Health inspection·August 23, 2023

F 0641 Ensure each resident receives an accurate assessment. 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 an accurate MDS was completed for 12 of 18 residents (Resident #s 7, 9, 15, 18, 24, 32, 46, 49, 50, 51, 55, and 56) reviewed for MDS assessment accuracy. Residents Affected - Some The facility did not accurately code Resident #s 7, 15, 32, 46, 49, 50, and 55's MDS for BIMS score (cognitive patterns), mood score, and daily routine and activity preferences. The facility did not accurately code Resident #s 9, 18, 24, 51, and 56's MDS assessment for BIMS score (cognitive patterns) and mood score. These failures could place residents at risk for not receiving the appropriate care and services to maintain the highest level of well-being. Findings included: 1.A review of Resident #7's face sheet dated 08/23/2023 indicated Resident #7 was an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses including diabetes, low back pain, high blood pressure, gastro-esophageal reflux disease (indigestion), fractures of first and fourth lumbar vertebrae, and muscle weakness. An admission BIMS (brief interview for mental status) score, dated 01/09/2023, was 13 indicating the resident was cognitively intact. A review of Resident #7's admission MDS (Sections F0300, F0400, F0600) dated 01/09/2023 indicated an interview for Daily and Activity Preferences should be conducted and the interview was not completed to indicate the resident's preferences for daily options and activity options. A review of Resident #7's quarterly MDS (Sections C0100, C0200, C0300, C0400, C0500, D0100, D0200, D0300), dated 04/11/2023, indicated a BIMS interview and an interview for mood should be conducted and the interviews were not completed to indicate the resident's cognitive status and mood status. A review of Resident #7's quarterly MDS (Sections C0100, C0200, C0300, C0400, C0500, D0100, D0200, D0300), dated 05/29/2023, indicated a BIMS interview and an interview for mood should be conducted and the interviews were not completed to indicate the resident's cognitive status and mood status. 2. A review of Resident #9's face sheet dated 08/23/2023 indicated Resident #9 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses including diabetes, heart disease, schizoaffective disorder bipolar type (mental health condition with symptoms of schizophrenia and mood disorders), atrial fibrillation (irregular often rapid heart rate that causes poor blood flow), anxiety, depression, insomnia, peripheral vascular disease a circulatory condition where narrowed blood vessels reduces blood flow to the limbs), high blood pressure, indigestion, and morbid obesity. An annual BIMS (brief interview for mental status) score, dated 07/21/2023, was 14 indicating the resident was cognitively intact. A review of Resident #9's significant change MDS (Sections C0100, C0200, C0300, C0400, C0500, D0100, D0200, D0300), dated 05/01/2023, indicated a BIMS interview and an interview for mood should be conducted and the interviews were not completed to indicate the resident's cognitive status and mood status. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675597 If continuation sheet Page 2 of 11 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 08/23/2023 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 0641 Level of Harm - Minimal harm or potential for actual harm 3. A review of Resident #15's face sheet dated 08/23/2023 indicated Resident #7 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses including dementia, diabetes, chronic obstructive pulmonary disease (lung disease with airflow blockage), major depression, insomnia, chronic pain, anxiety, and heart failure. An annual BIMS (brief interview for mental status) score, dated 03/28/2023, was 09 indicating the resident was mildly compromised cognitively. Residents Affected - Some A review of Resident #15's annual MDS (Sections F0300, F0400, F0600) dated 03/28/2023 indicated an interview for Daily and Activity Preferences should be conducted and the interview was not completed to indicate the resident's preferences for daily options and activity options. A review of Resident #15's quarterly MDS (Sections C0100, C0200, C0300, C0400, C0500, D0100, D0200, D0300), dated 06/28/2023, indicated a BIMS interview and an interview for mood should be conducted and the interviews were not completed to indicate the resident's cognitive status and mood status. A review of Resident #15's quarterly MDS (Sections C0100, C0200, C0300, C0400, C0500, D0100, D0200, D0300), dated 07/26/2023, indicated a BIMS interview and an interview for mood should be conducted and the interviews were not completed to indicate the resident's cognitive status and mood status. 