Inspection·April 11, 2024

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few MDS Coordinator to complete the MDS and the DON's responsibility to verify completion. The DON stated that a potential negative outcome to an inaccurate MDS assessment would be it could affect billing, but that depending on which section is incorrect it could affect other care areas. The DON said she remembered Resident #92 and that he was discharged home with family. In an interview on 04/11/24 at 12:50 PM with the Administrator, she stated the MDS was completed by an interdisciplinary team and that the MDS Coordinator is to verify it for accuracy and the DON is responsible for verifying its completion. The Administrator said a potential negative outcome to an inaccurate MDS assessment is it could affect billing and payments, or the resident may not receive their needed services depending on what section is incorrect. Record review of the facility MDS Coding Policy last revised 01/04/2023 revealed: affiliated facilities utilize the most up to date Resident Assessment Instrument (RAI) manual for determination of coding each section of the Resident Assessment, timely and accurately. Record review of the CMS RAI Manual last revised 10/20/23 revealed: 5.5 MDS Correction Policy Once completed, edited, and accepted into iQIES, providers may not change a previously completed MDS assessment as the resident's status changes during the course of the resident's stay-the MDS must be accurate as of the ARD. Minor changes in the resident's status should be noted in the resident's record (e.g., in progress notes), in accordance with standards of clinical practice and documentation. Such monitoring and documentation is a part of the provider's responsibility to provide necessary care and services. A significant change in the resident's status warrants a new comprehensive assessment (see Chapter 2 for details). It is important to remember that the electronic record submitted to and accepted into iQIES is the legal assessment. Corrections made to the electronic record after iQIES acceptance or to the paper copy maintained in the medical record are not recognized as proper corrections. It is the responsibility of the provider to ensure that any corrections made to a record are submitted to iQIES in accordance with the MDS Correction Policy. Several processes have been put into place to assure that the MDS data are accurate both at the provider and in iQIES. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676097 If continuation sheet Page 2 of 18 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 04/11/2024 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to refer all level II residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change in status assessment for 1 of 4 residents (Resident #53) assessments reviewed for PASARR evaluations. The facility failed to refer Resident #53 to the appropriate, State-designated authority when she was diagnosed schizoaffective disorder. This failure could place residents at risk for not receiving necessary PASARR mental health services, causing a possible decline in mental health. Findings included: Record review of Resident #53's face sheet dated 04/11/24 revealed a [AGE] year-old female admitted on [DATE] with a diagnoses of type 2 diabetes mellitus without complications (condition resulting from insufficient production of insulin causing high blood sugar), schizoaffective disorder bipolar type (a mental disorder in which a person experiences a combination of symptoms of schizophrenia and mood disorder) with onset date of 05/04/22, erythema intertrigo (inflammatory skin condition), and hyperlipidemia unspecified (abnormally high levels of any or all lipids or lipoproteins in the blood). Record review of Resident #53's MDS assessment dated [DATE] reflected a BIMS score of 15 suggesting cognition was intact. The MDS also reflect an active diagnosis of schizophrenia. Record review of Resident #53's PASARR Level 1 screening dated 03/05/21 reflected section c is there evidence or an indicator this is an individual that has a mental illness? was marked no. No additional PASARR screenings were found in Resident #53's records. In an interview on 04/10/24 at 03:45 PM with the MDS Coordinator she stated she had just turned in HHS form 1012 Mental Illness/Dementia Resident Review for Resident #53 on 04/10/24. The MDS Coordinator said that when Resident #53 first came in she did not trigger for a level 2 PASARR. She said an audit was conducted the week of 03/31/24 which is how the event was found. The MDS Coordinator said that audits are attempted every 6 months and she did not know why it wasn't caught sooner. She said that after the 1012 was submitted was when they would know if the resident in question would qualify for a level 2 assessment. The MDS Coordinator said that typically a diagnosis of a Mental Illness at admission would trigger them for a level 2 assessment or if they were to develop one later the added diagnosis would have a level 2 assessment triggered. The MDS Coordinator