Health inspection·February 24, 2023

F 0655 Level of Harm - Minimal harm or potential for actual harm Record review of Resident #120's admission Minimum Data Set Assessment (MDS) dated [DATE] revealed that the MDS had not been completed. Record review of the facility smoker list, no date provided revealed that Resident #120 was listed as a smoker. Residents Affected - Few Record review of the facility policy entitled Care Plans-Baseline, dated revised December 2016, read in part .a baseline plan of care to meet the resident's immediate needs shall be developed for each resident withing forty-eight (48) hours of admission . . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676304 If continuation sheet Page 2 of 5 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 676304 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Creekside Village 914 N Brazosport Blvd Richwood, TX 77531 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to revise and update a Comprehensive care plan for 1 (Resident #8), of 24 residents reviewed for comprehensive care plans in that: Resident #8 readmitted to the facility with an active diagnosis of Urinary Tract Infection (UTI) and the care plan did not address her diagnosis of infection. Resident #8's care plan did not address her antibiotic medication. These failures could place residents at risk for receiving decreased quality of care and or not receiving the appropriate required care and services to meet their individual needs. The Findings Include: Resident #8 Record review of an undated facility admission Record revealed Resident #8 was an [AGE] year old female who admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses, urinary tract infection, with an onset date of 12/27/2022 and Rank, Primary, abnormalities of gait (a person's manner of walking) and mobility, cognitive communication deficit (an impairment in organization/thought organization, sequencing, attention, memory, planning, problem-solving, and safety awareness), and other specified aftercare. Record review of Resident #8's Quarterly/5-day MDS dated [DATE] revealed she had a BIMS score of 9 indicating she had a moderate cognitive impairment. Further record review of section I, Active Diagnoses, revealed she coded under infections Urinary Tract Infection (UTI) (Last 30 Days). In section N for Medications, she was coded under medications received . within the last 7 days or since admission/entry or reentry for 7 days of antibiotics. Record review of Resident #8's physician Order Summary Report dated as Active Orders As Of: 01/01/2023 revealed the following entry, Amoxicillin Capsule 500 MG Give 1 capsule by mouth two times a day related to URINARY TRACT INFECTION, SITE NOT SPECIFIED .for 10 Days .Communication Method .Verbal .Order Status .Active .Order Date .12/27/2022 .Start Date .12/27/2022 .End Date 01/06/2023. Amoxicillin Tablet 500 MG 1 Tablet by mouth every 12 hours related to URINARY TRACT INFECTION, SITE NOT SPECIFIED .for 5 Days ADMINISTER 1 TABLET Q12HR X 5 DAYS .Communication Method .Verbal .Order Status .Active .Order Date .01/01/2023 .Start Date .01/01/2023 .End Date .01/06/2023. Cefdinir Capsule 300 MG Give 1 capsule by mouth two times a day for UTI for 14 Days .Communication Method .Phone .Order Status .Active .Order Date .12/26/2022 .Start Date .12/27/2022 .End Date .01/10/2023. Record review of Resident #8's MA Administration Record dated 12/1/2022-12/31/2022 and read in part, Amoxicillin Capsule 500 MG Give 1 capsule by mouth two times a day related to URINARY TRACT INFECTION, SITE NOT SPECIFIED for 10 Days .and was initialed with a check mark as being administered on 12/27/22, 12/28/22, 12/29/22, 12/30/22, and 12/31/22. Record review of Resident #8's MA Administration Record dated 1/1/2023-1/31/2023 and read in part, Amoxicillin Capsule 500 MG Give 1 capsule by mouth two times a day related to URINARY TRACT (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676304 If continuation sheet Page 3 of 5 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 676304 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Creekside Village 914 N Brazosport Blvd Richwood, TX 77531 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few INFECTION, SITE NOT SPECIFIED for 10 Days .and was initialed with a check mark as being administered on 1/1/23. Record review of Resident #8's MA Administration Record dated 1/1/2023-1/31/2023 and read in part, Amoxicillin Tablet 500 MG Give 1 tablet every 12 hours related to URINARY TRACT INFECTION, SITE NOT SPECIFIED for 5 Days .and was initialed with a check mark as being administered on 1/1/23, 1/2/23, 1/3/23, 1/4/23, 1/5/23, and 1/6/23. Record review of Resident #8's Care Plan which read Last Care Plan Review Completed: 02/23/2023, revealed