Health inspection·February 15, 2024

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interview with Resident #2 on 02/15/24 at 3:32 PM revealed he did not remember how long there had been stains on his privacy curtain. 2. Review of Resident #32's face sheet dated 02/15/2024 reflected the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included dementia (term for loss of memory, language, problem-solving and other thinking abilities) and chronic systolic heart failure (type of heart failure that occurs in the heart's left ventricle) , and chronic kidney disease(loss of kidney function). Review of Resident #32's quarterly MDS, dated [DATE], revealed the resident had severe cognitive impairment with a BIMS score of 3, and the resident required assistance with her ADLs. Observation and interview on 02/13/24 at 10:63 AM revealed the bed curtain in Resident #32's room had a dried brown substance on it. Resident #32 stated she had been showing the staff the curtain was dirty and need to be washed, but nobody has addressed the issue. She could not tell which staff she had reported this issue to. Observation and interview on 02/13/24 at 1:47 PM with CNA D revealed she worked at the facility only part-time. CNA D stated she was Resident #32's CNA and had worked with her for three days. CNA D stated she was aware the curtain was soiled, and she had not reported it to anybody because she thought it was housekeeping's responsibility to be checking and changing the curtains if soiled. She did not know the effect the dirty curtains might have for a resident. Observation and interview on 02/13/24 at 1:51 PM with LVN E revealed he did not see the soiled curtain in Resident #32's room while caring for Resident #32 on 02/13/24 since she was part-time. LVN E stated it was the nurse's responsibility to inform housekeeping so that housekeeping could change the curtain. LVN E stated the resident was supposed to be in a safe, clean, and homelike environment. Observation and interview on 02/13/24 at 2:51 PM with the Maintenance Director revealed he was responsible of changing the curtains. He stated there were staff from management, who were assigned to tour the rooms every morning and notify him of any issues with residents' rooms, including the walls, curtains, and call lights. He stated Resident #32's room was not one of the rooms that hadwere reported to have problems. He stated the curtain was dirty and needed to be changed. He stated he had done in-service on staff on how to report any room with a problem, and there was a form the staff were supposed to document the problem. He stated the curtains were washed in December, and he did not have documentation to show which rooms' curtains were washed. He did not provide documentation showing the in-service that had been conducted. Interview on 02/15/24 at 4:18 PM with the DON revealed she was not aware Resident #32's curtain had stains. The DON said all staff were responsible for checking the rooms and reporting any problems to the Maintenance Director and housekeeping. Interview on 02/15/24 at 5:01 PM with the Administrator revealed the associate assigned to the room was the DON, and she just resumed work. He stated communication of the rooms that needed repair and curtains that were dirty was usually communicated by the allocated manager in writing. He stated curtains were washed in January. He stated if the curtain was dirty, then it needed to be changed. Review of the facility's Home Like Environment policy, dated February 2021, reflected: .The facility staff and management maximizes, to the extent possible, the characteristics of the facility that (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676408 If continuation sheet Page 2 of 22 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 676408 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bear Creek Nursing and Rehabilitation 3729 Ira E Woods Avenue Grapevine, TX 76051 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 0584 reflect personalized, homelike setting. These characteristics include: Level of Harm - Minimal harm or potential for actual harm a. clean, sanitary, and orderly environment. Residents Affected - Some b Clean bed and bath linen that are in good conditions FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676408 If continuation sheet Page 3 of 22 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 676408 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bear Creek Nursing and Rehabilitation 3729 Ira E Woods Avenue Grapevine, TX 76051 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 observation, interview, and record review, the facility failed to ensure the comprehensive care plan was reviewed and revised by the interdisciplinary care team for 1 of 11 care plans reviewed (Resident #2). The facility failed to ensure Resident #2's care plan interventions were updated to reflect his improved condition. This failure could place residents at risk for injury. Findings included: Record review of Resident #2's Face Sheet, dated 02/14/24, revealed Resident #2 was an [AGE] year-old male, who was re-admitted to the facility on [DATE] and initially admitted on [DATE]. Resident #2's diagnoses included End Stage Renal Disease, Dependence on Renal Dialysis, Anemia in Chronic Kidney Disease, dementia, unsteadiness on feet, and other lack of coordination. Record review of Resident #2's