Health inspection·August 7, 2025

F 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some transfers through review period. Record review of Resident #5's clinical admission evaluation, dated 02/12/25, reflected no section related to risk of entrapment from bed rails. Record review of all assessments and evaluations for Resident #5, from 02/12/25 to 08/07/25, reflected no assessment for risk of entrapment from bed rails. Record review of all informed consent documents for Resident #5, from 02/12/25 to 08/07/25, reflected no consent for the use of bed rails. 3. Record review of Resident #6's, undated, face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included neurocognitive disorder with Lewy bodies (dementia caused by protein deposits in the brain), psychotic disorder with delusions, anxiety disorder, abnormal posture, bipolar disorder, Alzheimer's disease, major depressive disorder, neuroleptic-induced parkinsonism (symptoms similar to Parkinson's disease such as tremors and muscle stiffness, brought on by use of antipsychotic medication), need for assistance with personal care, fatigue (extreme tiredness), cognitive communication deficit (difficulty communicating due to cognitive impairment), lack of coordination, abnormalities of gait and mobility, and muscle weakness. Record review of Resident #6's quarterly MDS assessment, dated 07/22/25, reflected a BIMS score of 13, which indicated intact cognition. Resident #6 required substantial/maximal assistance moving from left to right in her bed and moving from a seated to a lying position in her bed. Record review of Resident #6's care plan, dated 02/01/25, reflected the following: [Resident #6] is at risk for falls r/t Parkinson's, Imbalance, weakness. [Resident #6] will not have major or minor injury r/t a fall thru review date. Record review of Resident #6's clinical admission evaluation, dated 01/20/23, reflected no section related to risk of entrapment from bed rails. Record review of all assessments and evaluations for Resident #6, from 01/20/23 to 08/07/25, reflected no assessment for risk of entrapment from bed rails. Record review of all informed consent documents for Resident #6 from 01/20/23 to 08/07/25 reflected no consent for the use of bed rails. 4. Record review of Resident #7's, undated, face sheet reflected an [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included Alzheimer's disease, gastrotomy status (surgical presence of a feeding tube into the digestive system), cognitive communication deficit (difficulty communicating due to cognitive impairment), fatigue (extreme tiredness), lack of coordination, anxiety disorder, muscle weakness, abnormalities of gait and mobility, and dementia. Record review of Resident #7's quarterly MDS assessment, dated 06/12/25, reflected a BIMS score of 0, which indicated severely impaired cognition. Resident #7 was completely dependent on staff to assist him with rolling left to right in his bed and did not go from sitting to lying in his bed. Record review of Resident #7's care plan, dated 07/08/25, reflected the following: Resident is at risk for falls r/t Imbalance, weakness, confusion. Resident will not have major or minor injury r/t a fall thru review date. Record review of Resident #7's clinical admission evaluation, dated 05/20/20, reflected no section related to risk of entrapment from bed rails. Record review of all assessments and evaluations for Resident #7, from 05/20/20 to 08/07/25, reflected no assessment for risk of entrapment from bed rails. Record review of all informed consent documents for Resident #7, from 05/20/20 to 08/07/25, reflected no consent for the use of bed rails. 5. Record review of Resident #20's, undated, face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included muscle weakness, dementia, major depressive disorder, insomnia, hemiplegia (paralysis on one side of the body), speech and language deficits, difficulty in walking, hallucinations, history of falling, and dependence on wheelchair. Record review of Resident #20's quarterly MDS assessment, dated 05/15/25, reflected a BIMS score of 08, which indicated severely impaired cognition. It reflected she was independent in rolling form left to right and going from sitting to lying in her bed. Record review of Resident #20's care plan, dated 03/13/25, reflected the following: [Resident #20] (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675979 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 675979 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/07/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Crestview Retirement Community 2505 E Villa Maria Rd Bryan, TX 77802 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 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some has an ADL self-care performance deficit r/t Dementia, Hemiplegia. [Resident #20] will receive assistance as needed with ADLs and transfers over the next 90 days. Record review of Resident #20's clinical admission evaluation, dated 03/01/24, reflected no section related to risk of entrapment from bed rails. Record review of all assessments and evaluations for Resident #20, from 03/01/24 to 08/07/25, reflected no assessment for risk of entrapment from bed rails. Record review of all informed consent documents for Resident #20, from 03/01/24 to 08/07/25, reflected no consent for the use of bed rails. 