Health inspection·June 21, 2023

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few blood pressure), methocarbamol (for muscle spasms), pantoprazole (for acid indigestion), potassium chloride (supplement replacement), rosuvastatin (for high cholesterol), trazadone (for insomnia), and vitamin B-12. Record review of Resident #1's nurses' MAR, dated 04/2023, indicated there were no entries on the MAR for any intravenous medications to be administered on 04/15/23 and 04/16/23. The intravenous medications were not listed on the nurses' MAR. Oral medications were present on the medication aide's MAR and given as ordered beginning on 04/16/23. Record review of Resident #1's Progress Notes indicated the following: on 04/15/23 at 7:17 PM the resident arrived at the facility via private car accompanied by a friend. He was alert and oriented and had no signs of distress or complaints of pain or discomfort. He walked with a rolling walker without difficulty. He was able to make his needs known and able to ambulate to the restroom without assistance. He was continent of bowel and bladder. The resident had a single lumen PICC line in his right upper arm as he was to receive intravenous antibiotics while at the facility. On 04/16/23 at 9:52 PM Resident #1 left the facility with a family member. The family member asked why the resident had not received his medications and the nurse explained the medications had been ordered but had not been received from the pharmacy. The family member got angry and accused the facility of neglect and left the facility. The resident's vital signs were within normal limits. Record review of the pharmacy manifest dated 04/15/23 indicated the pharmacy received the orders for the oral medications ordered by the facility through the integrated system. The orders dated 04/15/23 to the pharmacy did not contain orders for the IV antibiotics. Record review of a Provider Investigation Report written by the previous administrator dated 04/16/23 indicated the facility reported to the state agency an allegation of neglect regarding timeliness of medication administration for Resident #1 alleged by the resident's family member. The summary indicated the DON informed the administrator by text on 04/16/23 at 9:55 PM Resident #1 had left the facility and went home due to not receiving intravenous medications. She was not sure if the resident would be returning. The report indicated Resident #1 returned to the facility with his faly member on 04/17/23 at 9:30 AM. The DON explained to the family member, at that time, the Rocephin medication was available in the emergency medication kit and she could administer that medication and could order the ampicillin and it would be at the facility within 4 hours of when the call was placed to the pharmacy. The family member refused to allow the administration of the medication and said she wanted him evaluated by a physician before he received the antibiotics and said she was taking him to the hospital. She said at the time she left they would not be back. Further record review of the Provider Investigation Report dated 04/16/23 indicated a written statement from LVN H Resident #1 arrived at the facility with a friend. The friend stated he had no paperwork he was just giving the resident a ride. LVN H indicated she saw no discharge paperwork from the hospital. She indicated another nurse at the facility told her she had entered all the orders that were sent from the hospital. Resident #1 told LVN H he was at the facility to receive IV antibiotics and she told him the physician would have to clarify the antibiotic orders. She indicated she was told to verify the orders that were already in the computer so that his medications could be ordered from the pharmacy. She indicated she reported to the day shift that Resident #1's medication did not come in on the night shift and to please follow up with the pharmacy that morning. A written statement from LVN D indicated the nurse on Hall 200 had received a report from the hospital on [DATE] around 2:00 PM for a new resident (Resident #1) and she asked LVN D for assistance because she still had numerous tasks to complete before the end of her shift. LVN D indicated around 2:25 PM the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675597 If continuation sheet Page 2 of 6 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 675597 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Crestwood Health and Rehabilitation Center 1448 Houston St Wills Point, TX 75169 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 paperwork was available and she printed the referral paperwork so she could enter the most current diagnoses and medications. She indicated she had completed entering the orders around 4:00 PM and she took the paperwork to the charge nurse and told her she would need to enter the antibiotic order from her report or from the discharge orders due to the referral paperwork being unclear. LVN D indicated she let the nurse know when the resident arrives and gets into his room she would need to confirm medication orders to make them active and the nurse expressed understanding. LVN D indicated when she checked