Health inspection·November 27, 2024

F 0550 with meals, provide assistance to support level of need. Level of Harm - Minimal harm or potential for actual harm Observation on 11/25/24 at 12:30 PM of Resident # 3 in dining room seated at a table with Resident # 66 being assisted with her lunch meal by 1 staff member assisting to fed both residents. Resident # 66 was seated on the left and Resident # 3 was seated on the right with the staff member seated at the end of the table. The staff member proceeded to use her left hand to feed Resident # 66 and her right hand to feed Resident # 3. The staff member did not turn her body towards either resident when feeding them or check to see if they were enjoying their meal. Resident # 3 and Resident # 66 are both non-interviewable residents. Residents appeared not to have an issue with their tablemate sitting across from them being fed. Residents Affected - Some Record review of Resident # 11 quarterly MDS dated [DATE] reflected an [AGE] year-old female admitted to the facility on [DATE] with diagnoses of unspecified dementia with other behavioral disturbances, anxiety disorder, protein-calorie malnutrition, cerebral aneurysm, and osteoarthritis. Resident # 11 did not have a BIMS score recorded. Resident # 11 had it documented that she had it documented that she was dependent upon staff for all her ADL's including eating. Record review of Resident # 11 care plan reflected under nutritional status dated 9/27/24 outcome listed as nutritional intake meets needs with interventions of evaluate eating limitations, diet ordered regular/pureed/thin liquids. ADL function dated 11/26/24 outcome listed as functions at optimal level with ADL's with interventions of assist resident with meals, provide assistance to support level of need. Record review of Resident # 16 quarterly MDS dated [DATE] reflected an [AGE] year-old female admitted to the facility on [DATE] with diagnoses of unspecified dementia, chronic kidney disease stage 3, Parkinson, chronic pain, and anxiety disorder. Resident # 16 did not have a BIMS score recorded. Resident # 16 had it documented that she was dependent upon staff for all her ADL's including eating. Record review of Resident # 16 care plan reflected under nutritional status dated 9/27/24 outcome listed as nutritional intake meets needs with interventions of evaluate eating limitations, diet ordered consistent carbs/pureed/thin liquids. Aspiration precautions-oral feeding dated 1/13/24 outcome listed as oral feeding without aspiration, pureed diet, swallowing disorder, respiratory symptoms with interventions of evaluate for coughing when eating and drinking, evaluate for regurgitation with oral intake, evaluate for hoarseness and gurgling, use cueing and redirection and quiet room, provide liquids small controlled amounts, no straws while drinking, position food in mouth per SLP directions, use multiple swallow technique, clear pocketing from cheek, alternate solids and liquids, allow extra swallow time, and use chin tuck technique for swallows. ADL function dated 11/26/24 outcome listed as functions at optimal level with ADL's with interventions of assist resident with meals, provide assistance to support level of need. Observation on 11/25/24 at 12:33 PM of Resident # 11 in dining room seated at a table with Resident # 16 being assisted with her lunch meal by 1 staff member assisting to fed both residents. Resident # 11 was seated on the left and Resident # 16 was seated on the right with the staff member seated at the end of the table. The staff member proceeded to use her left hand to feed Resident # 11 and her right hand to feed Resident # 16. The staff member did not turn her body towards either resident when feeding them or check to see if they were enjoying their meal. The staff member did not follow the interventions in Resident # 16 care plan listed under her aspirations interventions. Resident # 11 and Resident # 16 are both non-interviewable residents. Residents appeared not to have an issue with their tablemate sitting across from them being fed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675886 If continuation sheet Page 2 of 20 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 11/27/2024 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 0550 Level of Harm - Minimal harm or potential for actual harm Record review of Resident # 31 quarterly MDS dated [DATE] reflected an [AGE] year-old female admitted to the facility on [DATE] with diagnoses of unspecified dementia, chronic obstructive pulmonary disease, chronic pain syndrome, osteoarthritis, rheumatoid arthritis, and major depressive disorder. Resident # 31 did not have a BIMS score recorded. Resident # 31 had it documented that she was substantial/maximal assistance from staff for eating. Residents Affected - Some Record review of Resident # 31 care plan under nutritional status dated 9/27/24 outcome listed as nutritional intake meets needs with interventions of evaluate eating limitations, diet ordered regular/pureed/thin liquids. ADL function dated 11/26/24 outcome listed as functions at optimal level with ADL's with interventions of assist resident with meals, provide assistance to support level of need. Record review of Resident # 38 quarterly MDS dated [DATE] reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of vascular dementia, cerebral infarction, dysphasia, congestive heart failure, muscle weakness, abnormalities of gait and mobility, acute kidney failure, and chronic kidney disease stage 3. Resident # 38 did not have a BIMS score recorded. Resident # 38 had it documented that they required supervision or touching assistance from staff for eating. Record review of Resident # 38 care plan under nutritional status dated 10/18/24 outcome listed as nutritional intake meets needs with interventions of evaluate eating limitations, diet ordered regular/mech soft/thin liquids, give 2 Cal supplement for weight loss with each meal. Aspirations precautions-oral feeding dated 1/8/24 outcome oral feeding without aspiration, swallowing disorder, respiratory symptoms with interventions of evaluate for coughing when eating and drinking, evaluate for regurgitation with oral intake, evaluate for hoarseness and gurgling, use cueing and redirection and quiet room, auscultate breath sounds with