6. Record review of Resident #40's, undated, face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included difficulty in walking, lack of coordination, muscle weakness, cognitive communication deficit (difficulty communicating due to cognitive impairment), fatigue (extreme tiredness), need for assistance with personal care, fibromyalgia (condition causing widespread body pain), lack of coordination, abnormalities of gait and mobility. Record review of Resident #40's admission MDS assessment, dated 05/15/25, reflected a BIMS score of 99, which indicated she could not complete the assessment. Record review of Resident #40's care plan, dated 04/23/25, reflected the following: [Resident #40] has an ADL self-care performance deficit r/t activity intolerance, Confusion, [Resident #40] will receive assistance as needed with ADLs and transfers through review period. impaired mobility, pain. Record review of Resident #40's clinical admission evaluation, dated 02/10/21, reflected no section related to risk of entrapment from bed rails. Record review of all assessments and evaluations for Resident #40, from 04/09/24 to 08/07/25, reflected no assessment for risk of entrapment from bed rails. Record review of all informed consent documents for Resident #40, from 04/09/24 to 08/07/25, reflected no consent for the use of bed rails. Observation on 08/05/25 at 10:00 AM revealed Resident #7 lying in bed with his covers pulled to his chest, his call button was in reach, and a peg tube connected to a feeding machine. He did not respond to efforts to interview him. His bed was furnished with 27-inch plastic side rails. Observation and interview on 08/05/25 at 10:22 AM revealed Resident #6 lying in her bed with the head of bed elevated, bed in low position, and a fall mat next to her bed. There were 27-inch plastic side rails affixed to both sides of the bed. Resident #6 stated she sometimes used the rails to move around in her bed and had never been stuck in them. She stated the facility had not talked with her about the risks and benefits of side rails. Observation and interview on 08/05/25 at 10:40 AM revealed Resident #5 seated in her wheelchair next to her bed. There were 27-inch plastic side rails affixed to both sides of the bed. She stated she did not use the rails very often and had never sustained any injuries from them. She stated she could not recall anyone from the facility discussing the risks and benefits of side rails with her. Observation on 08/05/25 at 11:02 AM revealed Resident #1 seated in his geriatric chair (specialized piece of medical equipment designed for individuals with mobility challenges, particularly the elderly) in the common area. He did not respond to efforts to interview him. Observation in his room revealed his bed was furnished with 27-inch plastic side rails. Observation and interview on 08/05/25 at 12:47 PM revealed Resident #40 seated in her wheelchair in her room having lunch next to her bed. There were 27-inch plastic side rails affixed to both sides of the bed. She stated she did not know what the side rails were for and had not noticed them. When asked if anyone from the facility had discussed the risks and benefits of side rails, she would not or could not answer and seemed confused by the question. During an interview on 08/05/25 at 12:47 PM, the private caregiver for Resident #40 stated she had never witnessed or heard about Resident #40 being injured or trapped by the side rails. She stated the facility and Resident #40's other caregivers were good at communicating any problems, so she thought she would have been notified if something like that had happened. Observation and interview on 08/05/25 at 03:04 PM revealed Resident #20 seated in a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675979 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 675979 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/07/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Crestview Retirement Community 2505 E Villa Maria Rd Bryan, TX 77802 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 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some wheelchair next to her bed, which was furnished with 27-inch side rails. She stated she had never had any problems with the side rails. She stated she used them regularly to get in and out of bed and reposition herself. An attempt was made to speak with a FM for Resident #1 on 08/07/25 at 01:15 PM. A voicemail was left, but contact was not returned. During an interview on 08/07/25 at 11:33 AM, the ADON stated she had been in her position for eight months. She stated her understanding of what was required to install side rails on a resident bed was the resident should be able to get around them and not be stuck in the bed. She stated she went over the consents for all residents with side rails, and some residents had consents while others did not. She stated they had thought there was an entrapment assessment included in the clinical admission document, but it was not there. She stated she had not conducted any entrapment risk assessments herself, but the procedure was supposed to be when a new resident came in, the admitting nurse should have assessed their need for side rails and ensured their safety for the resident. She stated specifically, they needed to ensure there was no risk of the resident becoming trapped. The ADON stated the admitting nurse was responsible for completing the assessments and obtaining consents from the family, but the person responsible for oversight in that process was a unit manager who was on leave. She stated a potential negative impact on not assessing for entrapment or