out at the end of her shift and she asked the 200 hall nurses if there had been any problems getting the new resident into the system and was informed the resident had just arrived and she stopped to make sure the agency nurse covering the night shift was able to get the resident moved from waiting list to current resident list, able to confirm orders, and she told her about the antibiotic order needing to be entered from the discharge paperwork. LVN D indicated she made sure the nurse was able to confirm orders and she exited the facility at that time. The report indicated all nurses were inserviced 04/17/23 on new admission order process/medication reconciliation, medication rights, physician orders policy, medication error policy, pharmacy services policy, missed medications, and how to order medications from the pharmacy after hours. Signatures indicated they had read and understood the policies and procedures. Record review of the hospital encounter summary for Resident #1 dated 04/17/23 indicated he arrived at 11:44 AM and his vital signs upon arrival were blood pressure 147/57, pulse 66, temperature 97.6, respiratory rate 18, and oxygen saturation 95%. The social worker notes indicated the facility was contacted on 04/17/23 at 12:23 PM and the facility explained the family was upset because the resident had not received the 2 IV antibiotics over the weekend. The facility said they had offered the Rocephin that morning and it had been refused and the ampicillin would be delivered that day. The facility reported the resident left AMA and could take him back but he would have to commit to staying. The physician's evaluation on 04/17/23 at 11:57 AM indicated the resident had stayed at the hospital previously from 4/11/23 until 04/15/23 for mitral valve endocarditis (infection of the heart's inner lining affecting a heart valve), and was supposed to have received ampicillin and Rocephin through his PICC line since the diagnosis. The rehab facility did not have the medications. He denied any fever or complaints at the time. The physical exam indicated no acute distress, normal heart rate and rhythm, normal pulmonary effort and no distress with normal breath sounds, and alert and oriented in all spheres. Lab work, dated 04/17/23, indicated white blood cells 9.1 (4.5-11.0), red blood cells 3.43 (4.5-5.90), hemoglobin 9.9 (13.5-17.5), hematocrit 30.6 (41.0-53.0), other findings were within normal limits. Resident #1 received 2 doses of 2 grams of ampicillin at 3:40 PM and 5:53 PM and one dose of Rocephin 2,000 mg at 1:48 PM. The social worker was attempting to find other rehab facility placement but due to his leaving AMA he was not accepted at any another facility. He agreed to return to the facility. The resident discharged from the hospital emergency department on 04/17/23 at 6:33 PM in good condition. Record review of Resident #1's Progress Notes indicated he returned to the facility on [DATE] at 7:45 PM. He received ampicillin 2 gm intravenously beginning on 04/18/23 every 6 hours at midnight, 6:00 AM, noon, and 6:00 PM. He received one dose of Rocephin 2,000 mg on 04/17/23 at 9:00 PM. The times for administration for the Rocephin were changed on 04/18/23 by nursing staff to be given at 1:00 AM and 1:00 PM and he received the medication as ordered. During an interview on 06/21/23 at 9:00 AM LVN D said the DON at the time of the reportable incident was fired on 04/17/23. She said the administrator at the time of the reportable incident left last week. She said she had just been elevated to ADON, treatment nurse, and infection preventionist. LVN D said she was working the day shift (6 AM-6 PM) on 04/15/23 in the memory care unit. She said the day shift nurse on 200 hall (new admissions) was very busy and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675597 If continuation sheet Page 3 of 6 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 675597 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Crestwood Health and Rehabilitation Center 1448 Houston St Wills Point, TX 75169 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 she came out to assist her with a new admission coming later that day. She said the nurses can type in the basic medication orders when they are expecting a new admission. She said the medications and diagnoses can be typed in prior to admission but just not activated (ordered). She said she typed in the information for Resident #1. She said those referral orders are not the final orders and she said those orders did not have any IV or oral antibiotics listed. She said she told the charge nurse she would have to double check the orders when the resident arrived at the facility with the final discharge orders and the physician or NP. She said he did not arrive before she left her shift at 6 PM. She said new admission orders are entered into the computer but not activated because the resident was not yet admitted to the facility. She said they are pending until they had final orders in hand. She said she thought an agency nurse was working the 6PM-6 AM on 04/15/23. She said the hospital will send a packet of paperwork that would contain discharge information, notes