4. A review of Resident #18's face sheet dated 08/23/2023 indicated Resident #18 was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses including diabetes, morbid obesity, heart disease, chronic obstructive pulmonary disease (lung disease with airflow blockage), gout, chronic kidney disease, high blood pressure, anxiety, congestive heart failure, and depressive disorders. A quarterly BIMS (brief interview for mental status) score, dated 08/07/2023, was 14 indicating the resident was cognitively intact. A review of Resident #18's annual MDS (Sections C0100, C0200, C0300, C0400, C0500, D0100, D0200, D0300), dated 04/06/2023, indicated a BIMS interview and an interview for mood should be conducted and the interviews were not completed to indicate the resident's cognitive status and mood status. A review of Resident #18's quarterly MDS (Sections C0100, C0200, C0300, C0400, C0500, D0100, D0200, D0300), dated 05/07/2023, indicated a BIMS interview and an interview for mood should be conducted and the interviews were not completed to indicate the resident's cognitive status and mood status. 5. A Review of Resident #24's electronic face sheet for August 2023 indicated Resident #51 was admitted to the facility on [DATE] with diagnoses including emphysema, shortness of breath, major depression, chronic pneumonia. A Review of Resident #24's MDS assessment dated [DATE] for sections C (section C - Cognitive Patterns) and D (Mood) had not completed for assessment. 6. A review of Resident #32's's face sheet for August 2023 indicated she was an [AGE] year-old female who re-admitted to the facility on [DATE] with diagnoses including dementia, anxiety, and chronic obstructive pulmonary disease. A review of Resident #32's Quarterly MDS dated [DATE] indicated she should receive a Brief Interview for Mental Status (BIMS). This same MDS further indicated this interview was not conducted and Resident #32 was not assessed for mental status. A review of Resident #32's Quarterly MDS dated [DATE] indicated she should receive a Resident Mood (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675597 If continuation sheet Page 3 of 11 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 08/23/2023 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 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interview. This same MDS further indicated this interview was not conducted and Resident #32 was not assessed for mood. A review of Resident #32's Comprehensive MDS dated [DATE] indicated she should have an Interview for Daily and Activity Preferences. This same MDS indicated this interview was not conducted and Resident # 32 was not assessed for daily routine and activity preferences. 7. A review of Resident #46's's face sheet for August 2023 indicated she was an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses including dementia, anxiety, glaucoma (vision disorder), and history of falls. A review of Resident #46's Quarterly MDS dated [DATE] and Comprehensive MDS dated [DATE] indicated she should receive a Brief Interview for Mental Status (BIMS) on both assessments. These same MDS assessments further indicated this interview was not conducted and Resident #46 was not assessed for mental status at either time. A review of Resident #46's Quarterly MDS dated [DATE] and Comprehensive MDS dated [DATE] indicated she should receive a Resident Mood Interview. These same MDS assessments further indicated this interview was not conducted and Resident #32 was not assessed for mood at either time. A review of Resident #46's Comprehensive MDS dated [DATE] indicated she should receive an Interview for Daily and Activity Preferences. This same MDS indicated this interview was not conducted and Resident # 46 was not assessed for daily routine and activity preferences. 8. A review of Resident #49's face sheet dated 08/23/2023 indicated Resident #49 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses including anxiety, insomnia, osteoporosis, dementia, falls, and hallucinations. An annual BIMS (brief interview for mental status) score, dated 04/29/2023, was 03 indicating the resident was severely Impaired cognitively A review of Resident #49's significant change MDS (Sections F0300, F0400, F0600) dated 07/29/2023 indicated an interview for Daily and Activity Preferences should be conducted and the interview was not completed to indicate the resident's preferences for daily options and activity options. A review of Resident #49's significant change MDS (Sections C0100, C0200, C0300, C0400, C0500, D0100, D0200, D0300), dated 07/29/2023, indicated a BIMS interview and an interview for mood should be conducted and the interviews were not completed to indicate the resident's cognitive status and mood status. 9. A review of Resident #50's's face sheet for August 2023 indicated he was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses including depression, anxiety, intellectual disabilities and dementia. A review of Resident #50's Quarterly MDS dated [DATE], Comprehensive MDS dated [DATE], and Quarterly MDS dated [DATE] indicated he should receive a Brief Interview for Mental Status (BIMS) on each of these assessments. These same MDS assessments further indicated this interview was not conducted and Resident #50 was not assessed for mental status on any of these three assessments. A review of Resident #50's Quarterly MDS dated [DATE], Comprehensive MDS dated [DATE], and Quarterly MDS dated [DATE] indicated he should receive a Resident Mood Interview. These same MDS assessments (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675597 If continuation sheet Page 4 of 11 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 08/23/2023 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 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some further indicated this interview was not conducted and Resident #50 was not assessed for mental status on any of these three assessments. 