Health inspection·December 27, 2023

F 0635 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some concerning for an ulcer. There is prominent latency in the posterior inferior calcaneus concerning for osteomyelitis. Plantar posterior calcaneal enthesophytes are present. The osseous structures are aligned. No fracture, dislocation or other osseous abnormalities are demonstrated. Joint has a normal appearance. No radiopaque foreign bodes are noted. Record review of Resident #1's Radiology results dated 12/19/23 indicated: Ulcer is seen in the right plantar aspect of the hindfoot with soft tissue gas. A comminuted extra-articular fracture is seen in the posterior third of the calcaneus which is new since prior exam. During an interview, on 12/22/23 at 12:30 PM, the DON stated Resident #1 did not admit to the facility with any orders. She stated all the documentation she received on 12/7/23, was to make a follow up appointment with PHYSICIAN A for 12/11/23. She stated that Resident #1 did admit with a boot but had almost no paperwork. She stated she has no idea why Resident #1 did not have any orders, other than to make a follow up appointment, and a boot. She stated when Resident #1 did not show up with orders LVN E should have reached out to the hospital or the wound care physician on what exactly needed to be done for resident #1. She stated she was being honest; she does not believe the hospital, or the physician were contacted and so no orders were received for resident #1. She stated on 12/13/23 she went into electronic medical records and found the orders for Resident #1 to be non-weight bearing to the right foot. She stated she was not sure why this was not done sooner. She stated that she accessed the hospitals electronic medical records that Resident #1 was transferred from and found the orders from physician A dated 12/7/23. She stated she did this on 12/13/23 because of the documentation recieved from wound care for Resident #1 on 12/11/23. During a telephone interview, on 12/23/23 at 3:30PM, LVN E stated she was the nurse that admitted Resident #1, to the facility, on the evening of 12/7/23. She stated Resident #1 had hardly any paperwork, upon admission. She stated the only documents she received was hospital discharge notes, which indicated to make a follow up appointment, with wound care, for 12/11/23, and a boot for the resident's right foot. She stated the first night Resident #1 was at the facility he walked without the boot on, no socks, just his dressing on his right foot for his wound. She stated he walked a lot, in the facility, with the boot on. She stated she should have reached out to the hospital or the primary care physician to know exactly what orders were needed for Resident #1. During a telephone interview on 12/21/23 at 11:40 AM Advocate stated Resident #1 was with home health before being admitted to the hospital from [DATE] to 12/7/23 for an infection and surgery to his right foot. She stated Resident #1 was transferred to the facility on [DATE] for IV antibiotics, wound care, and PT. She stated Resident #1 went to wound care at wound care facility (outside of the facility) on 12/11/23 and on 12/18/23. She stated on the visit to wound care on 12/18/12 it was decided by physician A Resident #1 needed to be admitted to ER due to the severity of right foot wound. She stated upon assessment at the ER on [DATE], it was determined Resident #1 would have right leg amputation just below the knee on 12/22/23. During an interview/observation of x-rays on Resident #1's right foot on 12/21/23 at 11:35 AM physician A revealed the concern and identified the differences between the x-rays. X-rays were reviewed by this investigator and physician A (we could not print the x-ray pictures). Physician A revealed, on 12/1/23, Resident #1's heel bone was intact, but did have an infection to the bone of the right heel. physician A stated the x-ray obtained on 12/18/23, revealed the heel bone had shattered into multiple pieces, bone shards were identified in the x-ray, showing 4 or more chunks of bone of right heel. He stated he reached out to physician B (podiatrist) who performed the operation, on Resident #1, on 12/1/23, and they both agreed that Resident #1's heel bone shattering could have been (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676031 If continuation sheet Page 2 of 12 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 12/27/2023 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 0635 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some prevented. Physician A stated the resident should have been non-Weight bearing, to the right foot. He stated on 12/18/23, Resident #1 walked into wound care appointment with no boot on and was not in a wheelchair. He stated the damage done to the heal was caused by pressure. He stated the shattering of the right heel was caused by the resident failing to be non-weight bearing to the right heel. He stated even when wearing a boot, the resident should not have been walking on that heel. He stated due to Resident #1 walking on that heel and the damage sustained, it was determined that the leg was to be amputated, just below the knee, and the surgery was scheduled to be completed on 12/22/23. During a telephone