said that by going that long without the PASARR level 2 assessment the negative outcome is the resident could have missed out on additional mental health services. In an interview on 04/11/24 at 12:26 PM with the DON she stated was the MDS Coordinators responsibility to complete a PASARR assessment and ensure accuracy. The DON said that she was not savvy on PASARRs, but she believed that a new PASARR assessment should be completed within 3 months of a new Mental Illness diagnosis or change that would require one. The DON said that it was her expectation that PASARRs are verified for accuracy and if the plan of care changes that they reassess. The DON said (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676097 If continuation sheet Page 3 of 18 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 04/11/2024 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few that a potential negative outcome to a PASARR level 2 not being completed was the potential for residents to miss needed treatment or services which would result in a decline of their health because they are not properly assessed or diagnosed. She stated the resident's quality of life could decline and that staff as a team should be ensuring assessments are being completed accurately. In an interview on 04/11/24 at 12:50 PM with the Administrator she stated it was the MDS Coordinator's responsibility to verify when a PASARR level 2 is needed. The Administrator stated it was her expectation that PASARR assessments are accurate and that PASARR level 2's are completed as soon as being identified as being needed. She said that a negative outcome to not having a timely PASARR level 2 completed would mean the resident could be missing out on getting necessary services to treat the mental illness. Record review of the PASRR Policy and Procedure last revised 07/18/18 revealed: [facility] uses the most current version of PASRR rules, TAC Title 40, Part 1 Chapter 19, Sub-chapter BB as they pertain to PASRR Level 1, Level 2 (PE), Specialized Services and IDT meetings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676097 If continuation sheet Page 4 of 18 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 04/11/2024 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 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure all Pre-admission Screening and Resident Review (PASARR) Level I Screening for residents diagnosed with mental illness were accurate and residents were provided with a PASARR Level II Screening for 1 of 4 residents (Resident #36) reviewed for PASARR coordination, in that: Residents Affected - Few A PASARR Level I was completed inaccurately for Resident #36 who had an active mental health diagnosis on admission. This failure could place residents at risk for not receiving necessary PASARR mental health services, causing a possible decline in mental health. Findings Included: Record review of Resident #36's face sheet revealed a [AGE] year old female admitted on [DATE] with a diagnosis of Variant Creutzfeld-[NAME] Disease (commonly referred to as mad cow disease or human mad cow disease is a rare and fatal prion (infectious protein particle) disease that affects the brain caused by abnormal prion proteins that accumulate in the brain leading to progressive damage), anxiety disorder-unspecified (a group of mental illnesses that cause constant fear and worry), psychotic disorder with delusions due to known physiological condition with onset dated 06/20/2019, and anorexia (eating disorder characterized by an abnormally low body weight, an intense fear of gaining weight, and a distorted perception of weight). Record review of Resident #36's MDS assessment dated [DATE] reflected a BIMS assessment was not completed (used to evaluate aspects of cognition in the elderly). Section I reflected Resident #36 had an active diagnosis of psychotic disorder (other than schizophrenia). Record review of PASRR Level 1 Screening completed 06/20/2019 revealed section c stated, Is there evidence or an indicator this is an individual that has a Mental Illness? Which was answered no. In an interview on 04/10/24 at 03:45 PM with the MDS Coordinator she stated she had just turned in HHS form 1012 Mental Illness/Dementia Resident Review for Resident #36 on 04/10/24. The MDS Coordinator said that when Resident #36 first came in she did not trigger for a level 2 PASARR, she said an audit was conducted the week of 03/31/24 which is how this event was found. The MDS Coordinator said that audits are attempted every 6 months and she did not know why this wasn't caught sooner. She said that after the 1012 is submitted is when they would know if the resident in question would qualify for a level 2 assessment. The MDS Coordinator said that typically a diagnosis of a Mental Illness at admission would trigger them for a level 2 assessment or if they were to develop one later the added diagnosis would have a level 2 assessment triggered. The MDS Coordinator said that by going this long without the PASARR level 2 assessment the negative outcome is