evaluation, use cueing and redirection and quiet room, provide liquids small controlled amounts, no straws while drinking, position food in mouth per SLP directions, use multiple swallow technique, clear pocketing from cheek, alternate solids and liquids, allow extra swallow time, and use chin tuck technique for swallows. ADL function dated 11/26/24 outcome listed as functions at optimal level with ADL's with interventions of assist resident with meals, provide assistance to support level of need. Observation on 11/25/24 at 12:36 PM of Resident # 31 in dining room seated at a table with Resident # 38 being assisted with her lunch meal by 1 staff member assisting to fed both residents. Resident # 31 was seated on the left and Resident # 38 was seated on the right with the staff member seated at the end of the table. The staff member proceeded to use her left hand to feed Resident # 31 and her right hand to feed Resident # 38. The staff member did not turn her body towards either resident when feeding them or check to see if they were enjoying their meal. The staff member did not follow the interventions in Resident # 38 care plan listed under her aspirations interventions. Resident # 31 and Resident # 38 are both non-interviewable residents. Residents appeared not to have a issue with their tablemate sitting across from them being fed. Record review of Resident # 30 quarterly MDS dated [DATE] reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of unspecified dementia, cerebral infarction, anxiety disorder, and gastro-esophageal reflux disease. Resident # 30 did not have a BIMS score recorded. Resident # 30 had it documented that they required supervision or touching assistance from staff for eating. Record review of Resident # 30 care plan under nutritional status dated 9/27/24 outcome listed as nutritional intake meets needs with interventions of evaluate eating limitations, diet ordered (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675886 If continuation sheet Page 3 of 20 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 11/27/2024 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 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some regular/no salt on tray/regular texture/thin liquids. ADL function dated 11/26/24 outcome listed as functions at optimal level with ADL's with interventions of assist resident with meals, provide assistance to support level of need. Record review of Resident # 15 Comprehensive MDS dated [DATE] reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of unspecified dementia, epilepsy, osteoarthritis, osteoporosis, dysphasia, and gastro-esophageal reflux disease. Resident # 15 had a BIMS score of 6 indicating severe cognitive impairment. Resident # 15 had it documented that they required supervision or touching assistance from staff for eating. Record review of Resident # 15 care plan under nutritional status dated 10/7/24 outcome listed as nutritional intake meets needs with interventions of evaluate eating limitations, diet ordered regular/mech soft/thin liquids. ADL function dated 11/26/24 outcome listed as functions at optimal level with ADL's with interventions of assist resident with meals, provide assistance to support level of need. Observation on 11/25/24 at 12:40 PM of Resident # 30 in dining room seated at a table with Resident # 15 being assisted with her lunch meal by 1 staff member assisting to fed both residents. Resident # 30 was seated on the left and Resident # 15 was seated on the right with the staff member seated at the end of the table. The staff member proceeded to use her left hand to feed Resident # 30 and her right hand to feed Resident # 15. The staff member did not turn her body towards either resident when feeding them or check to see if they were enjoying their meal. Resident # 30 and Resident # 15 are both non-interviewable residents. Residents appeared not to have an issue with their tablemate sitting across from them being fed. In an interview on 11/27/24 at 1:53 PM with LVN A revealed LVN A stated All staff members help with feeding during all meals, and it depends on which shift duties. She will do lunch or both breakfast and lunch, some staff do lunch and dinner, but it depends how many staff they have on that shift. If she is on shift, she will help with all meals and there is always a nurse in there before the meal starts and after the last person finishes their meal. She feels like it is manageable to feed two residents' at once. She can concentrate on feeding both residents one at a time while making sure they are clean during feeding. She doesn't have any concerns with feeding two residents at once. She doesn't remember the policy and what it says with assisted feeding, and she is not sure how many residents they are able to feed at once, but she can check. She thinks 1:2 assistance feeding is doable; she thinks what could make it better is feeding resident's and eating with them to make it more community based. They are not rushing the resident's and doesn't see a dignity or safety issue. She sees the facility as it is a community-based setting. There are not any cross-contamination issues during feeding, and they don't feed both at a time with each hand or giving the resident each other's food accidentally. In an interview on 11/27/24 at 2:00 PM with CNA C revealed CNA C stated one staff member for every 2 residents who need to be fed unless the resident won't eat for that staff member then another staff member comes to help and try and get the resident who is not eating to eat. CNA C stated they do not feel there is a safety issue because the staff member sits facing the two residents so they can watch for any swallowing issues and a nurse is always present in the dining room. CNA C stated they did not feel feeding two residents at the same time was a dignity issue because all of the residents who need to be fed are seated together on one side of the dining room and they are all encouraged to eat equally. CNA C stated that it appeared to them that the residents to not mind having a table mate who is also being fed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675886 If continuation sheet Page 4 of 20 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 11/27/2024 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 