Inspection·July 19, 2023

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of Resident #10's nursing progress notes dated 06/05/23 at 12:41 p.m. by LVN A, indicated she was laying on the floor with a laceration to the middle of her head. Resident #10 was unable to express how she fell at this time due to mental orientation. The Nurse Practitioner was notified and received an order to send her to the emergency room for sutures/staples. Record review of an Incident Report dated 06/05/23 at 12:15 p.m. by LVN A, indicated Resident #10 had an unwitnessed fall. LVN B found Resident #10 laying on the floor with a laceration to the middle of her head. Resident #10 was unable to express how she fell at this time due to mental orientation. The Nurse Practitioner was notified and received an order to send her to the emergency room for sutures/staples. Record review of Resident #10's nursing progress notes dated 06/05/23 at 5:44 p.m. by the DON, indicated she returned back to the facility after a laceration repair and had two staples to her scalp. Record review of Resident #10's Emergency Department Records dated 06/05/23, indicated she had a fall and was diagnosed with a laceration to her scalp. She had a laceration repair with staples. The doctor closed the cut on her skin with a special kind of metal staples. During an interview on 07/19/23 at 1:32 PM, LVN A said she was notified on 06/05/23 by an unknown CNA that Resident #10 was laying on the floor of her room. LVN A said she went to Resident #10's room immediately to assess her. LVN A said Resident #10 had blood on the top of her head with a laceration and provided first aid to her. LVN A said LVN A said she notified the physician and DON, and Resident #10 was sent to the Emergency Department. LVN A said when Resident #10 returned back to the facility she had 2 staples in her head. LVN A said Resident #10 was unable to explain how the injury occurred and there were no witnesses. LVN A said she had been trained on abuse, neglect, and exploitation and she reported any allegations to the Administrator, who is the abuse coordinator. During an interview on 07/19/23 at 1:47 PM, the DON said he was notified on 06/05/23 by LVN A Resident #10 had a laceration to her head. The DON said Resident #10 was sent to the Emergency Department and returned back to the facility with 2 staples in her head. The DON said he notified the Administrator, who is the Abuse Coordinator, immediately after Resident #10 had returned. The DON said Resident #10 was unable to explain how the injury occurred and there were no witnesses. The DON said he interviewed staff that had recently worked with her but did not document their statements. The DON said the incident report was the only documentation there was on Resident #10's injury. The DON said he was not sure why the incident was not self-reported to the State as it should have been, but believed the Administrator would have done so. The DON said he did not follow up with the Administrator to see if he had reported it to the State Agency. During an interview on 07/19/23 at 2:24 PM, the Administrator said he had worked at the facility for about 2 months and was the Abuse Coordinator and. The Administrator said he expected all staff to report allegations of abuse, neglect, injuries of unknown origin, and injuries causing serious bodily injury. The Administrator said he was responsible for investigating allegations and reporting it to the State Agency. The Administrator said he was unaware Resident #1 sustained a laceration to her head that required 2 staples to repair it. The Administrator said he did not investigate or report Resident #10's injury to the State Agency and it should have to rule out the possibility of abuse or neglect. The Administrator said he would have investigated and reported Resident #10's injury to the State Agency if he had known. The Administrator said he was not notified of Resident #10's injury or recall the DON telling him about it. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676286 If continuation sheet Page 2 of 7 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 676286 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadow Lake Health Center 16044 County Road 165 Tyler, TX 75703 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 0609 Level of Harm - Minimal harm or potential for actual harm 2. Record review of Resident #7's face sheet, dated 07/19/23, indicated she was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses including dementia (decline in cognitive ability that affects memory, thinking, and behaviors), Alzheimer's disease (a brain disorder that slowly destroys memory, thinking, and the ability to carry out the simplest tasks), anxiety disorder, major depressive disorder, and how someone uses language), and age-related osteoporosis. Residents Affected - Some Record review of Resident #7's MDS, dated [DATE] revealed she was rarely understood by others and rarely made herself understood. Resident #7 had impaired vision, unclear speech, short and long-term memory problems and severely impaired decision making. Resident #7 required extensive one-person assistance with dressing, toileting, personal hygiene and was totally dependent on staff with bathing requiring one-person assistance. Resident #7 did not walk. Record review of Resident #7's care plan dated 03/10/23 and last reviewed on 07/14/23 indicated she had an ADL self-care performance deficit related to dementia, poor balance and interventions included one-person staff assistance with bed mobility, dressing, personal hygiene, toileting and a one-two person assistance with transfers. Record review of