Inspection·March 16, 2023

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident #72 was observed to not have fluids with her lunch. LVN A stated resident was not on fluid restrictions but if they gave her fluids before she ate, she would not eat her meal. LVN A further stated that if Resident #72 was not assisted with her meals she would eat with her fingers. Observation on 03/15/2023 at 12:25 PM revealed Resident #72 in the locked unit dining room with her lunch. Resident #72 was provided mechanical soft food on a divided plate. Resident #72 was not being provided assistance with eating and was using her fingers and hands to eat her meal. Resident #72 was scooping large amounts of food into her hands and licking it off her fingers and palm. In an interview on 03/15/2023 at 12:45 PM CNA H stated they were short of help on the locked unit for feeding assist. She stated the ADON usually came down to assist but did not come down today. In an interview on 03/15/2023 at 1:00 PM the ADON stated she was not able to go assist with feeding on the locked unit since they were shorthanded in other areas of the facility, and she was passing medication. In an interview on 03/16/2023 at 9:41 AM LVN A stated the kitchen never sends Resident #72 finger foods. She stated that if you don't assist Resident #72, she will eat with her fingers. When LVN A was asked if they had enough staff to feed the residents, she stated they really had to hustle a lot and stated they are short often with feeding assistance. In an interview on 03/16/2023 at 11:24 AM the Administrator stated if a resident needs assist with feeding that staff should be available to assist the resident and the resident should not have to eat with their hands. In an interview on 03/16/2023 at 11:33 AM the DON stated the locked unit should have enough staff to ensure all residents are provided feeding assist. She stated the ADON should have gone down to the locked unit to assist with feeding. The DON stated it was a dignity issue to have residents eat with their hands. Review of the facility's policy Resident Rights dated 02/2021 reflected Employees shall treat all residents with kindness, respect, and dignity .These rights include the resident's right to: a dignified, existence .equal access to quality care . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676097 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 676097 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Golden Creek Healthcare and Rehabilitation Center 2100 Dover Crossing Lane Navasota, TX 77868 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. 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 ensure residents unable to carry out activities of daily living, received the necessary services to maintain good grooming and personal hygiene for 3 of 20 residents (Resident #58, Resident #2, Resident #21) reviewed for ADL quality of care. Residents Affected - Few The facility failed to ensure Residents #58's, Resident # 2's and Resident #21's fingernails were trimmed and clean. This failure could place residents at risk of scratches, infections, and poor self-esteem. Findings Included: Record review of Resident #58's Clinical Resident Profile reflected she was a [AGE] year-old female admitted to the facility for long term care. Record review of Resident #58's Medical Diagnosis sheet reflected she was admitted to the facility on [DATE] with diagnoses of Frontotemporal Neurocognitive Disorder (damage to the neurons [information messengers that use electrical and chemical signals to send information between different areas of the brain] in the frontal and temporal lobes of the brain resulting in unusual behaviors, emotional problems, difficulty communicating), Vascular Parkinsonism (one or more small strokes in the brain causing slow movements, walking and balance difficulties, muscle stiffness, rigidity and limb weakness), Major Depressive Disorder (persistent feeling of sadness or loss of interest), Hyperlipidemia (high level of fats in the blood), Urinary Calculi (solid particles in the urinary system), Gastro-Esophageal Reflux Disease without Esophagitis (stomach acid repeatedly flows back into the tube (Esophagus) connecting the mouth to the stomach without causing inflammation of the Esophagus), Primary Hypertension (high blood pressure), Type 2 Diabetes Mellitus (body either does not produce enough insulin or it resists insulin. Insulin is a hormone that transports glucose into the body's cells) with Diabetic Chronic Kidney Disease (persistent high blood sugar damages the blood vessels in the kidneys), and Hypothyroidism (condition in which the thyroid gland does not produce enough thyroid hormones which can disrupt heart rate, body temperature and all aspects of metabolism (the chemical processes that occur within a living organism to maintain life). Record Review of Resident #58's Care Plan dated 04/13/2021 reflected she had an ADL self-care performance deficit related to Dementia, fatigue, pain in right shoulder and Parkinson's Disease. Goal: The resident will maintain current level of function in ADLS. Interventions/Tasks: Bathing/Showering Check nail length and trim and clean on bath days and as necessary. Review of Resident #58's Quarterly MDS dated [DATE] reflected she had a BIMS score of 13 reflecting Intact cognitive status. Her functional status reflected she required one-person physical assistance for personal hygiene. Observation on 03/14/2023 at 10:04 AM of Resident #58 revealed she had approximately ¾-1-inch-long jagged fingernails on both hands with brown debris underneath . Record review of the CNA Skin Inspection Report for Resident #58 was not provided by administration prior to exit. A blank Skin Inspection Report reviewed had a section to document whether fingernails and toenails had been clipped. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676097 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 676097 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Golden Creek Healthcare and Rehabilitation Center 2100 Dover Crossing Lane Navasota, TX 77868 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of Resident #2's Clinical Resident Profile reflected he was a [AGE] year-old male admitted to the facility for short term care. Record review of Resident #2's Medical Diagnosis sheet reflected he was admitted to the facility on [DATE] with diagnoses of Unspecified Dementia (progressive loss of intellectual functioning, with impairment of memory), Type 2 Diabetes (body either does not produce enough insulin or it resists insulin. Insulin is a hormone that transports glucose into the body's cells) with diabetic peripheral angiopathy (blood vessel disease caused by high blood sugar levels) without gangrene (dead tissue caused by infection or lack of blood flow), Chronic Obstructive Pulmonary Disease (group of lung diseases that block airflow and make it difficult to breathe), Pressure Ulcer Stage 3 of Sacral regions (bedsore that has reached the fat layers beneath the skins second layer on the lower back and spine), Muscle weakness, Primary Hypertension, (high blood pressure), Acquired absence of right leg above knee, (amputation above knee), Acquired absence of left leg above knee (amputation above knee) Anemia (lack of red blood cells int eh body leading to reduced oxygen flow tot eh body's organs), and Gastro-Esophageal Reflux Disease without Esophagitis (stomach acid repeatedly flows back into the tube (Esophagus) connecting the mouth to the stomach without causing inflammation of the Esophagus). Record Review of Resident #2's Care Plan dated 05/09/2022 and revised on 08/01/2022 reflected he had an ADL self-care deficit related to confusion, Dementia, fatigue, impaired balance, limited mobility, and bilateral Above Knee A mputation. Goal: The resident will maintain current level of function in ADLs through the review date. Interventions/Tasks: Bathing/Showering: check nail length and trim and clean on bath days and as necessary. Review of Resident #2's Quarterly MDS dated [DATE] reflected he had a BIMS score of 4 reflecting severe cognitive status. His functional status reflected he require extensive assistance of one-person physical assist for personal hygiene. Observation on 03/14/2023 at 12:40 PM revealed Resident #2 eating in the dining room. He had approximately ¾-1-inch-long jagged fingernails on both hands with brown debris underneath. Interview on 03/16/2023 at 11:15 AM LVN B stated Resident #2 should have had a bath on Wednesday 03/15/2023 and had his nails trimmed and cleaned. She observed Resident #2's fingernails and stated his nails needed to be cut as the length could cause skin issues including scratching and infection . Interview on 03/16/2023 at 11:25 AM CNA E stated he was assigned to Resident #2 on Wednesday 3/15/2023 and was not aware the resident had a bath due that night. He stated the shower schedule was unclear and he had not noticed the residents' nails. He further stated aides were supposed to trim nails but didn't always have the supplies needed to cut nails. Review of a CNA Inspection Report (shower sheet) dated 03/09/2023 for Resident #2 reflected the section for fingernails and toenails clipped was not filled out. No more recent shower sheets were available. Interview on 03/16/2023 at 11:34 AM LVN B found one set of nail clippers in the facility supply room where she said aides could get supplies for trimming nails and stated she would need to get some more for the supply room, but they were available in the facility. Review of Resident #21's Clinical Resident Profile reflected she was a [AGE] year-old female admitted to the facility for long term care. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676097 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 676097 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Golden Creek Healthcare and Rehabilitation Center 2100 Dover Crossing Lane Navasota, TX 77868 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident # 21'of s Medical Diagnosis sheet reflected she was admitted to the facility on [DATE] with diagnoses of Emphysema (condition in which the air sacs of the lungs are damaged and enlarged causing shortness of breath), Hemiplegia (paralysis of one side of the body), difficulty in walking, muscle weakness, Gastro Esophageal Reflux Disease without Esophagitis (stomach acid repeatedly flows back into the tube (Esophagus) connecting the mouth to the stomach without causing inflammation of the Esophagus), and personal history of Traumatic Brain Injury (brain dysfunction usually caused by an outside force, usually a violent blow to the head.) Review of Resident # 21's Care Plan dated 09/20/2022 reflected she had an ADL self-care deficit related to Dementia, and impaired balance related to Hemiplegia. Interventions: Avoid scratching and keep hands and body parts form excessive moisture. Keep fingernails short. Review of Resident #21's Quarterly MDS dated [DATE] reflected her BIMS score was 0 as she was unable to complete the exam. Her functional status reflected she required extensive assistance of one-person physical assist for personal hygiene. Observation on 03/14/2023 at 1:30 PM Resident #21 revealed fingernails on both hands were approximately ¾-1-inch-long, and jagged with brown debris underneath. Interview on 03/14/2023 at 1:40 PM LVN B observed Resident #21's fingernails and stated they were dirty, needed to be cut and the nurse's aides should be cutting her nails. She further stated the resident could scratch herself and get an infection. Review of a CNA Inspection Report (shower sheet) dated 03/09/2023 for Resident #21 reflected the section for fingernails and toenails clipped was not filled out. No more recent shower sheets were available. Interview on 03/16/2023 at 12:56 PM the DON stated her expectations were for nails to be assessed every shower and cleaned and trimmed as needed. She stated the nurses' trim nails for residents with a diagnosis of Diabetes. She stated the nurses do weekly skin checks with full head to toe assessments but there was nothing on the weekly skin checks that specifically said to check nails or toenails. She stated the potential risks of long nails were skin breakdown, poor hygiene, self-inflicted wounds, and residents could scratch themselves putting them at risk of infections. Interview on 03/16/2023 at 1:29 PM LVN C stated her expectations were for nurses' aides to trim and clean residents' nails if they are not diabetics. She stated if the resident refuses nail care she would ask them if she could trim their nails. She further stated the problem with long nails is they could cut into the resident's skin, and they could scratch themselves. Interview on 03/16/2023 at 1:34 PM the Administrator stated her expectations were for nails to be cut and trimmed as needed. She stated the CNAs should be catching the long nails first then the charge nurses should be looking at the nails during their weekly skin checks. She stated the potential risks to the residents were skin breakdown, infection, and self-inflicted injuries. Interview on 03/16/2023 at 1:41 PM CNA F stated she had been working at the facility for three years, and if the aides saw long nails on the residents and they are not diabetics, they would cut them. She stated if the resident refused two times, she would notify the nurse. She stated they were supposed to document nails on the shower sheets. (CNA Skin Inspection Reports). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676097 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 676097 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Golden Creek Healthcare and Rehabilitation Center 2100 Dover Crossing Lane Navasota, TX 77868 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Review of the facility's Fingernails/Toenails, Care of policy and procedure dated 2001 and revised 02/2018 reflected The purposes of this procedure are to clean the nail bed, to keep nails trimmed and to prevent infections. Nail care includes daily cleaning and regular trimming. Documentation: The following information should be recorded in the resident's medical record: The date and time that nail care was given. The name and title of the individual(s) who administered the nail care. The condition of the residents' nails and nail bed. If the resident refused the treatment, the reason(s) why and the interventions taken. Event ID: Facility ID: 676097 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 676097 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Golden Creek Healthcare and Rehabilitation Center 2100 Dover Crossing Lane Navasota, TX 77868 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure 1of 20 residents reviewed with limited range of motion (Resident #72), received appropriate treatment and services to prevent a decline in range of motion. The facility failed to ensure Resident #72 had interventions in place for her right-hand contracture (A permanent tightening of the muscles, tendons, skin, and surrounding tissues that causes the joints to shorten and stiffen and a decrease in ROM) to prevent further decline of the range of motion in her right hand. This deficient practice placed residents with contractures at risk for decrease in mobility, range of motion, and contribute to worsening of contractures. Findings Include: Review of Resident #72's Face Sheet dated 03/15/2023 reflected a [AGE] year old female admitted to the facility on [DATE] with the following diagnosis Hemiplegia and Hemiparesis following cerebral infarction affecting right dominant side (Hemiplegia and hemiparesis are related conditions that cause weakness or paralysis on one side of the body), Aphasia (A comprehension and communication (reading, speaking, or writing) disorder resulting from damage or injury to the specific area in the brain.) and Vascular Dementia (A condition caused by the lack of blood that carries oxygen and nutrient to a part of the brain. It causes problems with reasoning, planning, judgment, and memory.) Review of Resident #72's Quarterly MDS dated [DATE] reflected Resident #72 was assessed to have a BIMS score of 0 indicating severe cognitive impairment. Resident #72 was further assessed to have range