indication for use) Crestor 10 mg 1-tab po daily Humalog 10 units subcutaneous injection with meals and bedtime Pantoprazole 40 mg 1-tab po daily Voltarin 1 app topical bid Aspirin 81 mg 1 daily po Levemir 24 units subcutaneous bid with meals Interview with the DON on 9/27/2023 at 5:30 pm, she said she was not aware that there were medications without a diagnosis that indicated what they were for. She stated she just started and have not had a chance to look at anything. She stated there was a potential harm to the resident as they may not be being treated for all their disease processes. Interview with the ADM on 9/28/2023 at 11:00 am, she stated that she was under the impression that indication for the medication was part of the physician order and she was not sure how it could have been missed by so many practitioners that review the charts. She stated that she saw a significate potential for harm to the residents who might not get the correct treatment needed. Attempted to contact Pharm on 9/28/2023 at 10:00 am and 11:30 am, no answer and no return phone call . Record review of the policy titled Medication and treatment orders undated read orders for medications must include a. name and strength of the drug b. number of doses, start and stop date, and/or specific duration of therapy; c. dosage and frequency of administration d. Route of administration E. Clinical condition or symptoms for which the medication is prescribed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675886 If continuation sheet Page 11 of 17 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 09/28/2023 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 that all drugs and biologicals were stored in locked compartments and inaccessible to unauthorized staff, visitors, and residents for 2( Hall E treatment cart , Wound care) of 9 medication/treatment carts reviewed for medication storage in that: Treatment Cart #1 was left unattended and unlocked at the nurse's station on 9/25/23 and 9/26/23. Wound care cart #2 was left unlocked outside of a resident room This failure could allow residents, unsupervised access to prescription and over the counter medications. Findings Include: Observation on 9/25/2023 at 10:21am revealed, Hall E treatment cart was unsupervised and unlocked at the nurse's station.RN A was sitting out of eyesight of the cart at the nurse's station, . Review of the contents of the cart revealed glucometer supplies, insulin pens, insulin syringes, some over the counter medication, prescription ointments and treatment, secured locked box. Treatment cart secured at 10:22 am by RN A Interview on 09/25/2023 at 10:25 am with RN A, she said she was the nurse assigned to E hall, and she stated she was responsible for the treatment cart. She stated she was not aware the cart was unlocked and does not remember how long ago she used it. She stated that if a resident was able to access some of the supplies or medications on the cart, potential harm could come to the resident for unauthorized use med medications. Interview on 09/25/2023 at 10:30 am with the IDON, she stated that the nurses were responsible for the treatment cart on their assigned halls. Treatment carts were considered medication carts and fall under the same policy. Medication and treatment carts were to be locked when not in use. Potential harm to the residents was access to unauthorized medication and treatments. Observation on 9/25/2023 at 11:00 am revealed, the Wound care cart was unsupervised and unlocked in front of a resident room on Hall B. The I DON was in the hall and noticed the cart was unlocked and secured it at 11:01 am. The cart was removed from the floor by the IDON. Cart contained prescription creams, dressing supplies, antiseptic wipes and several pair of scissors. Interview on 9/25/2023 at 11:15 am with wound care nurse, she stated she was aware that the cart was supposed to be locked, but the lock was broken and should be in this week. She stated that she placed a work order for repair of the lack a week ago and replacement has been ordered. She stated that she has removed most of the medications and creams. She stated that with most of the medication and creams off the cart there was not a potential danger. She stated she was not aware of a policy that stated it should not be used since most of the supplies were in her office. Interview on 09/25/203 at 11:20 am, the IDON stated that she was not aware the lock was broken, it should have been reported to her and the cart should have been taken out of service. She stated even (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675886 If continuation sheet Page 12 of 17 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 09/28/2023 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 with minimal medication on the cart there was still a potential risk to residents from the equipment and over the counter creams on the cart. Observation and interview on 9/26/2023 at 11:32 am revealed the E hall treatment cart was at nurses' station unsupervised and unlocked. RN B stated he was unaware the cart was unlocked and stated he last used it at about 9:30 am. Cart secured at 11:35 am By RN B. Interview on 9/26/2023 at 11:35 am with RN B, he stated he was an agency nurse and had been oriented to the facility medication cart policy. He stated he knew that medication and treatment carts should be locked when not in use. He stated he simply forgot to lock it. He said that he felt there was a potential danger for the resident to get something they don't need with the cart opened. Interview on 9/26/2023 at 11:50 am with the ADON, he stated that medication and treatment carts were to be locked when not in use. He stated that agency nurses were oriented to facility policies. He stated that residents were at risk for potential harm with access to unauthorized medications. Interview on 9/28/2023 at 11:00 am with the ADM, she stated her expectation was that the nursing staff treat all carts with medications on it as a medication cart and the policy states they were to be locked with not in use or eyesight. She stated that residents can have access to medication on an unlocked cart and that could be potential harm. Record Review of the policy storage of medications dated November 2020. 