interview, on 12/23/23, physician B stated Resident #1 had osteomyelitis (infection of the bone) to the right heel bone. He stated that Resident #1 should have never been walking on his right foot. He stated that he consulted with PHYSICIAN A on 12/18/23, requesting PHYSICIAN A review the x-rays of Resident #1's right foot, x-rays from 12/1/23 and 12/19/23. He stated they both agreed that this could have been prevented and the damage sustained to the right heel was directly related to Resident #1 failing to be non-weight bearing to his right foot. He stated due to the injuries of the heel, Resident #1's required a below the knee amputation to his right leg, which was scheduled to be completed on 12/22/23. During an interview, on 12/21/23 at 12:35 PM, LVN C stated resident #1 was always walking around the facility. She stated Resident #1 did have his boot on, but no sock, just his right leg, with its dressing, in the boot. She said he walked a lot in the facility. She stated she did not know that he should not be weight bearing. During an interview, on 12/22/23 at 11:45 AM, LVN D stated Resident #1 had the boot on and was allowed to walk with his walker. He stated during shift change, on 12/8/23, the night nurse informed him Resident #1 was admitted last night and he was allowed to walk with his walker. He stated that the resident #1 never used his walker, resident #1 would walk around the facility in his boot. During an interview on 12/22/23 at 12:45 PM DON stated she did not have any policy for physician orders. She stated she reached out to corporate and did not have any policy for physician orders. This was determined to be an Immediate Jeopardy (IJ) on 12/22/23 at 4:20pm. The Administrator and DON were notified. The Administrator and DON were provided with the IJ template on 12/22/23 at 4:20 PM. The following Plan of Removal was accepted on 12/23/23 at 4:30 PM and included: Please accept the following Plan of Removal of Immediate Jeopardy-Failure to ensure residents are free from Quality of Care. The facility failed to ensure the residents are Quality of Care. 1. All residents have the potential to be affected. Facility census on 12-22-2023 was 56. 2. All licensed nurses will be in-serviced on how to determine the weight bearing status for all residents by utilizing the special instructions tab in PCC. All licensed nurses will be in-serviced on 2 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676031 If continuation sheet Page 3 of 12 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 12/27/2023 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 0635 nurses verifying orders within 24 hours. Level of Harm - Immediate jeopardy to resident health or safety 3. Director of Nursing or designee will audit all new admissions for weight bearing status and for other orders since December 1, 2023. Residents Affected - Some 4. Two nurses will be reviewing orders for accuracy upon admission. 5. Non-weight bearing status will be identified in the care profile in the medical record. 6. Two nurses will review all orders for new admissions within 24 hours. 7. Any negative outcomes will be reported to the QAPI committee. 8. Director of Nursing or designee will audit all new admissions for weight bearing status and for other orders since December 1, 2023. 9. DON/designee will review all orders for new admissions within 24 hours. 10. Any negative outcomes will be reported to the QAPI committee. The Medical Director was notified about the immediate jeopardy on 12-22-2023. Surveyors monitored the facility's Plan of Removal and confirmed it was sufficient to remove the IJ through observations, interviews, and record reviews from 12/22/2023 at 4:20pm to 12/23/2023 at 4:30pm. Review of the facility's In-service, dated 12/22/23, at 6pm, presented by DON, covering admission process and WB status indicated: Two nurses will review new admission orders during shift change upon admission. Weight bearing status will be noted in electronic medical records under care provide under special instructions. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676031 If continuation sheet Page 4 of 12 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 12/27/2023 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 0635 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some All weight bearing status will be put on care profile. If there are no specific orders for wb status, then there are no restrictions. All nurses must document any non-compliance with weight bearing status and notify physician of any noncompliance. Record review of a Facility Audit, of the resident's medical records, performed by DON, dated 12/23/23, revealed review of orders on new admits since December 1st, verified that all resident orders were correct. She stated she added weight bearing status in electronic medical records under the special instructions. There was a total of 18 residents' records, that were audited. She stated that during the audit process the facility did have to add into special instructions for weight bearing for two residents. During an interview, on 12/23/23 at 1:55 PM, CNA F (morning Shift) revealed she had been working for the facility, since the end of May 2023. She stated she received an in-serviced, over