Health inspection·December 7, 2022

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some postprocedural respiratory failure, protein-calorie malnutrition, dementia, hypertension (high blood pressure), dysthymic disorder, cardiomegaly, muscle weakness and abnormalities of gait and mobility. Her code status was listed as DNR (Do Not Resuscitate). Review of Resident #12's admission Assessment MDS dated [DATE] revealed she had adequate hearing, clear speech, was able to make herself understood and understood other, and had adequate vision with the use of glasses. Her mental status assessment score was 5 out of 15 indicating severely impaired cognition and displayed no signs and symptoms of delirium. She exhibited other behavioral symptoms not directed towards others 1 to 3 days. She required one-person physical assistance for all ADLs except eating which she only needed setup assistance. The assessment indicated that she used a walker to ambulate on the unit, however at the time of observation (12/5/22 at 10:20 AM, 12/5/22 at 3:14 PM, 12/6/22 at 9:00 AM, 12/7/22 at 9:25 AM) Resident #12 was no longer able to use a walker and only used a wheelchair for her mobility. The assessment indicated she was always continent of bowel and bladder but at the time of observation (12/5/22 at 11:35 AM, 12/6/22 at 9:00 AM, 12/7/22 at 9:25 AM) this was no longer accurate due to cognitive decline. She reported rare, moderate pain. She had a history of falls prior to admission. She had a reported weight loss of 5% or more in the last month or 10% or more in the last 6 months prior to the assessment with no physician prescribed weight loss plan. She was at risk of developing pressure ulcers. She received insulin 3 of 7 days, antipsychotic medication 3 of 7 days, antidepressant medication 3 of 7 days and diuretic medication 3 of 7 days. Review of Resident #12's Care Plan dated 10/11/2022 with revisions on 10/27/2022 and 12/01/2022, revealed the following problems: resident has an area of maceration to perianal region; enjoys group activities; resident has an ADL self-care performance deficit weakness; new behaviors of verbally/physically aggressive with staff; resident is resistant to ADL care at times; I have chosen to be FULL CODE status; resident has impaired cognitive function/dementia or impaired thought process dementia; resident has dehydration or potential fluid deficit related to medication, cognition; DX Diabetes Mellitus; Thyroid disease; resident has an actual fall with minor injury; resident is at increased risk for falls related to dementia; resident uses antidepressant medication Sertraline related to Chronic Depression. There was no care plan in place for hospice, psychotropic medication use, wander guard, weight loss, constipation, risk of pressure ulcer development, hypertension (high blood pressure), congestive heart failure, indigestion with daily prescription medication use, prn oxygen use, respiratory failure or insomnia. Review of Resident #12's Order Summary Report dated 12/06/2022 revealed the following: Code Status: DNR (local hospice agency) to evaluate and treat (order date 11/10/2022) May have O2 at 2L/Min via NC PRN to maintain O2 sats >92% (start date 5/14/2022) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676031 If continuation sheet Page 2 of 13 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 676031 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadow Creek Nursing and Rehabilitation 4343 Oak Grove Blvd San Angelo, TX 76904 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 0656 Place wander guard on resident due to her wandering outside (order date 9/24/2022) Level of Harm - Minimal harm or potential for actual harm Pressure reducing cushion (order date 11/20/2021) Residents Affected - Some Pressure reducing mattress to bed (order date 11/20/2021) Wander guard check placement every shift (start date 9/24/2022) Wander guard check function every day (start date 9/24/2022) Lorazepam 0.5mg 1 tablet by mouth every 1 hour as needed for anxiety (start date 11/16/2022) Lorazepam 0.5mg 1 tablet by mouth in the evening for anxiety (start date 11/17/2022) Furosemide 40mg 1 tablet by mouth twice a day for CHF (start date 9/24/2022) Hydralazine HCL 50mg 1 tablet by mouth three times a day for hypertension (start date 9/24/2022) Isosorbide Mononitrate ER 60mg 1 tablet by mouth once daily for hypertension (start date 9/24/2022) Levothyroxine Sodium 100mcg 1 tablet by mouth daily low thyroid hormone (start date 9/25/2022) Escitalopram Oxalate 10mg 1 tablet by mouth daily for depression (start date 9/24/2022) Polyethylene Glycol 3350 17GM/scoop 1 scoop every 24 hours as needed for constipation (start date (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676031 If continuation sheet Page 3 of 13 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 676031 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadow Creek Nursing and Rehabilitation 4343 Oak Grove Blvd San Angelo, TX 76904 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 0656 5/25/2022) Level of Harm - Minimal harm or potential for actual harm Morphine Sulfate Solution 20mg/ml give 0.5ml every 3 hours as needed for pain/sob/agitation Residents Affected - Some Pantoprazole Sodium 40mg 1 tablet by mouth daily for indigestion (start date 9/24/2022) Risperidone 0.5mg 1 tablet by mouth at bedtime for agitation and hallucinations (start date 10/28/2022) Trazodone HCL 50mg 1 tablet by mouth at bedtime for insomnia (start date 9/23/2022) Review of Resident #12's EHR on 12/07/2022 revealed Out of Hospital Do Not Resuscitate Order signed by the resident and dated by the resident, witnesseswitnesses, and physician 7/03/2020 and a Consent for Antipsychotic or Neuroleptic Medication Treatment signed by the physician 7/22/2022 and resident representative 7/18/2022. Review of Resident #27's admission Record (face sheet) dated 12/06/22, revealed she was a [AGE] year-old female originally admitted to the facility on [DATE] with an additional admission date of 6/01/2022, with diagnoses which included dementia, supraventricular tachycardia (a rapid heartbeat that develops when the normal electrical impulses of the heart are disrupted), hyperlipidemia (high cholesterol), chronic respiratory failure with hypoxemia (low blood oxygen), hypothyroidism (low thyroid hormone), and hypoglycemia (low blood sugar). Her code status was listed as DNR. Review of Resident #27's Quarterly MDS assessment dated [DATE], revealed she had adequate hearing, clear speech, was understood by others and able to understand others, and had adequate vision. She was unable to complete her mental status assessment and showed no signs or symptoms of delirium. She did exhibit other behavioral symptoms not directed towards others 1 to 3 days and rejection of care 1 to 3 days. She required extensive assistance of at least one person for all ADLs except eating for which she required only setup assistance. She used a wheelchair for locomotion on the unit. She was frequently incontinent of bowel and bladder. She had sustained 2 or more falls since admission. She was a risk for pressure ulcers with pressure reducing device for her bed and nutrition or hydration interventions to manage skin problems. She received antianxiety medication 7 of 7 days, antidepressant medication 7 of 7 days and anticoagulant medication 7 of 7 days. Review of Resident #27's care plan dated 9/09/2022 with most recent revision of 11/22/2022 revealed a problem of I have chosen to be FULL CODES status initiated 5/23/2022. There was no care plan in place for hospice services. Review of Resident #27's Order Summary Report dated 12/06/2022 revealed the following: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676031 If continuation sheet Page 4 of 13 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 676031 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadow Creek Nursing and Rehabilitation 4343 Oak Grove Blvd San Angelo, TX 76904 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 0656 Code Status: DNR Level of Harm - Minimal harm or potential for actual harm - Residents Affected - Some (local hospice company) for routine care with a diagnosis of senile degeneration of the brain (order date 11/22/2022) Review of Resident #27's EHR on 12/07/2022 revealed Out of Hospital Do Not Resuscitate Order signed by the resident and dated by the resident representative, witnesses and physician dated 11/23/2022. In an interview on 12/7/22 at 2:42 p.m. the MDS Nurse stated she was responsible for all care plans in the facility. She stated she was gone for an extended period and had a lot of help while she was out to keep things caught up, so the care plans were not personalized the way she preferred them to be. She stated she corrected as many as she could. She stated she included CAAs flagged on MDS assessments in her care plans such as fall risk or high-risk meds like anticoagulants as well as anything management went over in morning meeting they felt should be included. When asked specifically if medications such as antidepressants, anxiolytics, benzodiazepines, and opiates required care plans, she stated yes, they would. She added that any medication with potential side effects should have a care plan as well as the associated diagnosis. She stated hospice services required a care plan. She stated code status required a care plan and it was completed by the facility's social worker, however, she stated she was not aware of his process for entering code status, but she believed he was supposed to update it as soon as he received a signed DNR. She stated that she had 14 days after a resident MDS assessment is closed to complete a care plan but she tried to do them at the same time, so nothing was missed. She stated Resident #27's Significant