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some In an interview on 11/27/24 at 2:10 PM with LVN B revealed LVN B stated one staff member feeds two residents and the staff members have a rotation as to which meal and what day they feed residents. LVN B stated they do not feel there is a resident safety issue since the staff member sits facing the residents and can see if they have swallowing problems. LVN B stated they do not feel that feeding two residents at a time is a dignity issue since all the residents who need to be fed are seated at tables next to each other and all encouraged to eat together from all the staff. In an interview on 11/27/24 at 2:20 PM with ADM revealed the ADM stated for residents who need meal assistance it is their expectation that 1 CNA to every 2 residents is acceptable parameters. ADM stated she did not feel having 1 staff member feed 2 residents at the same time was a dignity issue since the staff communicate and engage with the residents and even though eating is an ADL it is not the same as receiving a shower or toileting. ADM cited CNA training curriculum from 3/12 and HHSC module 5 feeding assistant training dated 12/22 saying both of which stated adequate staff with feeding. Record review of assistance with meals policy undated reflected under policy statement: Residents shall receive assistance with meals in a manner that meets the individual needs of each resident. Under heading policy interpretation and implementation Dining room Residents: All residents will be encouraged to eat in the dining room. 2. Facility staff will serve resident trays and will help residents who require assistance with eating. 3. Residents who cannot feed themselves will be fed with attention to safety, comfort, and dignity, for example: a. not standing over residents while assisting them with meals. b. keeping interactions with other staff to a minimum while assisting residents with meals. c. avoiding the use of labels when referring to residents (e.g., feeders); and d. avoiding the use of bibs or clothing protectors instead of napkins, unless requested by the resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675886 If continuation sheet Page 5 of 20 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 11/27/2024 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 resident's drug regimen was free from unnecessary drugs by having an indication for use of 5 (Residents #39, 72, 146, 69, and 70) of 5 residents reviewed. Residents Affected - Some The facility failed to have adequate indications for routine medications for Residents #39,72,146,69, and 70. This failure could potentially affect all residents that receive routine medications from receiving unnecessary medications. Findings included: Record review of Resident # 39 face sheet dated 11/26/2024 reflected an [AGE] year-old female admitted [DATE] with diagnoses that included Coronary Artery Disease (a type of heart disease involving the reduction of blood flow to the cardiac muscle due to a build-up of plaque in the arteries of the heart.), Hypertension ( a long-term medical condition in which the blood pressure in the arteries is persistently elevated), Diabetes Mellitus ( a chronic condition that happens when you have a persistently high blood sugar levels affecting your body to use insulin properly) Hyperlipidemia ( abnormally high levels of any or all lipids in the blood) Cerebrovascular Accident ( an event involving an interruption of blood flow or bleeding in a region of the brain), Vascular dementia ( a type of dementia caused by brain damage from impaired blood flow), gastro-esophageal reflux disease without esophagitis ( is a condition in which stomach acid repeatedly flows back up into the tube connecting the mouth and stomach without inflammation of the esophagus), Anxiety disorder ( a disorder characterized by excessive anxiety), Depression ( a mood disorder that causes feeling of sadness that won't go away) and Unspecified osteoarthritis ( a degenerative joint disease that can affect the many tissues of the joint,). Record review of Resident # 39's Annual MDS dated [DATE] reflected BIMS score of 5 which indicated severe cognitive impairment. Record review of Resident # 39 Physician orders dated 11/26/2024 reflected the following medications with no indication for use. Divalproex sodium (Depakote Sprinkles) 125 mg, oral, BID. Ordered 9/22/23. Lorazepam (Ativan) 0.5 mg, oral, tab daily. Ordered 8/26/2024. Amlodipine 10 mg, oral, tab, daily. Ordered 8/30/2024. Review of Resident # 72's Face sheet dated 11/26/2024 reflected a [AGE] year-old female admitted [DATE] with diagnoses of unspecified dementia ( a loss of cognitive functioning that interferes with daily life and activities ), Type 2 diabetes mellitus with diabetic polyneuropathy( a chronic condition that happens when you have a persistently high blood sugar levels affection you bodies use of insulin with nerve damage), Chronic kidney disease ( a long term kidney disease in which there is a gradual loss of kidney function), unspecified osteoarthritis ( a degenerative joint disease that can affect the many tissues of the joint,), Depression ( a mood disorder that causes feeling of sadness that won't go away), Hypertensive heart disease ( a group of medical problems that can happen when you (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675886 If continuation sheet Page 6 of 20 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 11/27/2024 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 Level of Harm - Minimal harm or potential for actual harm have unmanaged high blood pressure for a long time), and Anxiety disorder ( a disorder characterized by excessive anxiety). Record review of Resident # 72's Quarterly MDS dated [DATE] reflected BIMS score of 7 that indicated severe cognitive impairment. Residents Affected - Some Record review of Resident # 72's physician orders dated 11/26/2024 reflected the following medications with no indication for use. Atorvastatin 40 mg, 1 tab, oral every evening. Written 6/12/2023. Carvedilol 6.25 mg 1-tab, oral bid Give one tablet by mouth twice daily***hold (do not give medication) if SBP less than 100 or DBP less than 60 and HR less than 55*** ordered written 6/12/23. Omeprazole 20 mg, oral, cap-dr, daily, ***Do Not Crush**** written 6/12/2023. Gabapentin 