obtaining informed consent was the resident could become trapped and some had even suffocated in other facilities. She stated it could also take away their rights to do what they wanted if the rails kept them from getting out of bed. During an interview on 08/07/25 at 12:02 PM, the MAINT stated he was not the director of maintenance but was in charge while the director was out. He stated he did mock surveys once a month and part of that was checking the side rails on every bed. He stated he did document those checks sometimes, but he was not sure if he still had copies of them. He stated he would look for the copies and provide them if he found them. He stated he had not looked at the bed rail policy and did not know it stated he should be providing documentation of his bed rail checks to his administrator. He stated he had not done that. He stated he really only checked to make sure the bed rails were in good repair. He stated he had not found any in many months that were broken or needed maintenance. He stated he did not know anything about assessing for risk of entrapment but thought it would be important to make sure the residents did not fall out of their beds. During an interview on 08/07/2025 at 01:29 PM, the ADM stated his expectation was during the admission process the nurses would visit with the resident's family on the bed rails and determine if they were wanted. He stated their goal was to have the small assistive bars to help residents pull themselves up and move around in the bed. He stated they should have been assessing for entrapment and obtaining consents on the side rails during the admission process. He stated he had looked into consents and found a few for other residents, but for the most part, they did not have any on file. He stated the people responsible for ensuring the facility was compliant with bed rails were the ADON and DON. He stated the DON was on leave and unable to be reached by phone due to being in a no cell service area. He stated a potential negative impact of not conducting an assessment for entrapment risk or obtaining informed consent from the resident was a resident who did not need an assistive rail could be injured or have another adverse event. Record review of the facility's policy, dated August 2022, and titled Bed Safety and Bed Rails reflected the following: Policy statementResident beds meet the safety specifications established by the hospital bed safety work group. The use of bed rails is prohibited unless the criteria for use of bed rails have been met.Policy interpretation and implementation1. The resident's sleeping environment is evaluated by the interdisciplinary team.2. Consideration is given to the resident's safety, medical conditions, comfort, and freedom of movement, as well as input from the resident and family regarding previous sleeping habits and bed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675979 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 675979 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/07/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Crestview Retirement Community 2505 E Villa Maria Rd Bryan, TX 77802 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 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete environment.6. Maintenance staff routinely inspects all beds and related equipment to identify risks and problems, including potential entrapment risks.7. The maintenance department provides a copy of inspections to the administrator and report results to the QAPI committee for appropriate action. Copies of the inspection results and QAPI committee recommendations are maintained by the administrator and/or safety committee.Use of bed rails4. Prior to the installation or use of a side or bed rail, alternatives to the use of side or bed rails are attempted.5. If attempted alternatives, do not adequately meet the residence needs the resident may be evaluated for the use of bed rails. This interdisciplinary evaluation includes:A. An evaluation of the alternatives to bed rails that were attempted and how these alternatives failed to meet the resident needsB. The resident's risk associated with the use of bed rails;C. Input from the resident and/or representative; andD. Consultation with the attending physician.6. The resident assessment to determine risk of entrapment includes, but is not limited to:A. Medical diagnosis, conditions, symptoms, and/or behavioral symptoms;B. Size and weight;C. Sleep habits;D. Medication(s);E. Acute medical or surgical interventions;F. Underlying medical condition;G. Existence of delirium;H. Ability to toilet self safely;I. Cognition;J. Communication;K. Mobility in and out of bed; andL. Risk of falling.7. The resident assessment also determines potential risks to the resident associated with the use of bed rails, including the following:A. accident hazards:(1) the resident could attempt to climb over, around, between, or through the rails, or over the footboard; and/or(2) A resident or part of his/her body could be caught between the [NAME], the opening of the rails, or between the bed rails and mattress8. Before using bed rails for any reason, the staff shall inform the resident or representative about the benefits and potential hazards associated with bed rails and obtain informed consent. The following information will be included in the consentA. The assessed medical needs that will be addressed with use of bed rails;B. The resident's risks from the use of bed rails, and how these will be mitigated;C. The alternatives that were attempted, but failed to meet the residence needs; andD. The alternatives that were considered, but not attempted and the reasons. Event ID: Facility ID: 675979 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 675979 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/07/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Crestview Retirement Community 2505 E Villa Maria Rd Bryan, TX 77802 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 1 of 3 kitchens (main kitchen) reviewed for food safety. 