6. Compartments (including but not limited to, draws, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals are locked when not in use. Unlocked medication carts are not left unattended. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675886 If continuation sheet Page 13 of 17 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 09/28/2023 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 observation, interview and record review, the facility failed to ensure residents receive food that accommodates their preferences for 1 out of 1 resident (Resident #206) reviewed for food and nutrition services. The facility failed to complete required documentation to ensure Resident #206 was served a regular texture diet based on her preference and assessment. This failure could place residents at risks for a diminished quality of life. Findings include: Review of the electronic health records revealed Resident #206 was a 95 y/o female who was admitted on [DATE]. Review of an MDS dated [DATE] revealed Resident #206 had a BIMS score of 13. Review of a Baseline Care Plan dated 09/20/23 revealed Resident #206 had diagnoses of Hypertension (high blood pressure), Anemia, Diabetes, Respiratory Failure and Pneumonia, and reflected the following information: Dietary Goal: Maintain 5% of admission weight Intervention: No salt, puree texture and thin liquids; will endorse likes and dislikes; provide supplements as needed. Review of a Nutrition Note for Resident #206, completed by the RD, dated 09/25/23 reflected: Nutrition Goal: Maintain stable wright, good PO (by mouth) intake with no difficulty chewing or swallowing; maintain healthy skin Interventions: Continue with Boost with meals Comments: Reports good appetite, no difficulty chewing or swallowing; Resident was on baby food, resident did not like baby food, referred to SLP and now on regular texture. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675886 If continuation sheet Page 14 of 17 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 09/28/2023 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 Diet Orders: Diet Order, 09/25/23, 13:12:00, No salt tray, Regular texture, Thin liquids Level of Harm - Minimal harm or potential for actual harm During an interview on 09/25/23 at 2:50 PM, Resident #206 stated she doesn't like baby food, that she has teeth and can chew her food. Residents Affected - Few During an observation on 09/26/23, Resident #206 was observed eating lunch, the food had been pureed. During an interview on 09/27/23 at 11:55 AM, Resident #206 stated she had not received her lunch yet. She stated for breakfast, she was served solid foods which consisted of eggs, a sausage patty and oatmeal. Observation on 09/27/23 at 1:15 PM revealed Resident #206 had been served solid food which consisted of spaghetti, mashed potatoes, a dinner roll, and pudding. During an interview 09/27/23 at 1:15 PM, Resident #206 stated she was initially served pureed food for lunch, and she told staff she did not want to eat the food. She stated they returned with solid foods, reiterating that she was not a baby and that she has teeth. Review of Resident #206's meal ticket reflected that it was dated 09/25/23 and puree diet texture was highlighted. Review of the menu on the ticket reflected meal options were all noted to be puree options. Review of the ticket reflected that puree had been scribbled through and regular texture was now circled. The puree notation in front of the spaghetti, vegetables and bread was scribble through. During an interview on 09/27/23 at 11:42 AM, LVN A stated a resident may be admitted with puree diets due to their admitting orders. She stated new admissions were assessed during their first meal at the facility, and subsequently assigned an appropriate diet texture. She stated if a resident prefers a different texture, they can communicate that to the nurse who would complete and submit required documentation to reflect this request and relay this information to the doctor for an order for the change. She stated once the order was received, this should be communicated to dietary, and the changes should be reflected in the system and on the resident's meal ticket. During an interview on 09/27/23 at 2:05 PM, the DM revealed if a resident had a change to their diet order, an Order Communication Form was completed/updated by the nurses and sent to the dietary department; this change could also be communicated via e-mail. The DM stated the dietary department had not received any communication forms on 09/25/23 and they had not received an e-mail regarding Resident #206's diet order change. The DM stated normally, changes to diet orders should be honored on the residents next meal if the forms or changes were communicated by 7:30 PM the previous night. During an interview on 09/27/23 at 2:14 PM, LVN B stated changes to a resident diet order was submitted via S-BAR Communication Form, which was given to the ADON. The ADON would contact the Physician and the physician would send an order. She stated Resident #206 has an order for puree diet and this change has already been communicated to the ND due to Resident #206 receiving a puree diet for lunch (on 09/27/23) instead of regular texture diet. She stated an S-BAR nor Order Communication Form was not completed as of today (09/27/23), which was when she relayed the discrepancy to ND. She stated Resident #206 likely received a puree diet due to her being sick upon admission. She stated a risk of a resident not having their preferences honored was depression. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675886 If continuation sheet Page 15 of 17 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 09/28/2023 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 During an interview on 09/27/23 at 4:05 PM, the ND revealed he was informed about Resident #206's request for a new diet order on 09/27/23. He stated on 09/25/23, he did not receive a verbal report or Order Communication Form with notice that her diet order was changed. He stated he received a form on 09/27/23. During an interview on 09/28/23 at 8:44 AM, RN C revealed he was covering as ADON while their actual ADON was on leave. He stated when there was a diet order change, an SBAR form was submitted to the dietary department. He stated on Monday, the doctor visited Resident #206 during shift change. He stated the nurse working was an agency nurse (LVN D), and this was when a change was made to her diet order. He stated a communication form should have been submitted on 09/25/23, but he could not locate the completed form. He further stated the form was submitted on 09/27/23. During an interview on 09/28/23 at 9:00 AM, the RD stated that when there was a diet order change, the nurse would receive the order from the doctor and [the nurse would] relay the change to the food service department via a(n) [unspecified] form. She stated she assessed Resident #206 when she communicated that she didn't like the texture of her food. She stated this information was relayed to the SLP and they received the order from the physician for this change. She stated she would expect that this change would have been made by 09/28/23 as the order was received 09/25/23. She stated it was important to honor these changes as it was the resident's choice. During an interview on 09/28/23 at 10:00 AM, the DON stated yesterday (09/27/23), she met with the ND and reviewed the communication form used to reflect changes to resident diet orders. She stated she has started to in-service staff on the form and instructions for completion. The DON stated all changes should be reflected on the sheet, signed by the nurse, and taken to the dietary department. She stated the risks could be that if a resident fails a swallow study and needs a new diet texture, they could choke if inappropriately served. She stated regarding honoring resident preferences, this could be a quality of life issue as the facility has a duty to issue a homelike environment which included being respectful of residents choices. During an interview on 09/28/23 at 10:15 AM, LVN D stated he was not sure rather or not he worked on Monday. He stated he works on night shift on E-halls. He stated he was familiar with Resident #206 but was unsure of what diet texture she usually receives because she has had her meals by the time he arrives for work. He stated he did not put in an order for a changed diet texture for her. He stated the process was that if a new order was received, they can go into the system and input dietary orders. He stated then, there was a form completed by the nurse and filled out and given to the kitchen. During an interview on 09/28/23 at 11:33 AM, the SLP stated Resident #206 was admitted to the facility about a week ago with Puree diet texture. She stated on Monday, she was informed that the resident had requested a diet change. The SLP stated she evaluated Resident #206 for the three textures and found that she was safely consumed foods with the regular texture, adding that she had no history of swallowing issues. Following this assessment, the SLP stated she went into their charting software to input the order for the diet change. She stated in this situation, nurses were responsible for ensuring [residents] are getting the correct diet. Dietary should receive the order and it should be printed on the residents' meal ticket. She stated that nurses should double check that this change is reflected on the meal ticket. She stated previously, a communication form would be completed by the nurse, but due to changes to their charting software, she was unsure if these forms still existed. She stated when a resident was evaluated early in the morning, she would expect that the change to have been made by dinner; if evaluated the resident in the evening, she would expect the change to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675886 If continuation sheet Page 16 of 17 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 09/28/2023 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 be made by the next morning. She stated risks of not honoring a diet change order was that the resident would receive the wrong diet texture which may be important if they had swallowing issues. Review of a policy titled Interdepartmental Notification of Diet (Including Changes and Reports), last revised October 2017, reflected: Residents Affected - Few 1. When a resident is admitted or has a diet change, the nurse shall ensure that the food and nutrition services department receive a written or electronic notice of the diet order. 2. The food and nutrition services department will be notified verbally if the diet change occurs before a scheduled meal, or if the circumstances indicate that the written or electronic procedure will not be adequate to ensure service at the next meal. Review of a policy titled Resident Food Preferences, revised July 2017, reflected: 2. When possible, staff will interview the resident directly to determine current food preferences based on history and life patterns related to food and mealtimes. 3. The dietitian and nursing staff, assisted by the physician, will identify any nutritional issues and dietary recommendations that might be in conflict with the resident's food preferences. 6. If the resident refuses or is unhappy with his or her diet, the staff will create a care plan that the resident is satisfied with. Review of an in-service dated 09/28/23 titled Dietary Communication Form, completed by the DON, reflected: Use this form when you receive dietary orders and any changes This will need to be signed by the nurse receiving the order Take to Dietary Dept. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675886 If continuation sheet Page 17 of 17