600 mg, oral, TID written 6/21/2023. Methocarbamol 750 mg, Oral, TID Give two (2) 750 mg tablets to equal 1500 mg by mouth three times daily written 6/21/23. Ferrous Sulfate 325mg, Oral, Daily, ***Do Not Crush*** written 6/23/23. Ergocalciferol 2,000 units, oral, cap, daily, written 8/18/23. Insulin Glargine (Lantus) 45 units, subcutaneous, soln, every night at bedtime. Written 10/12/23. Insulin aspart (NovoLog FlexPen) 3 units, Subcutaneous, soln, TID (AC) written 10/16/23. Insulin aspart (NovoLog Medium sliding scale) Sliding scale, subcutaneous injection, TID with meals. Moderate sliding scale insulin. To be taken If accucheck <60 for alert patient give sweet snack and notify provider. If accucheck < 60 for patients unable to take by mouth give 1-amp D50.Order 6/20/2024. Divalproex sodium (Depakote Sprinkles) 250 mg, Oral, BID written 10/21/24. Record review of Resident # 146's face sheet dated 11/26/2024 reflected an [AGE] year-old male admitted [DATE] with diagnoses that included Dementia in other diseases classified elsewhere (a loss of cognitive functioning that interferes with daily life and activities), Coronary Artery Disease ( (a type of heart disease involving the reduction of blood flow to the cardiac muscle due to a build-up of plaque in the arteries of the heart.) Hypertension (a long-term medical condition in which the blood pressure in the arteries is persistently elevated) Renal Insufficiency (poor functioning kidneys) and Hyperlipidemia (abnormally high levels of any or all lipids in the blood). Review of Resident # 146's quarterly MDS dated [DATE] reflected a BIMS score of 9 which indicated a moderate cognitive impairment. Review of Resident # 146's Physician orders dated 11/26/2024 reflected the following medication ordered with no indication of use. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675886 If continuation sheet Page 7 of 20 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 11/27/2024 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Allopurinol 50 mg = 0.5 tab, oral, tab, daily at home patient was taking medication with the following details: comments give half a tablet to equal 50 mg tab. Written 2/27/2024. Famotidine 20 mg = 1 tab, oral, tab, BID. Written 2/27/2024. Losartan 75 mg= 1.5 tab, oral, tab, daily at home, patient was taking medication with the following details: Comments: give one and a half tablets to equal 75 mg dose written 2/27/2024 Rosuvastatin 10 mg, oral, cap, every night at bedtime. Written 2/27/24, Sertraline 100 mg, oral, tab, daily written 3/4/2024. Aspirin 81 mg, oral, tab-DR, daily, written 7/17/2024. Buspirone 10 mg, oral, tab, daily. Written 10/14/2024. Record review of Resident # 69's Face Sheet dated 11/26/2024 reflected a [AGE] year old male admitted on [DATE] with the diagnoses that included Dementia in other diseases classified elsewhere (a loss of cognitive functioning that interferes with daily life and activities ), Gastroesophageal reflux disease ( is a condition in which stomach acid repeatedly flows back up into the tube connecting the mouth and stomach without inflammation of the esophagus), Hyperlipidemia (abnormally high levels of any or all lipids in the blood), Diabetes mellitus type 2 ( a chronic condition that happens when you have a persistently high blood sugar levels affecting your body to use insulin properly), and Alzheimer's disease ( a disease that can cause trouble concentrating and thinking, especially about abstract concepts such a numbers) Review of Resident # 69's admission MDS dated [DATE] revealed a BIMS score of 8 which indicated moderate cognitive impairment. Review of Resident # 69's physician orders dated 11/26/2024 reflected the following medication had no indication for use. Ascorbic Acid 1,000 mg = 1 tab, oral, tab, daily written 10/18/2024. Aspirin 81 mg, oral, Tab-DR, daily, written 10/18/2024. Atorvastatin 40 mg = 1 tab, every evening. Written 10/18/2024. Calcium-vitamin D (Calcium 500 + D) 1 tab, chewed, tab-chew, BID. Written 10/18/2024. Cholecalciferol (Vitamin D3) 25 mcg= 1 tab, oral, tab, daily. Written 10/19/2024. Cranberry 1 tab, oral, tab, daily. Give 500 mcg tab. Written 10/19/2024. Cyanocobalamin 500 mcg=1 tab, oral, tab, daily. Written 10/19/2024. Donepezil 10 mg= 1 tab, oral, tab, daily. Written 10/19/2024. Famotidine 40 mg = 1 tab, oral, tab, every evening. Written 10/19/2024. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675886 If continuation sheet Page 8 of 20 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 11/27/2024 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 Ferrous Sulfate 325 mg, oral, Tab-DR, Daily, give with food/snack. Written 10/19/2024. Level of Harm - Minimal harm or potential for actual harm Metformin 500 mg, oral, Tab-ER, every evening, give with food/snack Written 10/19/2024. Multivitamin (Vitamin B Complex 100) 1 tab, oral, tab, daily. Written 10/19/2024. Residents Affected - Some Melatonin (Advanced Sleep Melatonin) 10 mg, oral, every night at bedtime. Written 10/23/2024. Memantine 10 mg, oral, tab, BID. Written 10/24/2024. Tamsulosin 0.4 mg, oral, every evening for 2 weeks start date 11/13/2024, stop date 11/27/2024. Monitor and document resident urinary symptoms. Written 11/13/2024. Review of Resident # 70's Face sheet dated 11/26/2024 reflected a [AGE] year-old female admitted on [DATE] with diagnoses, Bipolar Disorder ( a mental disorder characterized by periods of depression and periods of abnormally elevated mood that each last from days to weeks), Dementia with anxiety ( a long term disorder causing personality changes and impaired memory, reasoning and social function with anxiety) Osteoporosis ( s systemic skeletal disorder characterized by low bone mass) and Hyperlipidemia (abnormally high levels of any or all lipids in the blood). Review of Resident # 70's Quarterly MDS dated [DATE] revealed resident was unable to participate in BIMS score testing, A staff assessment for Mental status was conducted revealed the resident is severely impaired with cognitive skills for daily decision making. Review of Resident # 70's Physician orders dated 11/26/2024 reflected the following medication have no indication for use. Atorvastatin 10 mg= 1 tab, oral, tab, daily. Written 6/22/2023. Calcium-vitamin D (Calcium 550 +D) 2 tab, oral, daily, give two 500 mg tablets