Resident #7's nursing progress notes dated 06/09/23 at 10:38 a.m. by LVN B, indicated she had pain in her right hip. Resident #7's right hip was swollen and warm to touch. LVN B notified the hospice nurse and physician and received an order for a right hip x-ray. Record review of Resident #7's nursing progress notes dated 06/09/23 at 4:20 p.m. by LVN B, indicated she notified the physician the x-ray results showed the resident had a pathological fracture of the right femur (thigh bone). Record review of Resident #7's x-ray results dated 06/09/23 indicated she had a non-displaced fracture (bone breaks in one place and does not move) with mild angulation (axis of bone is slightly altered pointing off in a different direction) of the femoral neck (upper portion of thigh bone just below the ball part of the ball and socket joint) of indeterminate age. Record review of an Incident Report dated 06/09/23 at 4:25 p.m. by the DON, indicated Resident #7 had an injury of unknown origin. The resident was crying and holding her right leg showing signs of pain. Resident #7 was unable to explain what happened and there were no witnesses. An x-ray was ordered, and the results indicated she had a non-displaced fracture (bone breaks in one place and does not move) with mild angulation (axis of bone is slightly altered pointing off in a different direction) of the femoral neck (upper portion of thigh bone just below the ball part of the ball and socket joint) of indeterminate age. During an interview on 07/19/23 at 1:47 PM, the DON said he was notified on 06/09/23 by LVN B Resident #7 had pain in her right leg and he assessed her. The DON said Resident #7 was holding her right upper leg grimacing in pain and he notified the physician. The DON said he received an ordered for an x-ray of Resident #7's right hip and the results showed she had a right leg fracture. The DON said he called the physician who told him that Resident #7's fracture was pathological (caused by the physical condition or disease) due to her osteoporosis (a condition when bone strength weakens and is susceptible to fracture). The DON said he notified the Administrator, and the both of them had a conference call with the corporate office about Resident #7's fracture and reporting it to the State Agency. The DON said the corporate office determined Resident #7's fracture did not meet the State Agency reporting guidelines because the physician indicated the fracture was pathological. The DON said the facility did not investigate Resident #7's fracture or report it to the State Agency. The DON (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676286 If continuation sheet Page 3 of 7 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 676286 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadow Lake Health Center 16044 County Road 165 Tyler, TX 75703 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some said a resident with osteoporosis could sustain a fracture during ADL care if a staff member provided them care in a rough manner. The DON said a resident is at risk of abuse or neglect if an injury of unknown is not investigated and reported to the State agency and Resident #7's fracture should have been. During an interview on 07/19/23 at 2:24 PM, the Administrator said on 06/09/23 the DON notified him Resident #7 had a fracture to her right leg. The Administrator said he and the DON had a conference call with the corporate office about Resident #7's fracture and reporting it to the State Agency. The Administrator said the corporate office determined Resident #7's fracture did not meet the State Agency reporting guidelines because the physician indicated the fracture was pathological. The Administrator said he did not investigate Resident #7's fracture or report it to the State Agency. The Administrator said a resident is at risk of abuse or neglect if an injury of unknown is not investigated and reported to the State agency and Resident #7's fracture should have been. Record review of the facility's Abuse, Neglect, Exploitation and Reporting Requirements policy revised on 09/08/22 indicated, .If a covered individual reasonably suspects that a crime has occurred against a resident or person receiving care in the Health Center, the individual must report the suspicion to the Abuse and/or Neglect Coordinating and follow the Federal/State regulations. If the suspected crime involves serious bodily injury, the incident must be reported within 2 hours .or defined by state regulations . Record review of the facility's Fall Prevention and Management Program policy revised on 09/23/19 indicated, .Fall Types: Categorizing fall-related incidents by types helps to analyze fall related events .Unwitnessed fall: A fall that occurs unseen by staff or others .Any injury related to an unwitnessed fall should be reviewed for possible resident abuse .Documentation and Follow-up .3. Complete internal and external notification and reporting requirements, including to applicable licensing agencies .Reporting and Notification .4. Time frame to notify State Agency: Per state regulatory reporting requirements . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676286 If continuation sheet Page 4 of 7 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 676286 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadow Lake Health Center 16044 County Road 165 Tyler, TX 75703 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 0610 Respond appropriately to all alleged violations. 