MDS comprehensive assessment, dated 01/20/24, revealed Resident #2 had severe cognitive impairment with a BIMS score of 3. Record review of Resident #2's care plan, dated 10/20/23 and revised 01/26/24, revealed Resident #2 had the following: Fall on 10/20/23, Fall on 11/20/23, Fall on 12/17/23, Unwitnessed fall on 01/07/24. Record review of Resident #2's care plan revealed Resident #2 interventions included the following: Use floor mats when in bed and use personal or pressure alarms when the resident was in a chair or bed. Record review of Resident #2 physician orders, dated 11/03/23, revealed an order for Physical Therapy and Occupational Therapy to evaluate and treat. Observation on 02/13/24 at 11:46 AM revealed no fall mat observed when the resident was lying on his bed or pressure alarms on his bed. Observation on 02/15/24 at 2:41 PM revealed no fall mat observed when the resident was lying on his bed or personal or pressure alarms on his bed. Interview on 02/15/24 at 2:28 PM with Resident #2's Responsible Party revealed Resident #2 had not had a fall mat since he was on skilled therapy upon admission. Interview on 02/15/24 at 2:50 PM with LVN A revealed when Resident #2 was new, he was very weak and a fall risk requiring a fall mat and additional resources. LVN A added that Resident #2 went to dialysis three times per week. LVN A stated now a fall mat would increase Resident #2's fall risk if the care plan were followed. Interview on 02/15/24 at 4:38 PM with the DON revealed Resident #2 should not have a fall mat beside his bed because it would be a trip hazard. The DON also revealed the care plan should be updated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676408 If continuation sheet Page 4 of 22 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 676408 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bear Creek Nursing and Rehabilitation 3729 Ira E Woods Avenue Grapevine, TX 76051 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 to reflect the changes. The DON stated the MDS Coordinator was responsible for updating care plans. The DON stated the care plans were updated during morning meetings. Interview on 02/15/24 at 5:25 PM with the MDS Coordinator revealed it was everyone's responsibility to update care plans. She revealed each department was responsible for updating their department. The MDS Coordinator revealed if there was a significant change with a resident that required a care plan change, the charge nurse was responsible to update the care plan. Review of the facility's Care Plans, Comprehensive Person-Centered policy, dated March 2022, reflected: .11. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. 12. The interdisciplinary team reviews and updates the care plan: a. when there has been significant change in the resident's conditions FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676408 If continuation sheet Page 5 of 22 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 676408 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bear Creek Nursing and Rehabilitation 3729 Ira E Woods Avenue Grapevine, TX 76051 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 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on interview and record review, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for 7 (12/03/23, 12/23/23, 12/30/23, 12/31/23, 01/28/24, 02/04/24, or 02/11/24) of 90 days reviewed for nursing services. The facility failed to provide RN coverage for 8 consecutive hours daily for 7 (12/03/23, 12/23/23, 12/30/23, 12/31/23, 01/28/24, 02/04/24, or 02/11/24) of 90 days. This deficient practice could place residents at risk of no receiving specific nursing services due to staff being left without supervisory coverage. Findings included: Review of RN Y's timesheet for 12/03/23 reflected she worked from 5:45 AM to 10:45 AM for a total of 5 hours, clocked out for 30 minutes, then worked from 11:15 AM to 4:00 PM for a total of 4.75 hours. Review of RN X's timesheet for 12/03/23 reflected she worked from 1:45 PM to 6:00 PM for a total of 4.25 hours, clocked out for 45 minutes, then worked from 6:45 PM to 11:45 PM for a total of 4.5 hours. Review of RN V's timesheets for 12/23/23 reflected she worked 5 hours, clocked out and then worked an additional 5 hours; 02/04/24 she worked 5 hours, clocked out and then worked an additional 3.25 hours. Review of RN U's timesheet for 12/23/23 reflected she worked 5 hours, clocked out and then worked an additional 5 hours. Review of RN T's timesheets for 12/30/23 reflected she worked 5 hours clocked out and then worked an additional 5 hours, clocked out again and then worked an another 5 hours; 12/31/23 she worked 5 hours, clocked out and then worked an additional 3 hours, clocked out again and then worked another 5 hours, clocked out and then worked another 1.75 hours; 02/11/24 she worked 5 hours, clocked out and then worked an additional 3.25 hours. Review of RN U's timesheets for 01/28/24 reflected she worked 5 hours, clocked out and then worked an additional 4.25 hours; 02/11/24 she worked 4.25 hours, clocked out and then worked an additional 3.25 hours, clocked out again and then worked another 1.75 hours. Interview on 02/15/24 at 10:38 with the Staffing Coordinator revealed she made the schedules for the staff, including the weekend nurses. The Staffing Coordinator said she thought the 8 hours for RN's on the