to equal 1000 mg dose. Written 7/5/2023. Oxcarbazepine (Trileptal) 450 mg, oral, tab, BID. Written 5/2/2024. Paroxetine (Paxil) 60 mg, oral, tab, every night at bedtime. Written 10/1/2024. Cyanocobalamin (Vitamin B12), 1,000 mcg, oral, tab, daily. Written 10/16/2024. Buspirone 30 mg, oral, tab, BID. Written 11/19/2024. Interview with the DON on 11/26/2024 at 10:30 am stated that the facility was aware of the issue and was working with the company that does the EMR to fix the issue. She stated she audits the resident's chart but sometimes the indications do not save to the physician order. She stated the program they used for EMR was made for the hospital and there were no regulation at the hospital that required an indication for medication. They were working with the company to address the issue, but it is a slow process. She demonstrated that when indications were added they did not always save. She stated that this could put the residents at risk for overmedication due to duplicate of treatment. Interview with the Pharmacy consultant via phone on 11/26/2024 at 2:15 pm she stated that she was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675886 If continuation sheet Page 9 of 20 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 11/27/2024 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some aware of the limitations of the program for the indications and had been focusing on the PRN and psychotropic medications so that they were at least compliant with that regulation. She had offered to meet with the company that owns the EMR to come up with a solution but had not heard back about it. She stated that the residents could be at risk for duplicate treatment for the same illness if not corrected. Interview with the ADM on 11/26/2024 at 3:30 pm she stated that she was aware of the indications not always showing up on the physician orders and was working with her corporate lead and the EHR company to find a solution. She stated she had been aware since the last survey and they were trying to address the issue with weekly audits and that the medical director was aware of the issue. She stated the hospital did not have the same requirements as the Skilled facility and the program was developed for the acute care setting. She stated she felt they were doing their best to keep the residents safe but there was always a risk when giving resident care. Record review of the policy titled Medication orders revised November 2014 read Recording orders 1. Medication orders- When recording orders for medications, specify the type, route, dosage, frequency and strength of the medication. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675886 If continuation sheet Page 10 of 20 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 11/27/2024 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 Residents Affected - Many 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 in accordance with professional standards for food service safety for one of one kitchen reviewed for sanitation. 1. The facility failed to ensure sanitation practices of cleaning the ice machine, cleaning the microwave, hand hygiene, hair restrained, and clothing sleeves not touching food items were occurring in the kitchen. 2. The facility failed to ensure temperature logs were being completed. 3. The facility failed to ensure labeling and dating of all food items in the kitchen. 4. The facility failed to ensure all items were covered and stored properly. These failures could place residents at risk of foodborne illness. Findings included: Observation on 11/25/24 at 9:10 AM of the dining room kitchen entry door revealed a sign posted stating hair restraints required upon kitchen entry, the bin on the wall that was below the posted sign that was labeled for hair nets was empty of any hair restraints. Observation on 11/25/24 at 9:13 AM of the kitchen revealed the microwave had what appeared to be dried food particles and debris stuck to the inside of the roof. Observation on 11/25/24 at 9:15 AM of the kitchen revealed the ice machine inside of the door had splotches of a black and brown substance that appeared to be mold growing on the inside of the door. Observation on 11/25/24 at 9:18 AM of the kitchen walk-in refrigerator revealed: 1. An opened bag of salad mix loosely saran wrapped dated 11/24 (unsure if this is open date or use by date) and unlabeled. 2. An opened bag of chopped onions with the opening loosely tied in a knot unlabeled and undated. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675886 If continuation sheet Page 11 of 20 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 11/27/2024 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 3. Level of Harm - Minimal harm or potential for actual harm A storage bin with the lid unsecured and placed diagonally with loose salad mix inside unlabeled and undated. Residents Affected - Many 4. A bag of shredded cheese dated 11/22 (unsure if this is open date or use by date) loosely saran wrapped and unlabeled. 5. A package of chopped ham lunchmeat loosely saran wrapped unlabeled and undated. 6. A package of turkey breast lunchmeat loosely saran wrapped unlabeled and undated. 7. A shelf full of containers of individually packaged pieces of apple pie unlabeled and undated. 8. A shelf full of containers of individually packaged pieces of pumpkin pie unlabeled and undated. 9. An opened bag of baby spinach loosely saran wrapped unlabeled and undated. 10. A bunch of cilantro saran wrapped undated and unlabeled. 11. An opened bag of salad mix dated 11/2/24 that had brown slimy pieces throughout bag. 12. A utility rack full of packages of beef patties thawing unlabeled and undated. 13. A utility rack full of turkey breasts thawing unlabeled and undated. 14. A utility rack full of hams thawing unlabeled and undated. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675886 If continuation sheet Page 12 of 20 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 11/27/2024 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 Observation on 11/25/24 at 9:31 AM of the kitchen revealed a 55-gallon trash can in the kitchen near dish room without a lid. Level of Harm - Minimal harm or potential for actual harm Observation on 11/25/24 at 9:35 AM of the kitchen walk-in freezer revealed: Residents Affected - Many 1. A box that contained a opened package of sweet potato French fries unsealed with the open part of package just twisted together unlabeled and undated, an opened package of what appeared to be hush puppies undated and unlabeled, an open package of battered cauliflower bites unsealed with the package just folded over on itself undated and unlabeled, an open bag of what appeared to be frozen ravioli with a date of 11/6/24 no use by date recorded and bag was open with product falling out into box, an opened package of breaded zucchini fries unsealed with saran wrap on half of package undated and unlabeled, and an open package of what appeared to be battered onion rings wrapped in saran wrap undated and unlabeled. The box all these items were in was labeled crinkle cut French fries. 2. An opened bag of sliced okra with bag opening just folded over on itself unlabeled and undated. 3. An opened bag of whole kernel corn with the opening tied close undated and unlabeled. 4. A bag of what appeared to be frozen dinner roll dough with the bag just folded on itself unlabeled and undated. 5. An open bag of frozen chicken breast with the Ziploc seal portion of the bag wide open unlabeled and undated. 6. A saran wrapped bunch of what appeared to be chicken breasts unlabeled and undated. 7. An open bag of diced dark meat chicken unlabeled and undated. Observation on 11/25/24 at 9:40 AM of the kitchen dry storage revealed: 1. An open package of macaroni with opening loosely tied with saran wrap unlabeled and undated. 2. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675886 If continuation sheet Page 13 of 20 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 11/27/2024 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 A row of 4 dented cans of tomato sauce stored on the canned goods rack with all the other cans not in the dented can area outside of the dry storage room. Level of Harm - Minimal harm or potential for actual harm 3. Residents Affected - Many An unopened case box of granola stored on the dry storage floor. Observation on 11/25/24 at 9:55 AM of the kitchen grill prep area with storage racks of bread revealed 6 packages of hot dog buns dated 9/16/24 and 2 undated packages of hoagie buns. Observation on 11/25/24 at 10:00 AM of the kitchen salad prep refrigerator revealed: 1. Three trays of individually bowled up salads undated and unlabeled. 2. Container tomato slices undated and unlabeled. 3. Container of cut up cantaloupe and honeydew melon undated and unlabeled. 4. Container of cheese slices undated and unlabeled. 5. Container of mixed fruit salad undated and unlabeled. 6. Container of cut up lemons undated and unlabeled. 7. Plates of burger salads undated and unlabeled. Observation on 11/25/24 at 10:10 AM of the back service hall corridor with kitchen entry door revealed signage posted of required hair restraints, bin labeled hair nets below signage empty of any hair restraints. Observation on 11/26/24 at 10:47 AM of the kitchen salad prep refrigerator revealed: 1. Plates of burger salads undated and unlabeled. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675886 If continuation sheet Page 14 of 20 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 11/27/2024 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 2. Level of Harm - Minimal harm or potential for actual harm Three trays of individually bowled up salads undated and unlabeled. 3. Residents Affected - Many Container of chopped onion unlabeled and undated 4. Container of chopped lettuce undated and unlabeled. Observation on 11/26/24 at 10:55 AM of the kitchen revealed Chef was only wearing a ball cap without a hair restraint under it and no beard guard. The chef had hair roughly 1 inch below the ball cap and facial hair. Chef also was wearing a long sleeve chef jacket and while panning up cooked chicken for lunch chef jacket repeatedly rubbed across cooked chicken surfaces. Observation on 11/26/24 at 10:55 AM of the kitchen revealed [NAME] had hair restraint not covering all of cooks hair. [NAME] had hair at nape of neck not covered by hair restraint. Further observation revealed [NAME] cleaning prep table from breading chicken breast, [NAME] picked up copies of recipes and threw copies into trash can and shoved papers down in trash can with ungloved hand touching trash can. [NAME] then proceeded to pick up cleaning cloth and continue cleaning prep table without washing hands. After cleaning prep table [NAME] then proceeded to wash hands. [NAME] then picked up trash from floor and discarded into trash can touching trash can without washing hands. [NAME] then wiped hands on front of clothes and went to get new cleaning cloths for prep table area. [NAME] then rinsed out dirty mixing bowl and then proceeded to wash hands. [NAME] then used the new cleaning cloths she had just put on prep table area as potholders to take cooked chicken from oven. [NAME] then threw trash away again touched trash can and did not wash hands just put on gloves and proceeded to start cutting up cooked chicken. Interview attempted on 11/27/24 at 1:00 PM with the Dietary Director but unsuccessful as Dietary Director was on vacation at time of survey. Interview on 11/27/24 at 1:13 PM with the Chef revealed Chef stated hair restraints including hair nets and beard guards were to be always worn while in the kitchen. The Chef stated that even while wearing a ball cap a hair net was to be worn under the ball cap if employee has hair. The Chef stated shirt sleeves were to be rolled up if they extend past the wrist so they will not come in contact with food. The Chef stated hair contamination and clothing sleeves touching food could be a physical and biological contamination. The Chef stated these types of contaminations could negatively affect residents by being cross contamination. Interview on 11/27/24 at 1:22 PM with the ADD revealed ADD stated hair restraints were to be worn by all staff in the kitchen and all hair was to be covered. The ADD stated ball caps can be worn but staff must have a hair restraint on under the ball cap. The ADD stated beard guards were to be worn for all facial hair. The ADD stated it can negatively affect residents if hair gets into the food because it would be a turn off to the resident and they would lose their appetite and possibly lose weight. The