knowing the status of each resident. She stated for example, they discussed weight bearing and what exactly that means. She stated for example a new resident, was admitted , while she was on shift, she would sit down with the charge nurse, and they would go review all orders received for the resident and any needs, such as the resident being non weight bearing status. She stated if she were to observe the resident being non-compliant in any area, she would notate it in electronic medical records, tell her charge nurse, and inform the next CNA's coming on shift, during shift change. During a telephone interview, on 12/23/22 at 2:20 PM, LVN G (night nurse) stated an in-service was provided on this date, before she finished her shift. She stated they went over how to accept a new resident into the facility. She stated the facility staff were to make sure all orders and documentation was received, when receiving a new resident. She stated if everything does not seem like it is with the new resident, she was instructed to reach out, to the DON and the facility liaison. She stated the in-service also went over how to document all noncompliance, by any resident, and to bring that to the DONS's attention, regarding any resident that may be non-weight bearing or any resident that was being non-compliant. She stated for example if she was the nurse on shift when a new resident was admitted to the facility, she was to have 2 nurses sign off to make sure they both feel all new orders were in place and documented correctly. During a telephone interview, on 12/23/23 at 2:45 PM, CNA H (night shift) stated the in-service was at about 6 am in the morning on 12/23/23. She stated the in-service provided information on noncompliance of any resident, where to document that information in PCC, and who to inform (charge nurse). She stated, for example if she was on shift and a new resident was admitted to the facility, she would sit down with the charge nurse and the charge nurse would inform her of all orders for the resident and anything she needed to look out for. She stated for example weight bearing would be mentioned to her in this sit down and then when she was done with her shift and does shift change, she would inform the next CNAs of any noncompliance she had witnessed during her shift. During a phone interview, on 12/23/23 at 3:30 PM, LVN E stated she was in-serviced yesterday evening, 12/22/23. She stated the changes made to have a two nurse sign off on any new admits to the facility. She stated the residents' orders were to be checked and that if anything seemed to be missing or not there, she was to reach out to the DON or the facility liaison, who would then verify all orders were correct and were put in place for the resident. She stated the process was being changed to make sure no orders were missed for any resident in the facility. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676031 If continuation sheet Page 5 of 12 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 12/27/2023 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 0635 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete During an interview, on 12/23/23 at 3:55, PM LVN D stated this entire in-service covered documentation and verifying all information on new admits was received from the previous facility or the hospital. He stated there was now a two nurse sign off on newly admitted residents and this was to verify everything was correct. He stated if any documentation or orders were not received or did not seem correct, he was to inform his DON or the facility liaison to get the proper documentation. The Administrator was informed the Immediate Jeopardy was removed on 12/23/2023 at 4:30pm. The facility remained out of compliance at a severity level of actual harm, and a scope identified as pattern due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective actions. Event ID: Facility ID: 676031 If continuation sheet Page 6 of 12 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 12/27/2023 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice for one 1 (Resident #1) of 2 residents reviewed for quality of care. Residents Affected - Some The facility failed to ensure staff followed Resident #1's physician's orders by wound care physician for non-weight bearing when ambulating which led to Resident #1 having a below the knee amputation. An Immediate Jeopardy (IJ) was identified on 12/22/2023. While the IJ was removed on 12/23/23 at 4:30p.m, the facility remained out of compliance at a severity level of actual harm, and a scope identified as pattern due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective actions. This failure could place residents at risk of not receiving adequate care and services, and decreased quality of life. Findings included: Review of Resident #1's face sheet dated 12/27/23 reflected the resident was a [AGE] year-old male admitted to the facility on [DATE]. The diagnoses included Osteomyelitis (a serious infection of the bone that can be either acute or chronic), Type 2 Diabetes, Hyperlipidemia (an elevated level of lipids - like cholesterol and triglycerides - in your blood), anxiety disorder, and Hypertension (High blood pressure is a common condition that affects the body's