Change MDS had just been started and her care plan had not been updated to reflect any new changes at the time of the inspection. She stated that Resident #12's most recent care plan update was done by a coworker but there had been two care plan meetings for the resident since the update and the missing information should have been caught. She stated that she could add care plan items as they came up without having to revise the entire document when and if she had time, but she had been the only MDS nurse for the facility and was responsible for all residents, both long term and skilled, and there had been a lot of admissions in the last few months. In an interview on 12/7/22 at 3:28 p.m. the DON stated care plans should include information regarding a resident's diagnoses, medications, code status, fall risk, and general care needs. She stated the facility only has one MDS nurse and she was responsible for all care plans in the facility. The DON stated that was a reasonable and manageable task for one person because the census had been under 40 until the last few months. She stated the corporate MDS nurse had helped complete and revise some care plans because the facility MDS nurse had gotten behind for a time. She stated that the corporate MDS nurse was also responsible for monitoring the care plans and MDS assessments and she was not aware of how often that happened. When asked who was responsible for putting code status on the care plan she stated she was not sure and that she assumed it was the MDS nurse. The DON stated they had a weekly care meeting where they go over any changes in care or updates for all residents so care plans should have been updated accordingly. She stated that having inconsistencies in documentation could be dangerous for the residents especially regarding code status. She stated care plans were the basis for care each resident received and she didn't know she was dropping the ball on what was being included in the care plans. In an interview on 12/07/22 at 3:54 p.m. the Social Worker stated he was responsible for depression care plans, anxiety care plans, and behavioral care plans. He stated he got the information for the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676031 If continuation sheet Page 5 of 13 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 676031 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadow Creek Nursing and Rehabilitation 4343 Oak Grove Blvd San Angelo, TX 76904 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some care plans from the triggered CAAs on the resident's MDS assessment. He confirmed he was responsible for code status care plans. He stated he should update code status care plans immediately after receiving a signed DNR, but he didn't always do it. When asked if 3 weeks was an acceptable length of time for a care plan to remain stating a resident was a full code after a DNR had been signed and filed in the chart, he stated no it was not and it should be done within a few days at most. He stated he had no part in hospice care plans or medication care plans. Review of facility policy Care Plans, Comprehensive Person-Centered revised date March 2022 revealed the following: The comprehensive, person-centered care plan includes measurable objectives and timeframes; describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial wellbeing; includes the resident's stated goals upon admission and desired outcomes; builds on the resident's strengths; and reflects currently recognized standards of practice for problem areas and conditions. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. The interdisciplinary team reviews and updates the care plan when there has been a significant change in the resident's condition; when the desired outcome is not met; when the resident has been readmitted to the facility from a hospital stay; and at least quarterly, in conjunction with the required quarterly MDS assessment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676031 If continuation sheet Page 6 of 13 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 676031 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadow Creek Nursing and Rehabilitation 4343 Oak Grove Blvd San Angelo, TX 76904 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide pharmaceutical services, including procedures that ensure the accurate administering of all drugs to meet the residents needs for 2 of 2 medication rooms reviewed for medication storage. The medication rooms had expired and undated vials of Tuberculin (Tuberculin is used to test for Tuberculosis) medication in the refrigerator. This failure could place residents at risk of receiving medications that were expired and not produce the desired effect. The findings were: During an observation, interview and record review on [DATE] at 09:12 AM the medication room door on the north side of the facility was