ADD stated it was the Dietary Director responsibility to ensure hair restraints were being worn. The ADD stated long sleeves were to be pulled up or rolled up to prevent them from getting into the food. The ADD stated if the clothing sleeves got into food this could negatively affect (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675886 If continuation sheet Page 15 of 20 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 11/27/2024 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 Residents Affected - Many residents by being cross contamination. The ADD stated it was the Dietary Director responsibility to ensure staff clothing is not contaminating food products. The ADD stated staff were supposed to wash and sanitize their hands after discarding trash before their next activity. The ADD stated if staff did not perform hand hygiene correctly this could negatively affect residents by germs and residents getting sick. The ADD stated it was the Dietary Director responsibility to ensure staff were performing hand hygiene correctly. The ADD stated all food items in the kitchen were to be labeled and dated. The ADD stated everything was dated upon receipt and when opened /prepared and at that time also with a discard date. The ADD stated if items were not labeled and dated then this could negatively affect residents by them getting spoiled food and getting sick. The ADD stated it was the Chefs responsibility to ensure proper labeling and dating practices are occurring. The ADD stated food temperature logs were to be completed daily at every meal. The ADD stated if temperatures were not being taken and recorded then this could potentially negatively affect residents by foods being in the temperature danger zone and residents getting sick. The ADD stated it was their responsibility to ensure food temperature logs were completed daily at each meal. Interview on 11/27/24 at 1:36 PM with the [NAME] revealed [NAME] stated hair restraints were to be worn by all staff in the kitchen. The [NAME] stated all hair was to be covered by the hair restraint. The [NAME] stated it could negatively affect residents if hair got into the food by being a choking hazard. The [NAME] stated all food items were to be labeled and dated upon receipt and when open and at that time with a discard date. The [NAME] stated if food items were not labeled and dated this could negatively affect residents by bacteria growth and spoilage and make them sick. The [NAME] stated hygiene was to be performed after throwing away trash and touching the trash can before moving to the next task. The [NAME] stated if hand hygiene was not performed then this could negatively affect residents by there could be contamination and could make residents sick. The [NAME] stated food temperature logs were to be completed daily prior to the meal being served. The [NAME] stated by food temperatures not being taken then this could negatively affect residents by bacteria growth and sickness. Interview on 11/27/24 at 2:20 PM with the ADM revealed ADM stated it was their expectation that all food products were labeled and dated per policy. The ADM stated it was their expectation that sanitation practices were followed according to policy and guidelines. The ADM stated it was their expectation that hand hygiene practices were being followed according to policy and guidelines as that was the facilities biggest fight against infection. The ADM stated it was their expectation that temperature logs were being completed according to policy and guidelines. The ADM stated it was their expectation that hair restraints were being worn according to policy and guidelines. The ADM stated if labeling and dating, sanitation practices, hand hygiene, temperature logs, and hair restraints practices were not occurring then this could negatively affect residents by the residents could potentially receive spoiled food and get sick. The ADM stated it was the Dietary Director responsibility to ensure these practices were occurring. Record review of food temperature logs reflected 11/1/24 breakfast and lunch food temperatures not recorded, 11/7/24 lunch food temperatures not recorded, 11/11/24 lunch food temperatures not recorded, 11/18/24 dinner food temperatures not recorded, 11/19/24 dinner food temperatures not recorded, 11/21/24 lunch food temperatures not recorded, 11/24/25 lunch food temperatures not recorded, and 11/25/24 lunch food temperatures not recorded. Food temperature logs reviewed for 26 days with 8 meals temperatures not being recorded. Record review of ice machine cleaning and sanitizing log reflected the last time recorded for the ice machine to have been cleaned was 9/18/24. No documentation of cleaning to have occurred for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675886 If continuation sheet Page 16 of 20 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 11/27/2024 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 October or November Level of Harm - Minimal harm or potential for actual harm Record review of the food storage policy undated reflected under heading policy: Sufficient storage facilities will be provided to keep foods safe, wholesome, and appetizing. Food will be stored in an area that is clean, dry, and free from contaminants. Food will be stored at appropriate temperatures and by methods designed to prevent contamination or cross contamination. Under heading procedure: Residents Affected - Many 6. Food items will be stored on shelves, with heavier and bulkier items stored on lower shelves. 7. All stock must be rotated with each new order received. Rotating stock is essential to assure the freshness and highest quality of all foods. a. old stock is always used first (first in - first out method or FIFO). The person designated to manage stock should be trained to rotate it properly. b. Food should be dated as it is placed on the shelves if required by state regulation. c. Date marking should be visible on all high-risk food to indicate the date by which a ready-to-eat TCS food should be consumed, sold or discarded. d. Food will be stored and handled to maintain the integrity of the packaging until ready for use. Food stored in bins may be removed from its original packaging. 