the resident could have missed out on additional mental health services. In an interview on 04/11/24 at 12:26 PM with the DON, she stated it was the MDS Coordinators responsibility to complete a PASARR assessment and ensure accuracy. The DON said that she was not savvy on PASARRs, but she believed that a new PASARR assessment should be completed within 3 months of a new Mental Illness diagnosis or change that would require one. The DON said that it was her expectation that PASARRs are verified for accuracy and if the plan of care changes that they reassess. The DON (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676097 If continuation sheet Page 5 of 18 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 04/11/2024 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 0645 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few said that a potential negative outcome to a PASARR level 2 not being completed is the potential for residents to miss needed treatment or services which would result in a decline of their health because they are not properly assessed or diagnosed. She stated the residents quality of life could decline and that staff as a team should be ensuring assessments are being completed accurately. In an interview on 04/11/24 at 12:50 PM with the Administrator she stated it was the MDS Coordinators responsibility to verify when a PASARR level 2 is needed. The Administrator stated it was her expectation that PASARR assessments are accurate and that PASARR level 2's are completed as soon as being identified as being needed. She said that a negative outcome to not having a timely PASARR level 2 completed would mean the resident could be missing out on getting necessary services to treat the mental illness. Record review of the PASRR Policy and Procedure last revised 07/18/18 revealed: [facility] uses the most current version of PASRR rules, TAC Title 40, Part 1 Chapter 19, Sub-chapter BB as they pertain to PASRR Level 1, Level 2 (PE), Specialized Services and IDT meetings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676097 If continuation sheet Page 6 of 18 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 04/11/2024 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to ensure that a resident who needed respiratory care was provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 1 resident (Resident #4) reviewed for respiratory care. Residents Affected - Few The facility failed to ensure Resident #4's nasal cannula was properly stored when not in use. The facility failed to ensure Resident #4's oxygen treatment and tubing changes were documented on the respiratory MAR. These failures could place the residents at risk for respiratory infection and not having their respiratory needs met. Findings included: Record review of Resident #4's face sheet dated 04/11/24 revealed a [AGE] year-old female admitted on [DATE] with a diagnoses of panlobular emphysema (disease of the lungs in which the air sacs in the lungs are permanently damaged), chronic obstructive pulmonary disease- unspecified (chronic inflammatory lung disease that causes obstructed airflow from the lungs), generalized muscle weakness, insomnia-unspecified (sleep disorder where people have trouble falling asleep or staying asleep), and hyperlipidemia-unspecified (abnormally high levels of any or all lipids or lipoproteins in the blood). Record review of Resident #4's MDS assessment dated [DATE] reflected a BIMS of 15 suggesting cognition was intact . Record review of Resident #4's care plan last revised 05/09/22 reflected the resident has COPD r/t smoking with intervention of oxygen setting: O2 via NC @ 2L. Record review of Resident #4's clinical physician's orders reflected an active order for oxygen that reflected, O2 at 2 liters per minute via nasal cannula continuously. May titrate to 3 LPM to keep O2 sats >92% with order start date of 10/16/23 at 03:00 PM. Record review of Resident #4's respiratory MAR revealed there were no previous recorded documentation or orders of oxygen tubing changes . The Respiratory MAR reflected change nebulizer treatment tubing Q week on Sunday, every night shift every Sunday with a start date of 04/14/24 and change, label/date O2 tubing weekly on Sunday with a start date of 04/14/24. In an observation and interview on 04/10/24 at 09:22 AM in Resident #4's room, she was observed with the nasal cannula at her nose receiving oxygen. Neither the oxygen tubing to the nasal cannula or the humidifier bottle were dated. Resident #4 said she did not remember exactly when the last time it was changed, but she thinks it may have been on Sunday 04/07/24. In an observation on 04/11/24 at 09:55 AM in Residents #4's room, the humidifier bottle and oxygen tubing were observed not labeled/dated and the nasal cannula was observed lying on the floor , uncovered, under Resident #4's wheelchair. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676097 If continuation sheet Page 7 of 18 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 04/11/2024 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few In an interview and observation on 04/11/24 at 10:05 AM with LVN A, she stated oxygen tubing was to be changed every Sunday along with the humidifier bottle. She said there was supposed to be a date on both the humidifier bottle and the tubing to identify when it was changed . LVN A said that when the residents are not using the oxygen the tubing is supposed to be stored in a bag that keeps it sealed . LVN A said that a negative outcome to a resident whose cannula is on the ground could lead to an infection from bacteria if they were to pick it up and put the cannula back up to their face. LVN A was observed changing the humidifier bottle and tubing and dating the new items. LVN A was observed asking Resident #4 if she wanted to use her oxygen to which Resident #4 responded no. LVN A did not have a storage bag with her and was unable to properly store it. She was observed wrapping the tubing around her hand and then placing it in the handle of the oxygen concentrator. In an interview and observation on 04/11/24 at 12:26 PM with the DON, she stated it was her expectation that when oxygen is not being used by a resident that the tubing is stored appropriately in a bag. The DON said the tubing and humidifier bottle should be changed weekly and both should be dated. The DON said that a potential negative outcome to residents from tubing/nasal cannula on the floor would be a potential for infection. The DON was observed looking up the respiratory MAR and said she could not find dates of when the tubing was last changed. The DON said it appeared nobody was documenting when the tubing was being changed for Resident #4's oxygen therapy. The DON said she could see new orders starting on 04/11/24 possibly entered from LVN A who was interviewed earlier to change and document the oxygen tubing. In an interview on 04/11/24 at 12:50 PM with the Administrator she said it was her expectation that the oxygen tubing is stored in a plastic bag and that should be dated. She said a potential negative outcome to oxygen tubing on the flood is a risk for infection if the resident were to use it after. Record review of the Oxygen Administration policy last revised 02/2023 revealed: The purpose of this procedure is to provide guidelines for safe oxygen administration. Verify that there is a physician's order for this procedure. Review the physician order or facility protocol for oxygen administration. After completing the oxygen setup or adjustment, the following information should be recorded in the resident's medical record: 1. The date and time the procedure was performed. 2. The name and title of the individual who performed the procedure. 3. The rate of oxygen flow, route, and rationale. 4. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676097 If continuation sheet Page 8 of 18 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 04/11/2024 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 0695 The frequency and duration of treatment. Level of Harm - Minimal harm or potential for actual harm 5. The reason for PRN administration. Residents Affected - Few 6. All assessment data obtained before, during, and after the procedure. 7. How the resident tolerated the procedure. 8. If the resident refused the procedure, the reason(s) why the intervention was taken. 9. The signature and title of the person recording the data. Notify the supervisor if the resident refuses the procedure. Report other information in accordance with facility policy and professional standards. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676097 If continuation sheet Page 9 of 18 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 04/11/2024 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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, interviews, and record review the facility failed to accurately and safely provide or obtain pharmaceutical services, including the provision of routine and emergency medications and biologicals for 1 of 1 resident (Resident #38) reviewed for pharmacy services and procedures in that: The facility failed to ensure medication administered to a resident was taken and not left in the room. This failure could place residents at risk of not receiving their physician ordered medications resulting in a decreased quality of life. Findings include: Record review of Resident #38's face sheet dated 04/11/24 revealed an [AGE] year-old male admitted on [DATE] with a diagnoses of unspecified dementia-unspecified severity-without behavioral disturbance-psychotic disturbance-mood disturbance-and anxiety (a group of symptoms that affects memory, thinking and interferes with daily life.), constipation-unspecified (infrequent, irregular, or difficult evacuation of the bowels), major depressive disorder-recurrent-unspecified (persistent feeling of sadness and loss of interest), cognitive communication deficit (difficulty with communication that is caused by a problem with thinking), and generalized muscle weakness (reduction in the power exerted by the muscles resulting in the inability