arteries). Resident #1 cognitive status reflected moderate to good, depending on day. Review of Resident #1's Care Plan dated 12/11/23 reflected: *Resident #1 had potential/actual impairment to skin integrity of the right foot related to wound date Initiated: 12/11/2023. *Resident #1 had an ADL self-care performance deficit r/t inability to bear weight on right leg Date Initiated: 12/11/2023. Record review of physician order by Wound Care Physician dated 12/7/23 revealed resident #1 was to be transferred to Facility A with weight bearing status indicating: nwb (non-weight bearing) right foot. Record review of Resident #1's Radiology report, dated 12/1/23 (obtained at the hospital, prior to admission), indicated: there is a small defect in the skin of the right posterior plantar surface concerning for an ulcer. There is prominent latency in the posterior inferior calcaneus concerning for osteomyelitis. Plantar posterior calcaneal enthesophytes are present. The osseous structures are aligned. No fracture, dislocation or other osseous abnormalities are demonstrated. Joint has a normal appearance. No radiopaque foreign bodes are noted. Record review of Resident #1's Radiology results dated 12/19/23 indicated: Ulcer is seen in the right plantar aspect of the hindfoot with soft tissue gas. A comminuted extra-articular fracture is (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676031 If continuation sheet Page 7 of 12 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 12/27/2023 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 0684 seen in the posterior third of the calcaneus which is new since prior exam. Level of Harm - Immediate jeopardy to resident health or safety During a telephone interview on 12/21/23 at 11:40 AM Advocate stated Resident #1 was with home health before being admitted to the hospital from [DATE] to 12/7/23 for an infection and surgery to his right foot. She stated Resident #1 was transferred to the facility on [DATE] for IV antibiotics, wound care, and PT. She stated Resident #1 went to wound care at wound care facility (outside of the facility) on 12/11/23 and on 12/18/23. She stated on the visit to wound care on 12/18/12 it was decided by physician A Resident #1 needed to be admitted to ER due to the severity of right foot wound. She stated upon assessment at the ER on [DATE], it was determined Resident #1 would have right leg amputation just below the knee on 12/22/23. Residents Affected - Some During an interview/observation of x-rays on Resident #1's right foot on 12/21/23 at 11:35 AM physician A revealed the concern and identified the differences between the x-rays. X-rays were reviewed by this investigator and physician A (we could not print the x-ray pictures). Physician A revealed, on 12/1/23, Resident #1's heel bone was intact, but did have an infection to the bone of the right heel. physician A stated the x-ray obtained on 12/18/23, revealed the heel bone had shattered into multiple pieces, bone shards were identified in the x-ray, showing 4 or more chunks of bone of right heel. He stated he reached out to physician B (podiatrist) who performed the operation, on Resident #1, on 12/1/23, and they both agreed that Resident #1's heel bone shattering could have been prevented. Physician A stated the resident should have been non-Weight bearing, to the right foot. He stated on 12/18/23, Resident #1 walked into wound care appointment with no boot on and was not in a wheelchair. He stated the damage done to the heal was caused by pressure. He stated the shattering of the right heel was caused by the resident failing to be non-weight bearing to the right heel. He stated even when wearing a boot, the resident should not have been walking on that heel. He stated due to Resident #1 walking on that heel and the damage sustained, it was determined that the leg was to be amputated, just below the knee, and the surgery was scheduled to be completed on 12/22/23. During a telephone interview, on 12/23/23, physician B stated Resident #1 had osteomyelitis (infection of the bone) to the right heel bone. He stated that Resident #1 should have never been walking on his right foot. He stated that he consulted with PHYSICIAN A on 12/18/23, requesting PHYSICIAN A review the x-rays of Resident #1's right foot, x-rays from 12/1/23 and 12/19/23. He stated they both agreed that this could have been prevented and the damage sustained to the right heel was directly related to Resident #1 failing to be non-weight bearing to his right foot. He stated due to the injuries of the heel, Resident #1's required a below the knee amputation to his right leg, which was scheduled to be completed on 12/22/23. During an interview, on 12/21/23 at 12:35 PM, LVN C stated resident #1 was always walking around the facility. She stated Resident #1 did have his boot on, but no sock, just his right leg, with its dressing, in the boot. She said he walked a lot in the facility. She stated she did not know that he should not be weight bearing, so she did not stop him from walking with the boot on. She stated he never complained of pain. During an interview, on 12/22/23 at 11:45 AM, LVN D stated Resident #1 had the boot on and was allowed to walk with his walker. He stated during shift change, on 12/8/23, the night nurse informed him Resident #1 was admitted last night and he was allowed to walk with his walker. He stated that the resident #1 never used his walker, resident #1 would walk around the facility in his boot, he stated because he didnt know the resident was NWB he did not stop the resident from walking. He stated Resident #1 never complained about pain. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676031 If continuation sheet Page 8 of 12 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 12/27/2023 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 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some During an interview, on 12/22/23 at 12:30 PM, the DON stated Resident #1 did not admit to the facility with any orders. She stated all the documentation the facility received on 12/7/23, was to make a follow up appointment with PHYSICIAN A for 12/11/23. She stated that Resident #1 did admit with a boot but had almost no paperwork. She stated she has no idea why Resident #1 did not have any orders, other then to make a follow up appointment, and a boot. She stated when Resident #1 did not show up without orders LVN E should have reached out to the hospital or the wound care physician on what exactly needed to be done for resident #1. She stated she was being honest; she does not believe the hospital, or the physician were contacted and so no orders were received for resident #1. She stated on 12/13/23 she went into electronic medical records and found the orders for Resident #1 to be non-weight bearing to the right foot. She stated she was not sure why this was not done sooner. She stated the resident never complained about pain. She stated that because they did not know about the NWB of the right foot Resident #1 walked on the foot a lot. She stated that they never reached out to the physician to inform him of noncompliance because Resident #1 never complained about pain. During a telephone interview, on 12/23/23 at 3:30PM, LVN E stated she was the nurse that admitted Resident #1, to the facility, on the evening of 12/7/23. She stated Resident #1 had hardly any paperwork, upon admission. She stated the only documents she received was hospital discharge notes, which indicated to make a follow up appointment, with wound care, for 12/11/23, and a boot for the resident's right foot. She stated the first night Resident #1 was at the facility he walked without the boot on, no socks, just his dressing on his right foot for his wound. She stated he walked a lot, in the facility, with the boot on. She stated she should have reached out to the hospital or the primary care physician to know exactly what orders were needed for Resident #1. During an interview on 12/22/23 at 12:45 PM DON stated she did not have any policy for physician orders. She stated she reached out to corporate and did not have any policy for physician orders. This was determined to be an Immediate Jeopardy (IJ) on 12/22/23 at 4:20pm. The Administrator and DON were notified. The Administrator and DON were provided with the IJ template on 12/22/23 at 4:20 PM. The following Plan of Removal was accepted on 12/23/23 at 4:30 PM and included: Please accept the following Plan of Removal of Immediate Jeopardy-Failure to ensure residents are free from Quality of Care. The facility failed to ensure the residents are Quality of Care. 1. All residents have the potential to be affected. Facility census on 12-22-2023 was 56. 2. All licensed nurses will be in-serviced on how to determine the weight bearing status for all residents by utilizing the special instructions tab in PCC. All licensed nurses will be in-serviced on 2 nurses verifying orders within 24 hours. 3. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676031 If continuation sheet Page 9 of 12 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 12/27/2023 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 0684 Level of Harm - Immediate jeopardy to resident health or safety Director of Nursing or designee will audit all new admissions for weight bearing status and for other orders since December 1, 2023. 4. Two nurses will be reviewing orders for accuracy upon admission. Residents Affected - Some 5. Non-weight bearing status will be identified in the care profile in the medical record. 6. Two nurses will review all orders for new admissions within 24 hours. 7. Any negative outcomes will be reported to the QAPI committee. 8. Director of Nursing or designee will audit all new admissions for weight bearing status and for other orders since December 1, 2023. 9. DON/designee will review all orders for new admissions within 24 hours. 10. Any negative outcomes will be reported to the QAPI committee. The Medical Director was notified about the immediate jeopardy on 12-22-2023. Surveyors monitored the facility's Plan of Removal and confirmed it was sufficient to remove the IJ through observations, interviews, and record reviews from 12/22/2023 at 4:20pm to 12/23/2023 at 4:30pm. Review of the facility's In-service, dated 12/22/23, at 6pm, presented by DON, covering admission process and WB status indicated: Two nurses will review new admission orders during shift change upon admission. Weight bearing status will be noted in electronic medical records under care provide under special instructions. All weight bearing status will be put on care profile. If there are no specific orders for wb status, then there are no restrictions. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676031 If continuation sheet Page 10 of 12 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 12/27/2023 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 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some All nurses must document any non-compliance with weight bearing status and notify physician of any noncompliance. Record review of a Facility Audit, of the resident's medical records, performed by DON, dated 12/23/23, revealed review of orders on new admits since December 1st, verified that all resident orders were correct. She stated she added weight bearing status in electronic medical records under the special instructions. There was a total of 18 residents' records, that were audited. She stated that during the audit process the facility did have to add into special instructions for weight bearing for two residents. During an interview, on 12/23/23 at 1:55 PM, CNA F (morning Shift) revealed she had been working for the facility, since the end of May 2023. She stated she received an in-serviced, over knowing the status of each resident. She stated for example, they discussed weight bearing and what exactly that means. She stated for example a new resident, was admitted , while she was on shift, she would sit down with the charge nurse, and they would go review all orders received for the resident and any needs, such as the resident being non weight bearing status. She stated if she were to observe the resident being non-compliant in any area, she would notate it in electronic medical records, tell her charge nurse, and inform the next CNA's coming on shift, during shift change. During a telephone interview, on 12/23/22 at 2:20 PM, LVN G (night nurse) stated an in-service was provided on this date, before she finished her shift. She stated they went over how to accept a new resident into the facility. She stated the facility staff were to make sure all orders and documentation was received, when receiving a new resident. She stated if everything does not seem like it is with the new resident, she was instructed to reach out, to the DON and the facility liaison. She stated the in-service also went over how to document all noncompliance, by any resident, and to bring that to the DONS's attention, regarding any resident that may be non-weight bearing or any resident that was being non-compliant. She stated for example if she was the nurse on shift when a new resident was admitted to the facility, she was to have 2 nurses sign off to make sure they both feel all new orders were in place and documented correctly. During a telephone interview, on 12/23/23 at 2:45 PM, CNA H (night shift) stated the in-service was at about 6 am in the morning on 12/23/23. She stated the in-service provided information on noncompliance of any resident, where to document that information in PCC, and who to inform (charge nurse). She stated, for example if she was on shift and a new resident was admitted to the facility, she would sit down with the charge nurse and the charge nurse would inform her of all orders for the resident and anything she needed to look out for. She stated for example weight bearing would be mentioned to her in this sit down and then when she was done with her shift and does shift change, she would inform the next CNAs of any noncompliance she had witnessed during her shift. During a phone interview, on 12/23/23 at 3:30 PM, LVN E stated she was in-serviced yesterday evening, 12/22/23. She stated the changes made to have a two nurse sign off on any new admits to the facility. She stated the residents' orders were to be checked and that if anything seemed to be missing or not there, she was to reach out to the DON or the facility liaison, who would then verify all orders were correct and were put in place for the resident. She stated the process was being changed to make sure no orders were missed for any resident in the facility. During an interview, on 12/23/23 at 3:55, PM LVN D stated this entire in-service covered documentation and verifying all information on new admits was received from the previous facility or the hospital. He stated there was now a two nurse sign off on newly admitted residents and this was to verify (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676031 If continuation sheet Page 11 of 12 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 12/27/2023 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 0684 Level of Harm - Immediate jeopardy to resident health or safety everything was correct. He stated if any documentation or orders were not received or did not seem correct, he was to inform his DON or the facility liaison to get the proper documentation. The Administrator was informed the Immediate Jeopardy was removed on 12/23/2023 at 4:30pm. The facility remained out of compliance at a severity level of actual harm, and a scope identified as pattern due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective actions. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676031 If continuation sheet Page 12 of 12