1. The facility failed to ensure the ED and DRM wore a hair restraint while in the kitchen on 08/05/25. 2. The facility failed to ensure the DM wore gloves while preparing prepared ham sandwiches in the kitchen. These failures could place residents at risk of food-borne illness. Findings include: 1. Observation on 08/05/25 at 09:20 AM revealed the ED, who had short hair, and the DRM, who had shoulder length hair, standing in the kitchen and speaking to the cooks. Neither of them wore a hairnet or hair restraint. They both walked out of the kitchen and the DRM returned less than a minute later with a hairnet on. During an interview on 08/05/25 at 09:27 AM, the DRM stated she was required to wear a hairnet in the kitchen. She stated she did not know why she was in the kitchen not wearing one. She stated she was in a hurry and forgot to apply the hairnet. She stated residents could have gotten hair in their food. 2. Observation on 08/05/25 at 11:12 AM revealed the DM on the food preparation line making several ham sandwiches at once. He was handling bread, lettuce, and deli ham with his bare hands and not wearing gloves. He said out loud as if to himself, That's how you know the rookie is on the line. I'm not a chef! He then washed his hands, retrieved and donned gloves, and resumed his food preparation. During an interview on 08/06/25 at 12:20 PM, the LD stated all staff needed to wear hairnets when they entered the kitchen. She stated this was because they did not want hair falling into the food. She stated the DM and all staff who prepared food were to wear gloves while handling the food. She stated the purpose of wearing gloves was to prevent bacteria from going into the food and making residents sick. She stated she performed audits in the kitchen to ensure compliance, and if she saw noncompliance with food safety rules, and in-serviced the staff if she saw issues, but she had not done training with the ED, the DRM or the DM. During an interview on 08/14/25 at 01:01 PM, the DM stated he had been the manager of the facility kitchen for about two and a half years. He stated the kitchen served both the assisted living and the nursing facilities in the building. He stated he had done the food safety training courses and knew he was supposed to wear gloves while handing food directly. He stated he knew better than to try to do 800 things at once and had overlooked putting gloves on as a result. He stated his expectation was all staff wore hairnets in the facility kitchen. He stated the potential negative impacts to residents of his failure was cross contamination and food borne illnesses and even contamination with his own blood if he were to cut himself. He stated he did not provide any training for the ED, because the ED was his boss and had been at the facility for something like 30 years. He stated he worked for a contracted entity, and it would not have been appropriate for him to train the ED. He stated he did train the DRM to wear hairnets in the kitchen. He stated he had been somewhat concerned about some of the activities personnel and volunteers performing food service tasks and thought it would be a good idea to broaden their in-service audience. During an interview on 08/07/2025 at 01:29 PM, the ADM stated his expectation was any staff in the kitchen should have worn a proper hair restraint and staff should have worn gloves during food preparation. He stated he ensured that happened by making random rounds through the kitchen and by running around the facility all the time and looking at what was going on. He stated the responsibility for oversight on food safety compliance was on the dining and kitchen supervisor. He stated the potential negative outcome of breaches in food safety was poor sanitation. Record review of the facility's policy, dated January 2025, and titled Uniform Dress reflected the following: Policies: personal cleanliness and need appearance are essential for the food service worker. In addition to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675979 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 675979 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/07/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Crestview Retirement Community 2505 E Villa Maria Rd Bryan, TX 77802 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete this policy, associates must follow facilities appearance guidelines.Procedures:Associates working with foodWhere the approved hair restraint when on duty, regardless of length or presence of hair. The only exception is to remove hair restraints when delivering trays to patients/residents. Record review of the facility's policy, dated January 2024, and titled Disposable Glove Use reflected the following: Policies: disposable, non-latex gloves must be warm at the following times:When handling ready to eatIn most cases, when serving food or assembling patient meals. Event ID: Facility ID: 675979 If continuation sheet Page 7 of 7