8. Plastic containers with tight fitting covers or sealable plastic bags must be used for storing grain products, sugar, dried vegetables and broken lots of bulk foods or opened packages. All containers or storage bags must be legible and accurately labeled and dated. 10. Food should be stored a minimum of 6 inches above the floor, 18 inches from the ceiling and 2 inches from the wall with adequate space on all sides of stored items to permit ventilation. Racks and other storage surfaces should be clean and protected from splashes, overhead pipes or other contamination (ceiling sprinklers, sewer/waste disposal pipes, vents, etc.). 12. Leftover food should be stored in covered containers or wrapped carefully and securely and clearly labeled and dated before being refrigerated. Leftover food must be used within 7 days or discarded as per the 2022 Federal Food Code. (Also see policy on Use of Leftovers later in this chapter.) Check state regulations as some states may allow shorter time frames for the use of leftovers. 13. Refrigerated food storage: f. All foods should be covered, labeled and dated and routinely monitored to assure that foods (including leftovers) will be consumed by their use by dates, or frozen (where applicable) or discarded. 14. Frozen Foods: c. All foods should be covered, labeled and dated. All foods will be checked to assure that foods will be consumed by their use by dates or discarded. Record review of the Food Safety and Sanitation policy undated reflected under heading policy: All (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675886 If continuation sheet Page 17 of 20 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 11/27/2024 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 Residents Affected - Many local, state, and federal standards and regulations will be followed to assure a safe and sanitary food and nutrition services department. Under heading procedure: 2. Employees c. Employees are required to have their hair styled so that it does not touch the collar, and to wear clean aprons, clothes, and closed toe shoes. o Hair restraints are required and should cover all hair on the head. o Beard nets are required when facial hair is visible. d. Employees will wash their hands just before they start to work in the kitchen and after smoking, sneezing, using the restroom, handling poisonous compounds or dirty dishes, and touching face, hair, other people or surfaces or items with potential for contamination. 3. Food Purchasing e. Bulging or leaking cans, cans with severe dents on the seams or broken containers of food will not be used. 4. Food Storage a. Stored food is handled to prevent contamination and growth of pathogenic organisms. Leftovers are used within 72 hours (or discarded). Note: 2022 Federal Food Code guidelines allow 7 days for food safety with the day of preparation counted as day 1 of the 7 days and then food is discarded. Check local and state regulations and if different from the Federal Food Code, determine which regulation should be followed. Perishable foods with expiration dates should be used prior to the use by date on the package. Perishable ingredients should be refrigerated when they are not being used. All time and temperature control for safety (TCS) foods (including leftovers) should be labeled, covered and dated when stored. When a food package is opened, the food item should be marked to indicate the open date. This date is used to determine when to discard the food. Canned and dry foods without expiration dates should be used within six months of delivery or according to the manufacturer's guidelines. Record review of the General Hazard Analysis Critical Control Points Guidelines for Food Safety policy undated reflected under heading policy: Food and nutrition services staff will be educated and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675886 If continuation sheet Page 18 of 20 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 11/27/2024 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 supervised on all hazard analysis critical control points {HACCP) information and procedures. A good training program and the proper systems and tools will help to assure a successful HACCP/Food Safety program. Under heading procedure: Educate and monitor food and nutrition services staff on the following: Residents Affected - Many 1. Hand Washing Train staff to wash hands prior to working with food, after using the restroom or soiling hands in any way. 2. The Time-Temperature Connection a. Limit the time that food is in the temperature danger zone (TDZ). b. The TDZ: Food must be held at greater than 135° For less than 41° F. c. Limit the time that food is in the TDZ to no more than 4 hours combined total for all preparation (thawing, preparation, cooling and re-heating). This includes hot foods, cold foods and foods stored at room temperature being prepared for consumption (such as fresh fruits or hermetically sealed ready to eat foods stored at room temperature). 4. Prevent Cross Contamination and Employee Contamination a. Preparation: Avoid the TDZ, prevent cross contamination and employee contamination. b. Cooking: Final internal temperatures as noted earlier. c. Hot holding: greater than 135° F, cover and stir often. d. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675886 If continuation sheet Page 19 of 20 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 11/27/2024 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 Cooling: Safe cooling to less than 41° F within 4 hours, or to 70° F in 2 hours and from 70° F to 41° Fin 4 hours (not to exceed 6 hours). Level of Harm - Minimal harm or potential for actual harm e. Residents Affected - Many If food drops less than 135° F, reheat to 165° F for minimum of 15 seconds. 7. Food Temperatures for Meal Service a. Check to be sure the staff takes food temperatures correctly and records temperatures. 11. Receiving a. Take food temperatures upon receiving. Be sure the vendors have refrigerated trucks that are clean and in good repair. b. Label and date foods and put foods away promptly. c. Check temperatures upon delivery and reject any damaged goods: cans dented on the seams, refrigerator or freezer foods at improper temperatures, damaged boxes of dry goods that expose the foods, etc. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675886 If continuation sheet Page 20 of 20