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 that all alleged violations involving abuse and neglect are thoroughly investigated and report the results of all investigations to the State Survey Agency, within 5 working days of the incident for 2 of 16 Residents (Residents #7 and #10) reviewed for investigating abuse and neglect. Residents Affected - Some 1. The facility failed to investigate or report the results to the State Survey Agency when Resident #10 was found on the floor with a laceration to the top of her head and was sent to the hospital where she received 2 staples. Resident #10 could not state how she fell. 2. The facility failed to investigate or report the results to the State Survey Agency when Resident #7 had pain to her right leg and was found to have a fracture. Resident #7 could not state how the fracture occurred. This failure could place the residents at risk for abuse and neglect by not reporting the results of investigated incidents as required. The findings included: 1. Record review of Resident #10's face sheet, dated 07/19/23, indicated she was an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses including dementia (decline in cognitive ability that affects memory, thinking, and behaviors), Alzheimer's disease (a brain disorder that slowly destroys memory, thinking, and the ability to carry out the simplest tasks), anxiety disorder, major depressive disorder, cognitive communication deficit (difficulty with thinking and how someone uses language), and muscle weakness. Record review of Resident #10's MDS, dated [DATE] revealed she was sometimes understood by others and sometimes made herself understood. Resident #10 had impaired vision, unclear speech, and severely impaired cognition. Resident #10 had continuous inattention and disorganized thinking that did not fluctuate. Resident #10 had impairments to both lower extremities and did not walk. Record review of Resident #10's care plan dated 03/10/23 and last reviewed on 07/14/23 indicated she was at risk for falls related to confusion and interventions included to ensure the call light was in reach and encourage to use it for assistance. Resident #10 had behavior problems due to psychosis and interventions included to anticipate and meet the resident's needs. Record review of Resident #10's nursing progress notes dated 06/05/23 at 12:41 p.m. by LVN A, indicated she was laying on the floor with a laceration to the middle of her head. Resident #10 was unable to express how she fell at this time due to mental orientation. The Nurse Practitioner was notified and received an order to send her to the emergency room for sutures/staples. Record review of an Incident Report dated 06/05/23 at 12:15 p.m. by LVN A, indicated Resident #10 had an unwitnessed fall. LVN B found Resident #10 laying on the floor with a laceration to the middle of her head. Resident #10 was unable to express how she fell at this time due to mental orientation. The Nurse Practitioner was notified and received an order to send her to the emergency room for sutures/staples. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676286 If continuation sheet Page 5 of 7 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 676286 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadow Lake Health Center 16044 County Road 165 Tyler, TX 75703 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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of Resident #10's nursing progress notes dated 06/05/23 at 5:44 p.m. by the DON, indicated she returned back to the facility after a laceration repair and had two staples to her scalp. Record review of Resident #10's Emergency Department Records dated 06/05/23, indicated she had a fall and was diagnosed with a laceration to her scalp. She had a laceration repair with staples. The doctor closed the cut on her skin with a special kind of metal staples. During an interview on 07/19/23 at 1:32 PM, LVN A said she was notified on 06/05/23 by an unknown CNA that Resident #10 was laying on the floor of her room. LVN A said she went to Resident #10's room immediately to assess her. LVN A said Resident #10 had blood on the top of her head with a laceration and she provided first aid to her. LVN A said she notified the physician and the DON, and Resident #10 was sent to the Emergency Department. LVN A said when Resident #10 returned back to the facility she had 2 staples in her head. LVN A said Resident #10 was unable to explain how the injury occurred and there were no witnesses. LVN A said she had been trained on abuse, neglect, and exploitation and she reported any allegations to the Administrator, who is the abuse coordinator. During an interview on 07/19/23 at 1:47 PM, the DON said he was notified on 06/05/23 by LVN A Resident #7 had a laceration to her head. The DON said Resident #10 was sent to the Emergency Department and returned back to the facility with 2 staples in her head. The DON said he notified the Administrator, who is the Abuse Coordinator, immediately after Resident #10 had returned. The DON said Resident #10 was unable to explain how the injury occurred and there were no witnesses. The DON said he interviewed staff that had recently worked with her but did not document their statements. The DON said the incident report was the only documentation there was on Resident #10's injury. During an interview on 07/19/23 at 2:24 PM, the Administrator said had worked at the facility for about 2 months and was the Abuse Coordinator. The Administrator said he was responsible for investigating allegations and reporting it to the State Agency. The Administrator said he was unaware Resident #10 sustained a laceration to her head that required 2 staples to repair it. The Administrator said he would have investigated and reported Resident #10's injury to the State