her care plan area relating to Resident #8's UTI or any antibiotic medication had not been updated since 06/07/2022, with the following entry: RESOLVED: Resident #8 has (sic) A Urinary Tract Infection .Date Initiated: 03/28/2022 .Revision on: 06/07/2022 .Resolved Date .06/07/2022 .RESOLVED: Give antibiotic therapy as ordered .Date Initiated: 03/28/2022 .Revision on: 06/07/2022 .Resolved Date: 06/07/2022. Record review of Resident # 8's Care Plan which read Last Care Plan Review Completed: 02/23/2023, revealed the resident did not have a plan of care addressing her UTI or prescribed antibiotic medication upon readmission to the facility on [DATE]. Interview with DON and Corporate Nurse on 2/23/23 at 3:21 pm who both said that the MDS Coordinator completed both the comprehensive and acute care plans and would be the person responsible for any resident care plans and or revisions. When they were asked about the care plan for Resident #8, the DON said that there may be resolved care plans that would include the completed antibiotic medication/s and last readmission with a UTI. In a follow up interview with DON on 2/23/23 at 3:53 pm the DON returned with the resolved copies of Resident #8's comprehensive care plans. When the DON was advised that both the current and resolved copies of the care plans, she provided, did not include the 12/27/22 readmission diagnosis of UTI or her prescribed antibiotic medications, the DON said she did not know why the diagnosis and antibiotic medications had not been care planned. The DON said that she did not know how the diagnosis and antibiotic medications had been missed by the MDS Coordinator. When asked who was responsible for ensuring the MDS Coordinator revised and updated the resident care plans, the DON said that there was a Corporate MDS Coordinator that would be the facility MDS Coordinator's oversight. The DON said she did not know the last time the Corporate MDS Coordinator checked or audited the MDS Coordinator's work. Interview with MDS Coordinator on 2/24/23 at 10:06 am who said that she had worked at the facility since September 2022. She said that she had been trained for her position as the facility MDS Coordinator, by the Corporate MDS Coordinator. The MDS Coordinator said that she was responsible for Resident #8's comprehensive, acute and baseline hour care plans. She said that whenever a resident admits or readmits to the facility, she reviews any hospital medical records, physician orders and clinical progress notes to determine what to care plan. When asked why Resident #8 did not have a care plan that addressed her readmission diagnosis of UTI and prescribed antibiotic medication in and round 12/26/22, she said that she just missed it. She said that she must have just missed those care plans and did not know why or how they were missed. The MDS Coordinator said that she realized the mistake when the surveyor requested copies of the resolved and current comprehensive care plans. When asked what could happen as a result of residents' not being accurately or appropriately care planned in a timely manner, she said that a resident could potentially not receive the proper care or medications. The Corporate MDS Coordinator was not interviewed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676304 If continuation sheet Page 4 of 5 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 676304 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Creekside Village 914 N Brazosport Blvd Richwood, TX 77531 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of facility policy and procedure titled Care Planning-Interdisciplinary Team and dated as Revised September 2013 read in part: 1. A comprehensive care plan for each resident is developed within seven (7) days of completion of the resident assessment (MDS) . Record review of facility policy and procedure titled Care Plans, Comprehensive Person-Centered and dated as Revised December 2016 read in part: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident .8. The comprehensive, person-centered care plan will: g. Incorporate identified problem areas .13. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' condition change .14. The Interdisciplinary Team must review and update the care plan: c. When the resident has been readmitted to the facility from a hospital stay . Record review of an undated facility policy and procedure titled POLICY AND PROCEDURE (sic) COMPREHNSIVE CARE PLANNING .PURPOSE: ENSURE EVERY RESIDENT HAS A COMPREHENSIVE, COMPLETE, ACCURATE, AND ALL INCLUSIVE SPECIFIC CARE PLAN WRITTEN TIMELY TO MEET ALL REQUIREMENTS OF THE RAI AND REGULATORY PROCESS TO INCLUDE INPUT FROM ALL IDT MEMBERS. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676304 If continuation sheet Page 5 of 5