to perform a given task on the first attempt). Record review of Resident #38's MDS assessment dated [DATE] reflected a BIMS score not assessed (BIMS is used to evaluate aspects of cognition in the elderly). The MDS assessment revealed active diagnoses for anxiety disorder and depression. The MDS assessment reflected Resident #38 was currently taking an antidepressant. Record Review of Resident #38's care plan last revised 06/22/22 revealed the resident uses antidepressant medication Phenelzine Sulfate r/t depression with a goal of the resident will be free from discomfort or adverse reactions related to antidepressant therapy through the review date and interventions of: Administer antidepressant medications as ordered by physician. Monitor/ document side effects and effectiveness Q-Shift. Monitor/ document/ report PRN adverse reactions to antidepressant therapy; change in behavior/mood/cognition; hallucinations/ delusions; social isolation, suicidal thoughts, withdrawal; decline in ADL ability; continence, no voiding; constipation, fecal impaction, diarrhea; gait changes, rigid muscles, balance problems, movement problems, tremors, muscle cramps, falls; dizziness/vertigo; fatigue, insomnia; appetite loss, wt. loss, n/v, dry mouth, dry eyes, date initiated 11/21/2019, revision 06/22/22. Record review of Resident #38's clinical physician's orders reflected an active order of Phenelzine Sulfate Tablet 15 MG, give 1 tablet by mouth four times a day for depression related to major depressive disorder, recurrent, moderate. The order reflected a start date of 05/27/22 at 07:05 AM, medication class antidepressants. In an observation and interview on 04/09/24 at 11:15 AM revealed in Resident #38's room a small, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676097 If continuation sheet Page 10 of 18 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 04/11/2024 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few round, orange tablet with the markings PD270 lying on Resident #38's bed. Resident #38 stated he believed that was a medication for depression, but he did not remember how it got there. At the time, LVN A entered the room and stated she did not know what medication the pill was, but that the medication aide would know and that the medication aides were supposed to watch the residents take all their medications before leaving the room. LVN A stated a potential negative outcome to leaving the medication behind and not making sure residents take it could result in a missed dose to help their conditions or the possibility of an overdose if the resident were to find the medication later and take it close to their next scheduled dose. LVN A was observed reviewing Resident #38's medication orders and MAR and said it was a medication prescribed to Resident #38 for depression; and stated the last dose administered on 04/09/24 was by Medication Aide C. Record review of Resident #38's MAR reflected Phenelzine Sulfate Tablet 15 MG was marked as being administered by Medication Aide C 04/09/24 at 07:00 AM and 11:00 AM, and by Medication Aide B on 04/08/24 at 04:00 PM and 07:00 PM. In an interview on 04/10/24 at 02:30 PM with Medication Aide C, she stated she was familiar with Resident #38's medication and the small orange pill he takes is for his depression. Medication Aide C stated Resident #38 gets the Phenelzine Sulfate tablet 4 times a day. She said she catches Resident #38 in the morning on his way to get coffee and will administer his medication to him there (hall or dining room) and ensures he takes it before walking away. Medication Aide C said that a negative outcome to leaving medication in the residents' room is there is the potential for another resident to find it and take a medication they are not prescribed. In an interview on 04/10/24 at 02:42 PM via phone call to Medication Aide B, she stated that she normally provides the Phenelzine Sulfate to Resident #38 in his room, but she said she will hand him the medication cup which Resident #38 will dump in his hand and then take them one by one. Medication Aide B said that was done in her presence and she will not leave until all medications are taken. Medication Aide B said she was not sure how the medication was left behind in Resident #38s room, and she said a negative outcome to leaving medication behind is another resident could get ahold of the medication. In an interview on 04/11/24 at 12:26 PM with the DON, she said it was her expectation that all staff administering medications follow all the rights of administration. The DON said staff should provide education to the residents on their medications and should be staying with the residents and watching them take the medication. The DON said she was aware of the pill found in Resident #38's bed and that she wrote the incident as a medication error and notified Resident #38's physician. The DON said that a negative outcome to leaving medication behind unattended is the resident won't get the prescribed treatment or another resident could come and take the medication when it's