from day 1 of the hospital stay, discharge medication orders and what medications had been given at time of the discharge. She said the charge nurses are to call the physician or NP at the time of entry and go over the list and the physician or NP will decide what they want to keep giving or if they want to change any of the medications. She said that was not a new practice and they had always done new admissions in that way. She said the physician also had standing lab orders they like to get at the time of admission. She said the next shift nurse usually checks or re-reads the new admission orders. She said the 400 hall charge nurse was an employee of the facility and would have been available to assist the agency nurse if she had needed any assistance. She said only regular staff and not agency staff have access to the emergency medication kit (e-kit) so any medications needed to be pulled would need to be a facility employee. She said the nurses have to call the pharmacy for orders received on the weekend after hours. She said they can still get immediately needed medications they just have to call the pharmacy instead of it being ordered through the integrated system. LVN D said to her knowledge there were no IV antibiotics in the e-kit but some oral antibiotics were available. She said she was not aware of any problems with receiving medications they needed after hours. She said if there was a problem with obtaining a medication the physician would be called and asked what he wanted them to do and how should they proceed until the medication was available. She said medication orders were reviewed during the morning meeting held every weekday morning. She said the department heads, MDS, DON, BOM, and charge nurses would review the 24-hour report. She said weekend admissions were reviewed on Monday. During an interview on 06/21/23 at 10:40 AM RN E, a corporate resource nurse, said there were no residents in the facility currently receiving IV antibiotics. She said the DON at the time of the reported incident was let go but not entirely due to the incident. She said there were other issues the DON had not been following through on. She said the DON told her she had called the pharmacy on Sunday 04/16/23 and spent hours on the phone with them. RN E said if any medications are needed over the weekend and it was after the pharmacy closed, the pharmacy had to be physically called with the order. If the medication was just ordered through the integrated system it would just stay in the pharmacy received file until they opened for their regular hours. She said IV Rocephin was available in the e-kit but the ampicillin was not. She said Resident #1 left the faciity on [DATE] at 9:52 PM and returned between 9:30-10:00 AM on 4/17/23 and was angry due to not receiving IV medications. She said the granddaughter was very vocal and the DON tried to assist her and tell her they could give the Rocephin and order the ampicillin and it would be there within 4 hours. She said the granddaughter said they were leaving and would not be back. She said when he returned on 04/17/23 at 7:45 PM he received a dose of Rocephin at 9:00 PM. RN E said neither of the IV antibiotics were administered on 04/15/23 and 04/16/23. She said the facility began inservicing employees on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675597 If continuation sheet Page 4 of 6 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 675597 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Crestwood Health and Rehabilitation Center 1448 Houston St Wills Point, TX 75169 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 medications ordering, after hours ordering, and a packet was developed to give to agency and new staff explaining how to use the electronic record software as well as how to order from the pharmacy when something was needed quickly. She said a new procedure was also put in place for new admissions. She said the medical record would be reviewed within 24 hours including orders by nurse management. She said nurse management included the DON, MDS person, the resource nurse and it would be checked every day regardless of weekend days. During an interview on 06/21/23 at 12:15 PM RN E said it came to the attention of resources at 9:30-10:00 AM on 04/17/23, during the morning stand up meeting, that Resident #1 was to be receiving IV antibiotics and was not receiving them. The DON knew of the IV antibiotic therapy on 04/16/23 at 9:55 PM when the family member/neighbor was taking the resident out of the facility due to not receiving his medications. RN E said she had called the pharmacy and their records indicated they received the oral medications order on 04/15/23 and they did not receive an order for IV antibiotic medication until 04/17/23 when it was ordered stat (high priority to be delivered within 4 hours). During an interview on 06/21/23 at 11:50 AM LVN A said he had not witnessed any neglect. He said he would report it to the administrator if he did. He said there is enough staff to meet the needs of residents and he was not aware of any resident going without needed care. He said staff made rounds at least every two hours