10. A review of Resident #51's face sheet for August 2023 indicated Resident #51 was a 84 -year-old male who was admitted to the facility on [DATE] with diagnoses including: full code with use of AED, Alzheimer, unsteadiness on fee, history of falls, cognitive communication deficit, need for assistance with personal care, dysphagia, muscle weakness, attention deficit, dementia, anxiety disorder, repeated falls, hyperlipidemia, migraine, hypertension, benign prostatic hyperplasia. A review of Resident #51's Quarterly MDS, dated [DATE],6/8/23, 3/8/23 and 2/6/23 for sections C (section C - Cognitive Patterns) and D (Mood) had not completed for assessment. 11. A Review of Resident #55's electronic face sheet for August 2023 indicated Resident #55 was admitted to the facility on [DATE] with diagnoses including Alzheimer's, hypothyroidism, Dementia, delusional, major depressive disorder, aphasia, urinary tract infection history of malignant neoplasm of breast and ovary. A review of Resident #55's MDS assessment dated [DATE] for sections C (section C - Cognitive Patterns) and D (Mood) had not completed for assessment. MDS assessment dated [DATE] for section F (preferences for customary routine and activities) had not completed for assessment. 12. A review of Resident #56's electronic face sheet dated for August 2023 indicated Resident #56 was admitted to the facility on [DATE]with diagnosis including: Anxiety, hypertension, cognitive communication deficit, urinary tract infection, herpes zoster A review of Resident #56's MDS dated [DATE] and 7/6/2023 for sections C (section C - Cognitive Patterns) and D (Mood) had not completed for assessment. During an interview on 08/23/2023 at 10:10 AM with the RN MDS Resource Nurse, she said the RAI manual was used as the guideline for conducting the MDS assessment. She said the RAI did not indicate the MDS had to be done by a particular person or certain sections have to be done by a particular person. She said at their facilities the SW usually completed sections B, C, D, and Q. She said any staff member could complete these sections of the MDS if they are trained to do them and did not have to be the SW. She said she was not sure why those sections were not completed and not sure if there was a policy regarding certain sections of the MDS being assigned to any particular staff. During an interview on 08/23/2023 at 11:00 AM the RN MDS Resource Nurse said the facility did not have a specific policy that assigns any section of the MDS to any particular person to complete. She said at mmost of their facilities the social worker completed the cognitive patterns and mood sections of the MDS. She said the activity sections information came from teh activity director. A review of the RAI Version 3.0 Manual for MDS Section C: Cognitive Patterns indicated the following: When cognitive impairment is incorrectly diagnosed or missed, appropriate communication, worthwhile activities and therapies may not be offered. A review of the RAI Version 3.0 Manual for MDS Section D: Mood indicated the following: It is particularly important to identify signs and symptoms of mood distress among nursing home residents because these signs and symptoms can be treatable. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675597 If continuation sheet Page 5 of 11 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 08/23/2023 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 0641 Level of Harm - Minimal harm or potential for actual harm A review of the RAI Version 3.0 Manual for MDS Section F: Preferences for Customary Routine and Activities indicated the following: The intent of items in this section is to obtain information regarding the resident's preferences for his or her daily routine and activities. Quality of life can be greatly enhanced when care respects the resident's choice regarding anything that is important to the resident. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675597 If continuation sheet Page 6 of 11 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 08/23/2023 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents unable to conduct activities of daily living (ADLs) received the necessary services to maintain good grooming and personal hygiene that promotes maintenance or enhancement of his or her quality of life, for resident (Resident #51) review for quality of life. Residents Affected - Some The facility failed to provide Resident #51 with personal grooming for nail care These failures could place residents at risk for poor hygiene, dignity issues, and decreased quality of life. Findings included: Record review of Resident #51's admission record dated 11/2/2022 reflected Resident #51 was an [AGE] year-old male, diagnosis included full code with use of AED, Alzheimer's, unsteadiness on feet, history of falls, cognitive communication deficit, need for assistance with personal care, dysphagia, muscle weakness, attention deficit, dementia, anxiety disorder, repeated falls, hyperlipidemia (an excess of lipids or fats in your blood), migraine, hypertension, benign prostatic hyperplasia. Record review of Resident #51's MDS assessment, dated 07/27/23, reflected the following:-resident's cognitive status: not assessed -requiring extensive assistance for transfers, bed mobility. -required supervision for dressing, eating, and extensive assistance with toilet use and personal hygiene. Record review of Resident #51's care plans, initiated on 07/10/23, reflected Resident #51 had an ADL Self Care Performance Deficit r/t Dementia, memory loss, h/o falls, anxiety, Resident has history of L Hip fracture will need assistance with ADL's. Record review of resident #51's podiatry care dated 1/5/2023 reflected nails were trimmed and debrided reduced in length and thickness in 2 mm, progress notes stated: trimmed and debrided nails(s) to patient's tolerance. Reviewed medical record, patient to follow up in 2 months. Record review of Resident #51's nail task history dated 11/2/22 at time of admission nail care was shown as a related focus, with no reflection of staff following up with any nail care. Record review of Shower Report dated 08/21/2023 for resident #51 revealed complete bed bath given, linens changed no indication of nail care given, Shower scheduled revealed that Resident #51 received showers on Monday, Wednesday, and Fridays. There were no other shower reports to be reviewed. An interview and observation on 8/21/2023 at 9:43 a.m. with Resident #51 revealed he had elongated (longer than the nail bed) thick, discolored toenails to both right and left feet. The resident said they bothered him sometimes. He said he told the nurse, but he could not remember when or and when he last saw the foot doctor. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675597 If continuation sheet Page 7 of 11 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 08/23/2023 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an Interview on 8/23,23 at 10:00 A.M. with DON, she said that in the case of no Podiatrist that nurses were responsible for foot care. Poor foot hygiene could put residents at an increased risk for infection. Fungal nail infections were common infections of the toenails that could cause the nail to become discolored, thick, and more likely to crack and break. During an Interview on 8/23/23 at 2:20 pm with Agency LVN, said the CNAs performed foot care, but she did not know anything about residents that needed foot care. She said CNAs would notify them if foot care needed to be done. During an Interview on 8/23/23 at 2:45 p.m. with Agency CNA, she said she did not perform nail care. During an interview with the ADON on 8/23/23 at 3:00 p.m., she said there was a broken system regarding shower schedules and that the administration was working on it. She said broken system meaning, not all CNAs were using the paper system charting or charting their nail care in the electronic chart. She said it was nursing administration responsiblity to correct this problem, which they were working on. Record Review of the facility's Policy for Foot Care, dated 05/2007 Policy #NCRP 31(Nail Care Routine Procedures 31) POLICY: It is the policy of this facility to clean feet and to increase circulation. PROCEDURES: Equipment: mild soap and water, towel and washcloth, toenail clippers or nail scissors, nail file and lotion. * Examine feet carefully for evidence of discoloration, redness, blisters or skin tears. Report any irregularities to charge nurse. Note: Do not perform Nail Care nor Foot Care on residents with Diabetes and Peripheral Vascular Disease. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675597 If continuation sheet Page 8 of 11 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 08/23/2023 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 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 observations, interviews, and record reviews, the facility failed to ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning is provided such care consistent with professional standards of practice, the comprehensive person-centered care plan and the residents goals and preferences for 2 of 2 residents (Resident #24 and #42) reviewed for oxygen therapy, in that: Residents Affected - Few 1. The facility failed to ensure Resident #24's oxygen rate was set at 3-4 LPM (liters per minute) CONTINUOUS and not 2 LPM. 2. The facility failed to ensure monitoring of oxygen Saturation as ordered by the physician (maintain O2 saturation above 90%) 3. The facility failed to ensure there was an order for Resident #42 to