of motion impairments of the upper and lower extremity on one side. Review of Resident #72's Comprehensive Care Plan reflected a focus area dated 02/09/2023 I have an ADL self-care performance deficit related to hemiplegia with contracture . Review of interventions reflected no interventions for contracture management. Further review of Resident #72's care plan reflected no plan of care addressing Resident #72's ROM deficits. Review of Resident #72's Consolidated Physician orders reflected an order dated 10/31/2022 for Therapy eval as needed. No other orders were reflected for therapy or contracture management. Review of Resident #72's Physician progress note dated 02/15/2023 reflected diagnosis of flexion contractures (A flexion contracture is a bent (flexed) joint that cannot be straightened actively or passively.). Listed under physical exam extremities Flexion contractures. Observation on 03/15/2023 at 1:50 PM CNA H and the RNC were with surveyor to examine Resident 72's hand. Observation of Resident #72's hand revealed CNA H was able to open Resident 72's right hand slightly. Resident #72's hand was closed tight with her thumb under her other fingers. Resident #72's fingernails were long and digging into her hand. No splint or hand roll was observed. The RNC stated Resident #72's fingernails were long but had not caused any sores at this time. The RNC stated Resident #72 should use a roll or splint as tolerated. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676097 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 676097 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Golden Creek Healthcare and Rehabilitation Center 2100 Dover Crossing Lane Navasota, TX 77868 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 0688 Level of Harm - Minimal harm or potential for actual harm In an interview on 03/15/2023 at 2:13 PM the PTA stated Resident #72 was last seen by therapy in January 2023 and her discharge date was 01/02/2023. The PTA stated she did not see a restorative plan in Resident #72's documentation at discharge from therapy. The PTA stated she was new and would have to look more thoroughly in Resident #72's chart to see why she was not provided with a discharge plan of care for contracture maintenance. Residents Affected - Few Review of Resident #72's Occupational Therapy Discharge summary dated [DATE] reflected no plan to address or maintain Resident #72's right hand flexion contracture. In an interview on 03/16/2023 at 9:27 AM the PTA stated she evaluated Resident #72 on 03/15/2023 and she was picked up for therapy. She stated she was not sure why when they discharged Resident #72 in January, that a restorative plan was not provided. She stated she should have been discharged with a plan for nursing to follow to ensure the right-hand contracture did not worsen. Observation on 03/16/2023 at 9:40 AM revealed Resident #72 up in activity room with hand splint to her right hand. Resident #72 was smiling. Resident #72's fingernails were trimmed. In an interview on 03/16/2023 at 9:41 AM LVN A stated Resident #72 used to have a splint for her right hand but has not had one for a while. She stated she was not sure how long she went without one and further stated therapy came in yesterday and started her splint again. In an interview on 03/16/2023 at 11:24 AM the Administrator stated if a resident had therapy for contracture management the resident should be discharged from therapy with a plan for staff to assist resident and to maintain the resident's current function, so they do not have a decline in function. In an interview on 03/16/2023 at 11:33 AM the DON stated the facility and therapy are supposed to have a plan for residents with contractures. She stated that if no plan is in place, it could cause the resident to have skin issues including pressure ulcers and a decline in ROM. The DON further stated regarding the care that the care plan should not only address the contracture but have interventions for maintenance of the contracture. Review of the facility's policy Contracture Management Program dated 10/08/2020 and revised on 01/23/2023 reflected Intent: To have a program within the facility geared towards the prevention of new contractures and maintenance or improvement of range of motion. Standard: Residents will be assessed by a Rehabilitation Team member upon admit, re-admit, quarterly and when significant change occurs for contractures or any decline in range of motion .Possible treatments may include but not limited to splinting, ROM, and pain management. Discharge to restorative nursing care for ROM and / or splinting needs to prevent further declines and continue to improve ROM . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676097 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 676097 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Golden Creek Healthcare and Rehabilitation Center 2100 Dover Crossing Lane Navasota, TX 77868 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 kitchen sanitation. A. The facility failed to ensure the floors in the walk-in freezer and walk-in refrigerator was free of ice and water. B. The facility failed to properly store and label food in the facility's walk- in refrigerator and walk-in freezer. C. The facility failed to ensure Dietary Aide I and Dietary [NAME] J properly sanitized hands between tasks. These failures could place residents, who received food and beverages from the kitchen, at risk for health complications, foodborne illnesses, and decreased quality of life. Findings included: A. Observation on 03/14/2023 between 9:05 AM - 9:30 AM revealed small chunks of ice and water on the floor in the walk-in refrigerator and the walk- in freezer. The floor was very slippery and was difficult to walk. There was a small thin layer of ice on the floor in the walk-in freezer and did could not see the ice until walked on the section of the floor where the ice was located. In an interview on 03/14/2023 at 9:10 AM the Dietary Manager stated one of her staff left the freezer slightly opened and there was ice around the door. She stated she had to knock off the ice to close the walk-in freezer door. She stated she checked all the food on 03/14/2023 in the freezer and the temperature of the freezer and there were no issues of any foods defrosted . She stated all foods were frozen and had not begun to defrost. She stated she checked everything in the freezer. She also stated it was an accident hazard with the water and ice on the floors in the walk-in refrigerator and walk-in freezer. She also stated someone had potential to fall and hurt themselves and she stated it was difficult to walk in the freezer and refrigerator. She stated she had the maintenance supervisor to look at the refrigerator and freezer to ensure it was in proper working order and he did not find any issues. B. Observation on 03/14/2023 of the walk-in refrigerator between 9:05 AM - 9:30 AM revealed a half box of uncooked sausage and three boxes of stacked carton of eggs stored on the wet floor. One half-opened transparent plastic bag with variety of cheese not labeled or dated. Observation on 03/14/2023 of the walk-in freezer between 9:05- 9:30 AM revealed a box of frozen bread stored on the floor. There were three damp packages of pie shells stored next to the fan. A slightly damp box of cookie dough stored next to pipes covered in duct tape. Observation on 03/14/2023 of the food prep table in the kitchen between 9:05 AM - 9:30 AM revealed a pan of approximately 15 individually cellophane leftover wrapped rolls not labeled or dated. An opened transparent plastic bag of leftover cereal not labeled or dated. An open transparent plastic bag of uncooked grits not labeled or dated. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676097 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 676097 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Golden Creek Healthcare and Rehabilitation Center 2100 Dover Crossing Lane Navasota, TX 77868 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 C. Observation on 03/14/2023 at 10:20 AM revealed Dietary Aide I removed her gloves after placing approximately ten trays of bowls of spice cake on the meal tray cart. She exited the kitchen area and entered the dry storage area. When she was walking to the dry storage area, her middle finger, fore finger, and ring finger touched her shirt, and she moved portion of her hair found under the hair net. She pulled parchment paper from the box in the dry storage area and returned to the kitchen. She began to place the parchment paper on top of the bowls of spice cakes found on the trays. Dietary Aide I's middle finger and ring finger on her right hand touched approximately ten spice cakes. Dietary Aide I did not sanitize or wash hands after she removed her gloves. In an interview on 03/14/2023 at 10:30 AM Dietary Aide I stated she did remove her gloves after she placed the trays with bowls of cake on the meal cart. She stated she did not wash or sanitize her hands after she removed her gloves. She stated she did touch her clothes and part of her hair. She also stated she did go into the dry storage area due to needed parchment paper to place over the trays of cake. She stated her fingers did touch some of the cake when she tried to place the paper over the cake. She stated there was a possibility with her touching the cake without washing or sanitizing her hands she may have contaminated the cake. She also stated she had been in serviced on hand sanitizing when in the kitchen. She stated she did not know what may happen if a resident ate contaminated food. She later stated a resident may become ill with a stomach virus. Observation on 03/14/2023 at 10:40 AM revealed Dietary [NAME] J was wearing gloves when she placed her right hand inside the oven mitt and touched the outside of the oven mitt. She touched her shirt and touched the oven door when she removed pureed food from the oven. She also touched the top drawer of a small plastic container located in the kitchen with office supplies and the thermometer stored in the top drawer. The top drawer had brownish substance on it and was not clean. Dietary [NAME] J did not remove her gloves during these tasks. She removed her gloves and began to sanitize the thermometer. Dietary [NAME] J opened the top of the garbage can with both hands and she began to take temperature of the pureed food on the steam table. She touched inside of the pureed meat container with her middle finger and ring finger on her right hand. Dietary [NAME] J did not wash or sanitize her hands or donned new gloves. In an interview on 03/14/2023 at 10:50 AM Dietary [NAME] J stated she did not wash or sanitize her hands when she removed her gloves. She stated she did not place new gloves on her hands when she was taking