to check on the needs of residents. He was able to define neglect and give examples. He said he had been in-serviced on processing new admission orders with a focus on validating hospital discharge orders, ordering medications from the pharmacy during and after hours, and notifying the DON or his/her designee of any problems associated with obtaining needed medications. During an interview on 06/21/23 at 12:05 PM LVN B said she worked on an as needed basis (prn) and had not witnessed any neglect. She said she would report it to the administrator or DON if she did. She said she was not aware of any resident going without needed care. She said she checked residents at least every two hours. She was able to define neglect and give examples. She said she had not received any in-services on the new admission process nor the ordering of medications during or after hours. She said she would ask for assistance from one of the other nurses at the facility if she had any questions or needed help with admitting a new resident. She said she would either ask one of the other nurses or call the on-call nurse if she had any problems with obtaining needed medications. During an interview on 06/21/23 at 12:21 PM LVN C said she had not witnessed any neglect and would report it to the administrator or DON if she did. She said she was not aware of any residents going without care. She was able to define neglect and give examples. She said she had been in-serviced on processing new admission orders with a focus on validating hospital discharge orders, ordering medications from the pharmacy during and after hours, and notifying the DON or his/her designee of any problems associated with obtaining needed medications. She said would notify the DON, ADON, or on-call nurse if she had any problems obtaining medications from the pharmacy. During an interview on 06/21/23 at 1:25 PM RN F (DON for a sister facility) said when pending orders are entered into the computer they are automatically sent to the pharmacy and they would need to call if it was after hours and the medications were needed immediately. During an interview on 06/21/23 at 2:55 PM RN G, a corporate resource nurse, said she would immediately train LVN B on medication ordering since she had indicated she had not received any training. RN G said she was not sure who would be doing the training since the current DON had just started work that week. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675597 If continuation sheet Page 5 of 6 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 675597 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Crestwood Health and Rehabilitation Center 1448 Houston St Wills Point, TX 75169 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 Record review of hospital discharge orders for Resident #2 dated 06/13/2023 were reviewed and used to verify the accuracy of the facility's admission orders dated 06/13/2023 with no issues or concerns noted. The Medication Administration Record (MAR) was noted to be consistent with the discharge orders and medications were noted as being initiated upon admission and in a timely manner. Record review of hospital discharge orders for Resident #3 dated 06/13/2023 were reviewed and used to verify the accuracy of the facility's admission orders dated 06/13/2023 with no issues or concerns noted. The Medication Administration Record (MAR) was noted to be consistent with the discharge orders and medications were noted as being initiated upon admission and in a timely manner. Record review of hospital discharge orders for Resident #4 dated 06/08/2023 were reviewed and used to verify the accuracy of the facility's admission orders dated 06/08/2023 with no issues or concerns noted. The Medication Administration Record (MAR) was noted to be consistent with the discharge orders and medications were noted as being initiated upon admission and in a timely manner including orders for antibiotic therapy. Record review of facility policy Administration of Medications and/or Intravenous fluids dated 12/2019 indicated medications and intravenous fluids shall be administered as prescribed by the attending physician. Record review of an undated facility procedure indicated all new admission orders would be entered and reconciled with the physician prior to administration of any first dose. Nursing must document that medication reconciliation was completed and entered into the progress notes. All new admissions would be reviewed by the ADON/DON within 24 hours to assure for accuracy and completion. Record review of an undated facility Agency Orientation Packet indicated a licensed nurse reference guideline on entering of specific types of orders as well as notes, assessments, admitting and discharging residents in the software used in the electronic record. Included in the packet was information regarding the facility pharmacy hours of operation, delivery schedule, phone and fax numbers with an indication in large letters all stat (orders faxed after cut-off times) orders must be faxed and followed up with a phone call. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675597 If continuation sheet Page 6 of 6