not prescribed to them. In an interview on 04/11/24 at 12:50 PM with the Administrator, she said it was her expectation for staff that are administering medication to be following all the rights of medication administration. She said a negative outcome to leaving medication behind unattended is the resident could not get the medication which could lead to negative consequences if the medication is not consumed that has been ordered. Record review of Administering Medications policy last revised 04/2019 revealed: Medications are administered in a safe and timely manner, and as prescribed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676097 If continuation sheet Page 11 of 18 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 04/11/2024 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 0755 Medications are administered in accordance with prescriber orders, including any required time frame. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676097 If continuation sheet Page 12 of 18 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 04/11/2024 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, and distribute food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen and food sanitation. 1. The facility failed to dispose of expired milk located in the kitchen's reach in refrigerator. 2. The facility failed to label and date all food items located in the reach in refrigerator, walk in refrigerator, and dry storage room. 3. The facility failed to properly store all food items to prevent contamination or spoilage. 4. The facility failed to sanitize the blender and thermometer during food preparation and temperature checks. 5. The facility failed to maintain a clean microwave, toaster, fryer, and clean the oven drip pans. 6. The facility failed to ensure dietary staff wore hairnets and beard guards while in the kitchen. 7. The facility failed to ensure dietary staff followed proper handwashing and glove use. 8. The facility failed to ensure industrial size trash cans used for food remnants/ debris in the kitchen had lids. These failures could place residents at risk for food contamination and foodborne illness. Findings Included : During the initial tour of the kitchen on 04/09/24 at 09:00 AM the following was observed: 1. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676097 If continuation sheet Page 13 of 18 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 04/11/2024 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 The reach in refrigerator contained 1 gallon of chocolate milk that expired on 04/07/24, and a tray containing a plastic cup of an unknown fluid. The plastic cup was not covered and neither the tray or cup were labeled or dated. 2. Residents Affected - Many A plastic cup of sugar was observed near the prep station used to fill smaller individual plastic sugar cups. The plastic cup of sugar had a metal spoon with clumped sugar stuck to the spoon from mixing other fluids. 3. The walk-in refrigerator contained separate metal containers of chicken patties, spinach, pineapples, and gravy that were not properly labeled or dated. 4. The walk-in freezer contained a bag of home-style fries that was not labeled or dated and the fries were exposed to air. 5. The dry storage room contained a tray with two individual-serving bowls of cereal. Neither the tray or bowls were labeled or dated and were not properly sealed exposing contents to air. 6. The dry storage room contained 2 boxes of instant food thickener, 1 box of white rice, and a bag of marshmallows not properly sealed and all items exposed to air. 7. The dry storage room contained 1 bottle of ketchup that had been opened and used, not refrigerated and the bottle reflected, refrigerate after opening. 8. The kitchen microwave, toaster , fryer, and oven drip pans were visibly soiled. The drip pans had a thick layer of burnt food and grease; the fryer had dried stuck on grease and food particles that covered the outside; the microwave appeared to have splattered dried food on the inner back and top; and the fryer had crumbs on the inside and on top and what appeared to be dried food stuck to the exterior. 9. The food temperature logs were observed to have missing temperatures recorded for dinner temperatures on 04 /08/24 and breakfast on 04/09/24. 10. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676097 If continuation sheet Page 14 of 18 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 04/11/2024 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 The bottom food prep counter shelf contained a plastic bin of individual serve bags filled with cornbread. The plastic bin was not labeled or dated, and the bags were not properly sealed which exposed the contents to air. 11. Residents Affected - Many The industrial size 32-gallon trash can near the steam table food preparation area was filled with trash such as food remnants/ debris did not have a lid. In an interview on 04/09/24 at 09:25 AM with Dietary aide D, she stated it is their responsibility to check the refrigerators for expired items daily