Agency if he had known. The Administrator said he was not notified of Resident #10's injury or recall the DON telling him about it. The Administrator said staff members should immediately report allegations of abuse, neglect, injuries of unknown origin, and injuries causing serious bodily injury to him or the DON to rule out the possibility of abuse or neglect. The Administrator said he did not investigate Resident #10's injury to the State Agency and it should have. 2. Record review of Resident #7's face sheet, dated 07/19/23, indicated she was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses including dementia (decline in cognitive ability that affects memory, thinking, and behaviors), Alzheimer's disease (a brain disorder that slowly destroys memory, thinking, and the ability to carry out the simplest tasks), anxiety disorder, major depressive disorder, and how someone uses language), and age-related osteoporosis. Record review of Resident #7's MDS, dated [DATE] revealed she was rarely understood by others and rarely made herself understood. Resident #7 had impaired vision, unclear speech, short and long-term memory problems and severely impaired decision making. Resident #7 required extensive one-person assistance with dressing, toileting, personal hygiene and was totally dependent on staff with bathing requiring one-person assistance. Resident #7 did not walk. Record review of Resident #7's care plan dated 03/10/23 and last reviewed on 07/14/23 indicated she had an ADL self-care performance deficit related to dementia, poor balance and interventions (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676286 If continuation sheet Page 6 of 7 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 676286 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadow Lake Health Center 16044 County Road 165 Tyler, TX 75703 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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some included one-person staff assistance with bed mobility, dressing, personal hygiene, toileting and a one-two person assistance with transfers. Record review of Resident #7's nursing progress notes dated 06/09/23 at 10:38 a.m. by LVN B, indicated she had pain in her right hip. Resident #7's right hip was swollen and warm to touch. LVN B notified the hospice nurse and physician and received an order for a right hip x-ray. Record review of Resident #7's nursing progress notes dated 06/09/23 at 4:20 p.m. by LVN B, indicated she notified the physician the x-ray results showed the resident had a pathological fracture of the right femur (thigh bone). Record review of Resident #7's x-ray results dated 06/09/23 indicated she had a non-displaced fracture (bone breaks in one place and does not move) with mild angulation (axis of bone is slightly altered pointing off in a different direction) of the femoral neck (upper portion of thigh bone just below the ball part of the ball and socket joint) of indeterminate age. Record review of an Incident Report dated 06/09/23 at 4:25 p.m. by the DON, indicated Resident #7 had an injury of unknown origin. The resident was crying and holding her right leg showing signs of pain. Resident #7 was unable to explain what happened and there were no witnesses. An x-ray was order and the results indicated she had a non-displaced fracture (bone breaks in one place and does not move) with mild angulation (axis of bone is slightly altered pointing off in a different direction) of the femoral neck (upper portion of thigh bone just below the ball part of the ball and socket joint) of indeterminate age. During an interview on 07/19/23 at 1:47 PM, the DON said he was notified on 06/09/23 by LVN B Resident #7 had pain in her right leg and he assessed her. The DON said Resident #7 was holding her right upper leg grimacing in pain and he notified the physician. The DON said he received an ordered for an x-ray of Resident #7's right hip and the results showed she had a right leg fracture. The DON said he called the physician who told him that Resident #7's fracture was pathological (caused by the physical condition or disease) due to her osteoporosis (a condition when bone strength weakens and is susceptible to fracture). The DON said the facility did not investigate Resident #7's fracture. The DON said a resident is at risk of abuse or neglect if an injury of unknown is not investigated and Resident #7's fracture should have been investigated. During an interview on 07/19/23 at 2:24 PM, the Administrator said on 06/09/23 the DON notified him Resident #7 had a fracture to her right leg. The Administrator said he and the DON had a conference call with the corporate office to discuss Resident #2's fracture. The Administrator said he did not investigate Resident #7's fracture or report it to the State Agency because they all concluded it did not meet the State Agency guidelines. The Administrator said a resident is at risk of abuse or neglect if an injury of unknown is not investigated and Resident #7's fracture should have been investigated. Record review of the facility's Abuse, Neglect, Exploitation and Reporting Requirements policy revised on 09/08/22 indicated, .If a covered individual reasonably suspects that a crime has occurred against a resident or person receiving care in the Health Center, the individual must report the suspicion to the Abuse and/or Neglect Coordinating and follow the Federal/State regulations. If the suspected crime involves serious bodily injury, the incident must be reported within 2 hours .or defined by state regulations . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676286 If continuation sheet Page 7 of 7