weekends was throughout the day not consecutive. The Staffing Coordinator said the RN's on the weekends would clock out for a break or for lunch which was why they were not working a consecutive 8 hours. The Staffing Coordinator said she and the DON were responsible for ensuring there was an RN scheduled each day for at least 8 hours. The Staffing Coordinator said the purpose of this was because if there was an emergency an RN was available, who can do more than an LVN. In an interview on 02/15/24 at 4:07 PM with the DON revealed she did not know the RN coverage was a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676408 If continuation sheet Page 6 of 22 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 676408 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bear Creek Nursing and Rehabilitation 3729 Ira E Woods Avenue Grapevine, TX 76051 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 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete consecutive 8 hours each day and that the RN's were clocking out for breaks or lunches. The DON said she was responsible for ensuring there was RN coverage for each day for at least 8 hours. The DON said the purpose of this was that the RN served as a clinical resource to other nurses in the building and they had additional knowledge some other nurses did not. Review of the facility's policy dated August 2022, and titled Staffing, Sufficient and Competent Nursing reflected the following: .3. A registered nurse provides services at least eight (8) consecutive hours every 24 hours, seven (7) days a week . Event ID: Facility ID: 676408 If continuation sheet Page 7 of 22 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 676408 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bear Creek Nursing and Rehabilitation 3729 Ira E Woods Avenue Grapevine, TX 76051 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were stored securely for 3 (Resident #2, #20, and #26) of 3 residents and labeled in accordance with currently accepted professional principles for one (300 and 500 hall nurses' medication cart) of three medication carts reviewed for labeling and storage and temperatures were maintained within normal ranges for two of two refrigerators reviewed 100,200 halls and 300 and 500 halls. 1. The facility failed to ensure a bottle of dry eye relief was not stored or placed in a secured place for Resident #2. 2. The facility failed to ensure that Resident #26 and #20 's one bottle Saline Nasal Spray Solution, one bottle Systane Solution 0.4-0.3 % and one bottle of Dry eye relief lubricant eye drop propylene glycol 1.0% were securely stored. 3. The facility failed to ensure insulin were dated with opening dates on the nurse's cart that served 300 and 500 halls. 4. The facility failed to ensure vaccines insulins and suppositories were stored at the right temperatures and refrigerator temperatures were being maintained within normal ranges and equipped with thermometer for 100 and 200 halls and 300 and 500 halls . These failures placed residents at risk of receiving medications that were ineffective. Findings included: 1. Record review of Resident #2's Face Sheet, dated 02/14/24, revealed Resident #2 was an [AGE] year-old male who was admitted to the facility on [DATE] and initially on 10/8/23. Resident #2's diagnoses included End Stage Renal Disease, Dependence on Renal Dialysis, Anemia in Chronic Kidney Disease, unspecified dementia, unsteadiness on feet, and other lack of coordination. Record review of Resident #2's MDS comprehensive assessment, dated 01/20/24, revealed Resident #2 had severe cognitive impairment with a BIMS score of 3. Record review of Resident #2's physician's order, dated 02/14/24, revealed Resident #2 did not have an order for dry eye relief. Record review of Resident #2's EHR on 02/14/24, revealed no documented evidence the resident could self-administer medication. Observation and interview on 02/13/2024 at 11:46 AM revealed Resident #2 lying in bed in his room. Observation revealed a bottle of dry eye relief sitting on his bedside table beside the resident's bed. Resident #2 stated he used the eye drops himself but was not sure if he was supposed to have them. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676408 If continuation sheet Page 8 of 22 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 676408 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bear Creek Nursing and Rehabilitation 3729 Ira E Woods Avenue Grapevine, TX 76051 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interview on 02/15/24 at 10:01 AM with LVN A revealed he was not aware the resident had the eye drops in his room. LVN A also stated the medication aide should dispense the eye drops for the resident if it was required. LVN A also stated the resident's Responsible Party comes daily to visit and probably brought them. LVN A also revealed Resident #2 did not have an order for the eye drops. Interview on 02/15/24 at 11:12 AM with the ADON revealed the drops were not supposed to be bedside for the resident.The ADON also stated the medication was supposed to be supervised due to possible drug interactions and should be given to Resident #2 by a MA. 2. Record review of Resident #26's face sheet, dated 02/15/24, revealed the resident was admitted to the facility on [DATE] with diagnoses that included diabetes. Record review of Resident #26's care