and discard anything expired. She said all stored items should have had the received or prepared date and she believed they should have been discarded after a week from the prepared date. In an interview on 04/09/24 at 09:28 AM with the Cook, she stated that she was swamped this morning and did not have time to log any of the breakfast temperatures, but that she knows they are supposed to be logged right away after ensuring food is at a safe temperature . The [NAME] said that dietary staff typically clean the oven drip pans every day to every other day but she did not know when they were last cleaned. In an observation on 04/09/24 at 11:38 AM in a kitchen follow up revealed, Dietary aide D was observed handing the [NAME] a thermometer. The [NAME] then placed the thermometer in the regular texture chicken alfredo pasta without sanitizing the probe. In an observation on 04/09/24 at 11:52 AM the [NAME] was observed in the preparation of 3 separate pureed meals which included corn with broth, puree chicken alfredo pasta, and pureed bread. The [NAME] did not sanitize the blender in between each pureed item, and only rinsed it with plain water in a two-compartment sink. The C ook also failed to change her gloves or wash her hands in between touching soiled kitchen equipment and utensils and then returning to the food preparation . In an observation on 04/09/24 at 12:06 PM revealed Dietary aide E failed to properly sanitize the blender before using it to make a fruit salad puree. The blender was not placed in the dishwasher before use, or washed in the 3 compartment sink with soap and water and sanitized. In an observation on 04/09/24 at 12:08 PM the [NAME] was observed sanitizing the thermometer used to take food temperatures in a small bucket of liquid dish sanitizer that was also being used by Dietary aide F to dip a cloth that was used to clean the prep table counter tops. In an observation on 04/09/24 at 01:04 PM in the dining room during lunch service, Dietary Aide G was observed entering the kitchen during meal tray preparation and assembly area without a hairnet or beard guard despite nursing staff being heard telling him to put them on before entering the kitchen. Dietary Aide G had hair long enough to go past his ears and hair on his chin approximately half an inch long. In an interview and observation on 04/09/24 at 01:30 PM with Dietary aide G in the dining room, he stated that he believed hairnets should be worn prior to entering the kitchen but he was not sure what the facility's policy was on them. He said a negative outcome to not wearing hairnets or proper hair restraints was hair could fall into the food. Dietary Aide G was then observed returning to the kitchen with no beard guard. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676097 If continuation sheet Page 15 of 18 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 04/11/2024 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 In an interview on 04/10/24 at 02:57 PM with the Interim DM she stated it was her expectation that all food items are properly labeled with the open or prepared date and the use by date. She stated it was her expectation that any leftovers have a use by date of 3 days (including the date it was labeled) and be discarded after. She stated all food items should be sealed properly and not exposed to air. The Interim DM said if cereal is poured into a bowl, the bowl or tray should have the date it was poured and the date it will be used by. She said the bowls should be sealed airtight. The Interim DM said it was her expectation that the blender be properly sanitized in between every pureed item by being ran through the dishwasher because that was the best way of ensuring it was clean. She said the proper way of sanitizing thermometer probes is by using alcohol wipes before and in between each food item checked for temperature. The Interim DM said it was her expectation that the kitchen be maintained in sanitary condition and that sanitation rounds are made at the beginning and end of each shift to ensure the kitchen including appliances, and fryers etc. are cleaned. She said drip pans are to be checked and cleaned after each use of the stovetop. The Interim DM said that hairnets and beard guards (as needed) are part of the uniform and should be worn before you step in the kitchen. The Interim DM said anytime gloves are used you must wash your hands, and hands are supposed to be washed before putting on new gloves on. She said if gloves become contaminated such as if taking out the trash, touching dirty dishes, or raw meat they should be changed, and hands should be washed. The Interim DM said trash cans are to have lids to prevent contamination and pests. She said a negative outcome to no hair or beard guard is hair is a hazard and could get into the food and she said a negative outcome to items not being properly labeled, dated, or sealed could cause a resident to get a foodborne illness and get sick and they also wouldn't know when to throw items out. Record review of the facility's Sanitation