temperature of the pureed meat. She stated she was expected to wash or sanitize hands after she touched: the garbage can, the drawer in the small plastic organizer, inside of oven mitts, outside of oven mitts and her clothes. She stated it was a possibility she could contaminate the food from her unclean hands. She stated if she did have something on her hands and it was transferred to the food a resident may become ill and need to go to hospital with stomach problems. She stated she had been in serviced on kitchen hand hygiene. She also stated she was expected to sanitize hands after she removed her gloves and before placing new gloves on her hands. She stated if she was not wearing gloves, she was to sanitize hands immediately if her hands touched anything contaminated. In an interview on 03/15/2023 at 3:00 PM the Dietary Manager stated all staff was expected to wash their hands after removing their gloves. She stated there was an expectation of all dietary staff to wash their hands in between tasks. She also stated she was not sure when the oven mitts had been washed and they would be considered not sanitized. She also stated the small three drawer plastic container was dirty and the dietary cook was expected to wash her hands after she touched the plastic container, and the lid of the garbage can. She stated this was unacceptable. She also stated the staff had potential of cross contaminating the food served to the residents when they do not wash hands or wear gloves according to guidelines. She stated all foods were to be labeled and dated no matter (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676097 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 676097 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Golden Creek Healthcare and Rehabilitation Center 2100 Dover Crossing Lane Navasota, TX 77868 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 where the foods were being stored. She also stated if foods were not labeled or dated it was difficult to determine when the left-over food was used. She stated a resident had potential of becoming very sick with stomach viruses and would require hospitalization. She stated it was serious when staff did not wash or sanitize their hands. In an interview on 03/15/2023 at 3:30 PM the Maintenance Supervisor stated he checked the refrigerator and freezer in the kitchen and there was nothing needed to be repaired. He stated the ice and water was from the door of the walk-in freezer was slightly left opened and caused ice to surround the door. He stated the water was from the ice melting. He stated the walk-in freezer and refrigerator was in good working order. In an interview on 03/16/2023 at 12:45 PM the Administrator stated all staff in the kitchen were to wash their hands after removing gloves, between tasks and after touching anything contaminated. She stated there was a potential of a resident becoming physically ill if the staff hands touched residents' food prior to serving the meals. She stated all left-over food, or any food was to be labeled and dated. She stated if residents ate undated left-over foods there was a possibility for the resident to become ill. She also stated the boxes of food was not to be stored on the floor anywhere in the kitchen including the walk-in refrigerator and freezer. She stated boxes or containers of food were not appropriate to store next to the fan or pipes in the refrigerator or freezer. She also stated the ice and water on the floors in the refrigerator and freezer was expected to be clean immediately to prevent someone from falling. She stated it was Dietary Manager's responsibility to monitor all aspects of the kitchen especially hand sanitation. The Administrator did not specify what type of illness a resident could obtain if they ate contaminated food. Review of Food Receiving and Storage Policy dated 10/2022 revealed foods shall be received and stored in manner that complies with safe food handling practices. Food Services, or other designated staff, will always maintain clean food storage areas. All foods stored in the refrigerator or freezer will be covered, labeled, and dated (use by date). Review of Refrigerators and Freezers Policy dated 10/2022 revealed this facility will ensure safe refrigerator and freezer maintenance, temperatures, and sanitation, and will see food expiration guidelines. Refrigerators and freezers will be kept clean, free of debris, and mopped with sanitizing solution on a scheduled basis and more often as necessary. Review of undated Handwashing Policy revealed food service personnel shall wash hands: 1. Whenever hands are obviously soiled. 2. After working with unclean equipment, work surfaces, clothing, wash cloths, etc. 3. Before preparing or handling food. 4. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676097 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 676097 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Golden Creek Healthcare and Rehabilitation Center 2100 Dover Crossing Lane Navasota, TX 77868 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 Before and after removing gloves (note: gloves can cause contamination. Gloves should be changed often). Level of Harm - Minimal harm or potential for actual harm 5. Whenever in doubt. Residents Affected - Many 6. Upon completion of duty. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676097 If continuation sheet Page 12 of 12