plan, revised 02/14/24, revealed a care plan for self-medication administration. The care plan reflected: Interventions included: Confirm and document the medications administered. Periodic safety assessment/evaluation of patient's ability to dispense medications. Record review of Resident #26's admission MDS assessment,dated 11/27/23, revealed Resident #26 had severe cognitive impairment with a BIMS score of 6. Record review of Resident #26's clinical record revealed she did not have a self-administration of medication assessment completed. Record review of February 2024 physician orders for Resident #26's revealed there was an order for Polyethylene Glycol 400 Ophthalmic Solution 1% (Polyethylene Glycol 400 (Ophthamalic), Instill 1 drop in both, eyes four times a day for dry, itchy eyes supervised self-administration. Record review of Resident #26's February 2024 MAR revealed the Resident #26 was being administered the eye drops 4 times a day. Record review of Resident #20's face sheet, dated 02/15/24, revealed the resident was admitted to the facility on [DATE] with diagnoses that included unspecified macular degeneration (a degenerative condition affecting the central part of the retina and resulting in distortion or loss of central vision). Record review of Resident #20's care plan, revised 02/26/24, did not address self-medication administration. Record review of Resident #20's admission MDS assessment,dated 12/29/23, revealed Resident #20 had moderate cognitive impairment with a BIMS score of 12. Record review of Resident #20's clinical record revealed she did not have a self-administration of medication assessment completed. Record review of Resident #20's February 2024 physician orders revealed there was no order for Saline Nasal Spray Solution (Saline) 1 spray and Systane Solution 0.4-0.3 % (Polyethyl Glycol-Propyl Glycol) until when it was brought to the facility's attention on 02/14/24. Observation and interview with Resident #26 on 02/13/24 at 11:23 AM. He was observed to have one (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676408 If continuation sheet Page 9 of 22 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 676408 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bear Creek Nursing and Rehabilitation 3729 Ira E Woods Avenue Grapevine, TX 76051 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some bottle of dry eye relief lubricant eye drop propylene glycol 1.0%. He stated it was brought by his daughter and he administer to himself as needed. Resident#26 stated the facility staffs were aware he had the eye drops in the room. Observation and interview with Resident #20 on 02/14/24 at 9:02 AM. She was observed with her husband in her room. She was observed to have one bottle of Systane Solution 0.4-0.3 % and Saline Nasal Spray Solution. She stated she applied the nasal spray in the morning, and the resident's family member applied eye drops for her. She stated she has had the two bottles of eye drops and nasal spray since admission [DATE]). She stated the facility staff were aware of her having the nasal spray and the eye drops in her room. She stated one time the staff had picked them up and later she was given the bottles back. Interview on 02/14/24 at 9:07 AM, LVN G revealed she was the charge nurse, and she was not aware Resident #26 and #20 had the nasal spray and the eye drops in their room. She stated the residents were not supposed to keep the medications in their rooms unless they had orders and the self-administration assessment was completed. She stated Resident #26 was supposed to be supervised while administering the eye drops. LVN G stated the risk of residents keeping medications in their room was overdose, misuse, and other residents getting the medications. She stated she had done training on medication administration online. Observation on 02/14/24 at 2:38 PM of the facility's refrigerator used for the 100 and 200 Halls with LVN H revealed the following: 7 bottles of Humulin insulin 3 vials Novolin insulin 1 pen glargine insulin Tubersol injection 5/0.1 ml - 1 bottle. The temperature in the fridge read 30 degrees.Temperatures were being documented daily and were within normal ranges 36 degrees to 46 degrees Fahrenheit. Interview on 02/14/24 at 2:43 PM, LVN H revealed the night shift are responsible of checking the temperatures and documenting. She stated she knew the right temperatures were between 36 degrees and Fahrenheit and 46 degrees Fahrenheit. Observation on 02/14/24 at 2:47 PM of the nurse's medication cart used for the 300 and 500 Halls with LVN J revealed two insulin pens of Lispro Kwik pen Subcutaneous Solution 100 unit/ml and Admelog Solostar Solution Pen-injector 100 unit/ml were open and partially used, and without an opening date. Interview on 02/14/24 at 3:24 PM, LVN J revealed it was all nurses' responsibility to check the medication carts and putting the dates on insulin once opened. She stated all nurses should check on their carts for the labelling and opening dates. LVN J stated if the insulin was not dated with opening date, they would not be effective since they were not aware whether the medication had expired. She stated she had completed in-service on labelling and checking of expired medications. She could not recall the dates of in-service. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676408 If continuation sheet Page 10 of 22 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 676408 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bear Creek Nursing and Rehabilitation 3729 Ira E Woods Avenue Grapevine, TX 76051 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 0761 Observation and interview on 02/14/24 at 3:26 PM of the facility's refrigerator used for the 300 and 500 Halls with LVN J revealed there was: Level of Harm - Minimal harm or potential for actual harm 2 bottles of Humulin insulin Residents Affected - Some 36 vials Novolin insulin Acetaminophen suppositories 650 mg -16 Bisacodyl suppository 10 mg - 8 Procrit injectables 20,000 units - 4 pens Latanoprost 0.005% - 1 Alphagan Solution 0.1 % - 1. There was no thermometer in the refrigerator, but the staff had documented temperatures ranging from 36 degrees Fahrenheit to 46 degrees Fahrenheit up to 02/14/24 and were within normal ranges. LVN J stated the night shift was responsible of checking the temperatures and documenting the temperatures. She stated there was no thermometer,but she could see the nurses were documenting. Observation and interview with MA F on 02/14/24 at 3:13 PM revealed Resident #26 and Resident #20 had eye drops and nasal spray in their rooms. She stated Resident #26 was on her MAR, but she did not administer to Resident #26 because the resident self-administered. MA F stated the orders were to supervise, but she did not supervise. She stated she went back later and asked whether he had administered the medication, and she then charted it on the MAR. She stated she was not aware that she was supposed to supervise Resident #26 as he administered the medication until today 02/14/24. MA F stated the risk of not supervising the resident could be a missed dose or overdose. MA F stated she had done an in-service on medication administration. Interview on 02/14/24 at 3:37 PM with the ADON revealed the night shift nurses were responsible for checking the refrigerators and monitoring the temperatures.The ADON revealed he was responsible for checking temperatures after the nurses, but he could not tell the last time he had checked. He stated he was also responsible for auditing the carts for labelling and opening dates. The Pharmacist came every month and checked the refrigerator and carts for temperatures and labelling and open dates. He stated if staff were not checking the refrigerator with a thermometer and ensuring they were within normal ranges 36-46 degrees Fahrenheit, the insulins and vaccines would not be effective if administered to residents. He stated he had done in-service on refrigerator temperatures and opening dates in December 2023. The ADON stated the night shift staff were responsible for checking the temperatures and documenting. Interview on 02/14/24 at 3:46 PM, the DON revealed her expectation was for all nurses to put opening dates on insulin once they were removed from the refrigerator, and those not being used should be stored in the refrigerator. She stated the risk of not putting the opening dates nurses will not be able to tell when they expire. She stated if insulin expired, it would not be effective and residents blood sugars would not be controlled. She stated night shift staff were responsible for checking the refrigerator temperatures, documenting and removal of expired medications and all other staff that opens the refrigerators were responsible of checking the temperatures.She stated it was the ADON's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676408 If continuation sheet Page 11 of 22 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 676408 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bear Creek Nursing and Rehabilitation 3729 Ira E Woods Avenue Grapevine, TX 76051 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some responsibility to check the carts and refrigerator after the nurses. She stated the refrigerator was supposed to be maintained between 36- and 46-degrees Fahrenheit.She stated she had done training on refrigerator monitoring with staff. Interview on 02/14/24 at 7:53 PM, LVN K said she worked night shift, and they were supposed to check the temperatures of the refrigerators. She stated the refrigerator temperatures should be between 36-46 degrees Fahrenheit. She stated she had checked the refrigerator that served 300 and 500 halls on 02/13/24 and she documented the temperatures, and she had left the thermometer inside the refrigerator. She stated the risk of not having the thermometer in the refrigerator would be they are not able to tell whether the vaccines and insulins were stored in the right temperatures, and they would not be effective. Interview on 02/15/24 at 12:28 PM, the ADON revealed Resident#26 was supposed to keep the eye drops in the room. He stated Resident #26 was supposed to have a self-administration assessment, but he did not have one.He stated the order was Resident #26 to be supervised by a medication aide when he administered the eye drops. He stated they were supposed to stand and see Resident #26 administer the eye drops. He stated he was not aware the staff were not supervising him. He stated the risk of Resident #26 keeping the medication in the room other residents could get hold of them, overdose and outcome will not be achieved.He stated the eye drops are supposed to be stored in a safe place. He stated the facility has done in-service on medication