inspected with the DON present. Inside the medication refrigerator there was an open Tuberculin vial with an open date of [DATE]. The Tuberculin container indicated Once entered, vial should be discarded after 30 days. The DON said the vials should be dated when opened and disposed after it expired. The DON said if a resident received a TB test with an expired tuberculin, they could get a false reading or negative reaction. The DON said the failure occurred because this vial got overlooked and not disposed when it had expired. During an observation and interview on [DATE] at 09:22 AM the medication room door on the south side of the facility was inspected with the ADON present. Inside the medication refrigerator there was an open Tuberculin vial that did not have an open date. The ADON said the vials were supposed to be dated when opened and that she would dispose of that vial as there was no way to tell when it had been opened. The ADON said it was everyone's job to make sure they dated the vial when it was opened. During an interview on [DATE] at 4:30 PM the Administrator was made aware of the expired and undated vials in the medication rooms. The Administrator said staff should have disposed of the expired vial and staff were expected to make sure they dated the vials when they were opened. Record review of the facility's policy titled Storage and expiration of medications dated [DATE] indicated in part: This policy 5.3 sets for the procedures relating to the storage and expiration dates to medication, biologicals, syringes and needles. Once any medication or biological package is opened, facility should follow manufacturer/supplier guidelines with respect to expiration dates for open medications. Facility staff should record the date opened on the medication container when the medication has a shortened expiration date once opened. Record review of the Tuberculin Purified Protein Derivative Tubersol manufacture pamphlet dated [DATE] indicated in part: A vial of Tubersol which has been entered and in use for 30 days should be discarded. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676031 If continuation sheet Page 7 of 13 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 676031 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadow Creek Nursing and Rehabilitation 4343 Oak Grove Blvd San Angelo, TX 76904 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 - Few 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 and interview, the facility failed to store all drugs and biologicals in locked compartments and permit only authorized personnel to have access for one (North side medication room) of two medication rooms reviewed for medication storage. The medication room door was left unlocked and unsupervised. This failures could place residents at risk for having access to medications resulting in drug diversion or accidental ingestion. The findings included: During an observation and interview on 12/06/22 at 09:08 AM the medication room door on the north side of the facility was seen open and unattended. The DON and LVN D arrived five minutes later and noticed the surveyors with the medication room door open. LVN D said the door would not close automatically unless it was pushed closed. The DON said the medication room door was supposed to closed when it was unattended. The medication room contained multiple medication blister packs such as blood pressure medications, multiple over the counter medication bottles such as aspirin, Tylenol and a small refrigerator that contained insulin pens in it. The DON said she was not aware the door had not been fully closing. The DON said if the door was not locked residents or visitors could have entered the room. LVN D said she must have walked away from the medication room and had not pushed the door close. LVN D said they would notify the maintenance man to repair the door. The LVN said she did not know how long the door had not been automatically closing on it's own. During an interview on 12/07/2022 at 4:28 PM the Administrator was made aware by the surveyor of the observation of the unlocked and unattended medication room door. The Administrator said the medication room doors were supposed to be locked when staff were not using them. The Administrator said they had the maintenance man fix the door so that it now closed on its own. Record review of the facility's policy titled Storage and expiration of medications dated 10/31/16 indicated in part: This policy 5.3 sets for the procedures relating to the storage and expiration dates to medication, biologicals, syringes and needles. Facility should ensure that only authorized facility staff, as defined by the facility, should have possession of the keys, access cards, electronic code or combinations with open medication storage areas. Facility should ensure that all medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676031 If continuation sheet Page 8 of 13 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 676031 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadow Creek Nursing and Rehabilitation 4343 Oak Grove Blvd San Angelo, TX 76904 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 in the facility's only kitchen reviewed for kitchen sanitation, in that: 1. The dishwasher did not get up to a sanitizing temperature 2. [NAME] B did not take food temperatures before meal service. 