policy revised 01/2024 revealed: The food service area shall be maintained in a clean and sanitary manner. All kitchens, kitchen areas and dining areas shall be kept clean free from litter and rubbish and protected from rodents, roaches flies, and other insects. All utensils, counters, shelves, and equipment shall be kept clean, maintained in good repair and shall be free from brakes, corrosion, open seams, cracks, and chipped areas that may affect their use or proper cleaning. Seals, hinges, and fasteners will be kept in good repair. All equipment, food, contact services, and utensils shall be washed to remove or completely loosen soils by using the manual or mechanical means necessary and sanitized, using hot water and or chemical sanitizing solutions. Sanitizing of utensils and removable parts of equipment should be accomplished in one of the following ways: Contact for at least 30 seconds with an iodine solution (at approved concentration); Contact with QAC (at approved concentration) per manufacturers instruction; Contact for least 10 seconds with a chlorine (at approved concentration); or Immersion for 30 seconds in hot (at least 171°F) water. Between uses cloths and towels, used to wipe kitchen surfaces will be soaked in containers filled (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676097 If continuation sheet Page 16 of 18 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 04/11/2024 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 with approved sanitizing solution. Sanitizing solution will be changed at least once per shift or if solution becomes cloudy or visibly dirty. Level of Harm - Minimal harm or potential for actual harm Manual washing and sanitizing will employ a three-step process for washing, rinsing, and sanitizing; Residents Affected - Many Scrape food particles and wash using hot water and detergent; Rinse with hot water to remove soap residue; and Sanitize with hot water or chemical sanitizing solution. Chemical sanitizing solutions may consist of: Chlorine 50 ppm for 10 seconds; Iodine 12.5 ppm for 30 seconds; or Ammonium compound 150 to 200 ppm for time designated by manufacturer. Fixed equipment: 1. Fixed equipment will be routinely cleaned and maintained in accordance with the manufacturer's directions. 2. Staff members will be trained in the cleaning and maintenance of all equipment. 3. Food contact equipment will be cleaned and sanitized after every use. 4. Non-food contact equipment will be clean and free of debris. The food service manager will be responsible for scheduling staff for regular cleaning of kitchen and dining areas. Food service staff will be trained to maintain cleanliness throughout their work areas during all tasks, and to clean after each task before proceeding to the next assignment. Record review of the facility's Food Receiving and Storage policy revised October 2022 revealed: Food shall be received and stored in a manner that complies with safe food handling practices. Food services or other designated staff will maintain clean food storage areas at all times. Dry foods that are stored in bins will be removed from original packaging, labeled, and dated (use by date). Such foods will be rotated using a first in- first out system. All food stored in the refrigerator or freezer will be covered, labeled, and dated (use by date). Beverages must be dated when opened and discarded after 24 hours. Other open containers must be dated and sealed or covered during storage. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676097 If continuation sheet Page 17 of 18 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 04/11/2024 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 Record review of the facility's Food Preparation and Service policy revised October 2022 revealed: Level of Harm - Minimal harm or potential for actual harm Food and nutrition services employees prepare and serve food in a manner that complies with safe food handling practices. Residents Affected - Many Appropriate measures are used to prevent cross-contamination. These include: Cleaning and sanitizing work surfaces, including cutting boards and food-contact equipment between uses, following food code guidelines. Food preparation staff adhere to proper hygiene and sanitary practices to prevent the spread of foodborne illness Food thermometers used to check food temperatures are clean, sanitized, and calibrated for accuracy. Food and nutrition services staff, including nursing services personnel, wash their hands before serving food to residents. Employees also wash their hands after collecting soiled plates and food waste prior to handling food trays. Bare hand contact with food is prohibited. Gloves are worn when handling food directly and changed between tasks. Disposable gloves are single use items and are discarded after each use. Food and nutrition services staff wear hair restraints (hairnet, hat, beard restraint, etc.) so that hair does not contact food. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676097 If continuation sheet Page 18 of 18