receive oxygen. These failures could place residents who received oxygen therapy at risk for respiratory distress Record Review of Resident #24's electronic face sheet for August 2023 indicated she was admitted to the facility on [DATE] with diagnoses including emphysema, shortness of breath, major depression, chronic pneumonia. Review of Resident #24's MDS assessment dated [DATE] had not been completed. A review of Resident #24's physician orders for August 2023 indicated she was to receive oxygen via nasal canula at 2 -3 LPM (liters per minute) to maintain oxygen saturation above 90%. During observations Resident #24 was receiving oxygen at 2 LPM on the following dates and times: - 08/21/2023 at 3:00 pm - 08/22/2023 at 4:00 p.m. Record review on 8/21/23 and 8/22/23 there was no oxygen saturation recorded in the electronic chart. During an interview on 08/22/2023 at 04:07 pm with ADON, she said Resident #24's oxygen rate was ordered for 3-4 LPM for oxygen saturation to maintain at 90%. She was asked if she could show where the saturation is recorded, she said it is in the flow chart and nurses' medication administration record, she could not find any recent recording, the last recorded saturation was 8/11/2023. She said she would get that corrected immediately. Review of Resident #42's electronic face sheet for August 2023 indicated she was admitted to the facility on [DATE] with diagnoses including chronic respiratory failure, congestive heart failure, hypoxia (the state in which oxygen is not available in sufficient amount at the tissue level to maintain adequate homeostasis), major depression, chronic obstructive pulmonary disease, shortness of breath. Review of Resident #42's MDS assessment dated [DATE] indicated she scored 12 out of 15 which (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675597 If continuation sheet Page 9 of 11 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 08/23/2023 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 0695 indicated she was cognitively intact. Level of Harm - Minimal harm or potential for actual harm A review of Resident #42's physicians orders for August 2023 did not indicate any orders for oxygen. Residents Affected - Few During an interview on 08/22/2023 at 04:07 pm with the ADON, she stated she could not find an order for Resident #42 to have oxygen. She stated Resident #42's oxygen rate was observed at 3 LPM, She said she would get that corrected immediately. She said Resident #42 had been in and out of the hospital and that order was missed. A review of the facility's Oxygen Administration Policy dated 05/2007 indicated the following: It is the policy of this facility that oxygen therapy is administered, as ordered by the physician or as an emergency measure until the order can be obtained. 1. Obtain appropriate physician orders for oxygen administration. 17. Document all appropriate information in medical record. *Oxygen therapy, Respiratory assessment findings, method of oxygen delivery, flow rate, residents' response, any adverse reaction or side effects . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675597 If continuation sheet Page 10 of 11 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 08/23/2023 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 0732 Post nurse staffing information every day. Level of Harm - Potential for minimal harm Based on observation, interview, and record review, the facility failed to ensure that the daily nurse staffing was posted as required for 3 of 3 days (8/19/23, 8/20/23 and 8/21/23) reviewed for nursing services. Residents Affected - Many The facility failed to update the daily staffing information posting. This failure could affect residents, their families, and facility visitors by placing them at risk of not having access to information regarding staffing data and facility census. Findings included: Record review on 08/21/23 at 08:30 a.m., revealed the daily staffing pattern was posted on the desk by the front door in a clear acrylic holder and dated 08/18/23, which did not reflect the current date. During a record review on 08/22/23 at 8:30 a.m., the required nurse staffing data was posted on the desk in the front lobby, dated 08/22/23. During an interview with the Nursing scheduler/Recruiter on 8/23/23 at 3:00 p.m., she said it was her responsibility to make sure nurse staffing is posted. She said she would call the facility and talk to the nurse in charge to make sure the posting was changed. However, that weekend, she could not get in touch with anyone, so she sent a text and did not follow up. During interviews on 08/23/23 at 4:00 PM with the DON, the DON said the Staffing Scheduler was responsible for ensuring the nurse staffing data was posted, but the whole process is a work in process that the facility is working on. The DON said the facility did not have a policy on required staffing posting. The facility did not provide a policy on nursing staff postings at time of exit. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675597 If continuation sheet Page 11 of 11