3. Foods were left on the floor. 4. Leftovers were not labeled and stored in a manner that prevented contamination. 5. Staff did not wash their hands in a manner that prevented cross contamination. 6. Dishes were stored in a manner that did not prevent pest or debris contamination. These deficient practices could place residents who receive meals prepared from the kitchen and served by facility staff at risk for food borne illness and cross contamination. The findings included: Observation and interview on 12/5/22 beginning at 09:43 a.m. through 10:08 a.m. of the facility's only kitchen revealed: Refrigerator #1: Ham sandwich meat out of the original wrapping in a sealed zipper bag dated 11/18/22; Plastic container with lid labeled Chicken Noodle Soup dated 11/19/22; Plastic container with lid labeled Pimento Cheese dated 11/10/22; A set-up for a sandwich with brown, wilted lettuce, a tomato, and slices of onion dated 11/23/22; A tomato sauce dated 11/27/22; plastic container with lid of what appeared to be Cranberry Sauce, undated, unlabeled; A zipper bag of appeared to be chicken unlabeled, undated; Plastic container with lid labeled Cheese sauce, dated 11/30/22; Plastic container of Sour Cream labeled best by 11/11/22; Refrigerator #2: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676031 If continuation sheet Page 9 of 13 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 676031 B. Wing (X3) DATE SURVEY COMPLETED A. Building 12/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadow Creek Nursing and Rehabilitation 4343 Oak Grove Blvd San Angelo, TX 76904 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 Zipper bag labeled Corn Bread dated 11/29/22; Level of Harm - Minimal harm or potential for actual harm Plastic container with lid labeled Fruit salad dated 11/18/22; Zipper bag containing wilted lettuce that was brown that was dated 11/29/22; Residents Affected - Many A burrito was stacked in the box of green peppers. Observation of the dry storage showed: 2 oz containers of syrup on a shelf, undated, Bag of flour on the floor. Interview and observation on 12/5/22 at 10:00 AM [NAME] A said the facility policy on leftovers was three days. She went through the refrigerator with surveyor and could not find a label or date on the above listed food. She said she thought the facility would keep sandwich meat longer than regular leftovers. She stated she thought the facility kept sandwich meat for two weeks. She said she did not know why the facility had so many bags of sandwich meat . Observation on 12/6/22 at approximately 3:45 p.m. showed the food delivery truck leaving . Observation and interview of food preparation on 12/6/22 beginning at 4:12 PM through 5:26 PM revealed DA C washed his hands and turned off the faucet with his bare hands three times; Plates and bowls were stored with the eating surface up; The first dinner plate of the substitute was set up at 4:38 p.m. and placed on the delivery cart ; At 4:47 p.m. surveyor noted a box of frozen chicken on the floor in the doorway between the food service area and the meat freezer. Surveyor asked [NAME] B about it and she stated she forgot to put the chicken up and went back to serving the dinner meal; At 4:52 p.m. [NAME] B made the first tray of the regular meal. Surveyor asked when meal temperatures were taken and [NAME] B stated, I didn't, sorry . [NAME] B immediately returned to serving the dinner meal trays. Hot dishes included: corn chowder, green beans, and carrots. Observation of the open dry storage door revealed posted: Remember to take Temp on food and equipment daily. (highlighted) Don't forget Interview on 12/06/22 at 4:54 p.m. the DM stated there was a possibility to food borne illness if the chicken was thawed and refrozen uncooked. He stated there was icicles in the chicken causing it to be tough in texture. He said to monitor normally he made sure that everything go put away. He was shown the box of the thawing chicken with water dripping down the box and he immediately put it in the freezer. He stated the food delivery truck came that afternoon. The DM said the dietary staff should have caught the chicken not being in the freezer. The DM stated the policy on food leftovers was three days and if there was not enough to re-use then the staff were to throw it out. He said temperatures for meals should be taken before meals. He said he was not in the kitchen when the staff were supposed to take temperatures. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676031 If continuation sheet Page 10 of 13 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 676031 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadow Creek Nursing and Rehabilitation 4343 Oak Grove Blvd San Angelo, TX 76904 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 Observation and interview on 12/6/22 at 5:10 p.m. revealed the DM went to check the sanitization level of the dishwasher and could not find sanitizer strips. [NAME] B told him where the boxes of strips were. When the DM checked the sanitizer level it showed no sanitizer in the water. He said the sanitizer should reach 50 PPM of sanitizer. He said the dishwasher was not working properly because there was no solution coming out of the dishwasher. After priming the machine multiple times, the DM was able to get the sanitizer level up to 25 PPM. The DM stated he would instruct the staff to hand wash the dishes that evening. The DM was calling the service provider as surveyor left the kitchen. Interview on 12/06/22 at 5:32 PM the Administrator was informed of the findings in the kitchen and stated, we'll get it. Surveyor followed up with the DM on 12/6/22 at 5:51 p.m. and after running it two times and priming it once, the sanitizer level got to 100 PPM of sanitizer . Review of the facility's policy on Food Storage, revised 2018, revealed: To ensure that all food served by the facility is of good quality and safe for consumption, all food will be stored according to state, federal and US food Codes. Procedure: Dry Storage: Store all items at least 6 inches above the floor Refrigerators: Store all foods on racks or shelves off the floor; Date, label and tightly seal all refrigerated foods using clean, nonabsorbent, covered containers that are approved for food storage; Use all leftovers within 72 hours, discard items that are over 72 hours old. Freezers Store all frozen meats, poultry, seafood, fruits and vegetables, and some dairy products such as ice cream, in the freezer at a temperature that maintains the frozen state of the foods. Store frozen foods immediately upon receiving. Store all foods on racks or shelves off the floor. Review of the facility's dietary policy on Hand Washing, revised 2018, revealed: The facility recognizes that food-borne illness has the potential to harm elderly and frail residents., All Nutrition and Foodservice employees will practice good hand washing practices in order to minimize the risk of infection and food borne illness. Handwashing steps: turn off the faucet with the paper towel to avoid contaminating hands and discard towel. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676031 If continuation sheet Page 11 of 13 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 676031 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadow Creek Nursing and Rehabilitation 4343 Oak Grove Blvd San Angelo, TX 76904 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 1 (Resident #40) of 3 resident reviewed for infection control in that; Residents Affected - Some LVN D failed to wash her hands or use hand sanitizer between glove changes during wound care for Resident #40. These failures could place resident's risk for cross contamination and the spread of infection. Finding included: Record review of Resident #40's admission record dated 12/06/2022 indicated he was admitted to the facility on [DATE] with diagnoses of dementia and muscle weakness. He was [AGE] years of age. Record review of Resident #40's Order Summary Report dated 12/06/2022 indicated in part: Cleanse right heel wound with normal saline or wound cleanser and pat dry. Crush flagyl (antibiotic medication) tablet and add Anasept (antibiotic that fights bacteria) to make paste. apply to wound and cover with nonadherent dressing daily. Record review of Resident #40's care plan dated 12/01/22 indicated in part: Problem: Unstageable area to right heel. Venous ulcer to right inner foot. GOAL: He will have no untreated pain related to wounds through the review date. Interventions: See MARS (medication administration records) for current treatment orders. Low air loss mattress to promote wound healing, comfort and decrease risk of further breakdown. Dietary supplements to enhance wound healing. During an observation on 12/06/22 at 01:18 PM LVN D performed wound care to Resident #40 wound. LVN D opened her treatment cart and removed some items. LVN D then entered the resident's room and placed the items on his bedside table. LVN D then put on some gloves without first washing her hands or using hand sanitizer. LVN D then took a pair of scissors out of her scrub pocket and cut the old dressing off Resident #40's right foot. LVN D then removed the dressing and disposed of it in the trash. LVN D then put on a pair of clean gloves without first washing her hands or using hand sanitizer. The LVN then removed the bandage from Resident #40's wound. While still wearing the same gloves, LVN D took the wound cleanser bottle and sprayed and wiped the wound with a gauze. While still wearing the same gloves the nurse applied the medication on the wound. While still wearing the same gloves, the LVN then took the new bandage and dressing and placed it on Resident #40's foot. While still wearing the same gloves, LVN D took the scissors and cut a piece of tape from a roll of tape and secured the dressing to the resident's foot. LVN D then removed her gloves and washed her hands. The LVN then took the wound cleanser bottle and roll of tape and placed them back in the treatment cart. During an interview on 12/06/22 at 03:44 PM LVN D said she had washed her hands prior to touching the treatment cart. LVN D said she should have washed or sanitized her hands prior to putting on gloves since she had touched the treatment cart. LVN D said she should have washed or sanitized her hands after she removed her gloves and put a new pair on. LVN D said she should have changed gloves after she cleansed the wound and then applied the new clean dressing. LVN D said the wound cleanser bottle and tape were used to perform wound care for the other residents in the facility and could cause (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676031 If continuation sheet Page 12 of 13 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 676031 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadow Creek Nursing and Rehabilitation 4343 Oak Grove Blvd San Angelo, TX 76904 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm cross contamination due to her touching the items with her contaminated gloves. LVN D said the failure could cause residents to get an infection. LVN D said she did not think to sanitize her hands in between glove changes and also that her hands could have become contaminated after touching the treatment cart. LVN D said she understood how her not changing gloves, sanitizing hands and touching items with the same gloves could lead to cross contamination. Residents Affected - Some During an interview on 12/07/22 at 11:16AM the DON said staff was expected to wash their hands prior to performing resident care. The DON said staff was expected to wash their hands or use hand sanitizer in between glove changes. The DON was made aware of the observation of wound care performed by LVN D. The DON said LVN D not following infection control procedure could place the residents at higher risks of infections. The DON said the staff received training on infection control steps and the nurse should have known to wash her hands, change gloves at the appropriate times. The DON said she believed the failure occurred because the nurse might have become nervous and forgot the steps. During an interview on 12/07/2022 at 4:24 PM the Administrator was made aware by the surveyor of the observation of wound care performed by LVN D. The Administrator said the LVN should have washed her hands and changed her gloves at the appropriate times. He acknowledged it was a concern that could cause cross contamination. Record review of the facility's policy titled Standard precautions dated 09/2022 indicated in part: Hand hygiene refers to hand washing with soap or the use of alcohol-based hand rub (ABHR) which does not require access to water. Hand hygiene is performed with a ABHR or soap and water. Before and after contact with the resident. Before moving from work on a soiled body site to a clean body site on the same resident. After contact with items in the resident's room and after removing gloves. After contact with blood, body fluids or contaminated surfaces. Gloves - gloves are worn when in direct contact with blood, body fluids, mucous membranes, non-intact skin and other potentially infected material. Gloves are changed and hygiene performed before moving from a contaminated body site to weight clean body side during resident care. Gloves are changed as necessary, during the care of a resident to prevent cross contamination from one body site to another (when moving from a dirty site to a clean one). After gloves are removed, hands are washed immediately to avoid transfer of microorganisms to other residents or environments. Record review of the facility's policy titled Handwashing/Hand hygiene dated 08/2019 indicated in part: This facility considers hand hygiene the primary means to prevent the spread of infections. Use an alcohol-based hand rub containing at least 62% alcohol or alternatively, soap and water for the following situations: after contact with objects example medical equipment in the immediate vicinity of the resident, after removing gloves. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare associated infection. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676031 If continuation sheet Page 13 of 13