administration. ADON stated he was not aware Resident #20 had eye drops and nasal spray in the room.When he was notified, he called the doctor, put the orders on the MAR, and the resident's family member opted to take the medications (eye drops) home. Record review of the wound care in-service, dated 12/20/23, revealed all nurses were responsible for signing off on their tretments once completed. Record review of refrigerator temp checks in-service, dated 12/13/23, revealed night nurses were responsible for montoring all temperatures but every nurse must check for temperatures. Record review of the facility's current self-administration of medication policy, revised February 2021, reflected the following: .8. Self-administered medications are stored in a safe and secure place which is not accessibly by other residents . Record review of the facility's current Medication labelling and storage policy, revised February 2023, reflected the following: Multi dose vials that have been opened or accessed are date and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vials. Record review of the facility's current refrigerator and freezers policy, revised November 2022, reflected the following: 1. Refrigerators and/or freezers are maintained in good working condition . 2. Monthly tracking sheets for all refrigerators and freezers are posted to record temperatures. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676408 If continuation sheet Page 12 of 22 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 676408 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bear Creek Nursing and Rehabilitation 3729 Ira E Woods Avenue Grapevine, TX 76051 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 0761 .5. The supervisors takes immediate actions if temperatures are out range . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676408 If continuation sheet Page 13 of 22 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 676408 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bear Creek Nursing and Rehabilitation 3729 Ira E Woods Avenue Grapevine, TX 76051 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 0803 Level of Harm - Minimal harm or potential for actual harm Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, interview, and record review, the facility failed to ensure that the menu was followed for 1 out of 2 meals (the lunch meal on 02/14/24) reviewed for food and nutrition services. Residents Affected - Some The facility failed to ensure residents on a pureed diet were served pureed bread during the lunch meal on 02/14/24. This failure could place residents at risk for unwanted weight loss, hunger, unwanted weight gain, and metabolic imbalances. Findings included: Review of a list of residents served a pureed diet, dated 02/15/24, reflected the facility had a total of nine residents on a pureed diet. Review of the facility's menu for the lunch meal on 02/14/24 revealed pork chops, pinto beans, turnip greens, banana pudding, and cornbread. Observation and interview on 02/1 4/24 at 12:59 PM with [NAME] Z revealed she brought a pureed sample tray to the conference room. [NAME] Z said she cooked all the food served today (02/14/24) during the lunch meal service. [NAME] Z and the surveyors observed the pureed sample tray had green beans, corn, and pork roast. [NAME] Z said there was not any pureed bread served because she forgot to make it. [NAME] Z said there was a lot going on in the kitchen and she got side tracked and never made the pureed bread. [NAME] Z said she was responsible for making the pureed bread as the cook. [NAME] Z said all residents should receive all components of the meal with no exceptions. [NAME] Z said if residents were not receiving all the components of each meal, they could be at risk for weight loss. Interview on 02/14/24 at 2:15 PM with the DM revealed he forgot to follow-up with [NAME] Z to make sure the pureed bread was made and served during the lunch meal earlier in the day. The DM said [NAME] Z was responsible for making the pureed bread, but he was ultimately responsible for making sure all components of each meal were made and served to each resident. The DM said he was not sure why the pureed bread was forgotten about today during lunch. The DM said the concern with the pureed bread missing was that it contributed towards the nutritional values for that meal for that resident and they could be at risk of weight loss. Review of the facility's Menus policy, dated October 2017, reflected the following: .1. Menus meet the nutritional needs of residents in accordance with the recommended dietary allowances of the Food and Nutrition Board (National Research Council and National Academy of Sciences). 2. Menus for regular and therapeutic diets are written at least two (2) weeks in advance, and area dated and posted in the kitchen at least one (1) week in advance . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676408 If continuation sheet Page 14 of 22 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 676408 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bear Creek Nursing and Rehabilitation 3729 Ira E Woods Avenue Grapevine, TX 76051 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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to ensure each resident received and the facility provided food and drink that was palatable, attractive, and at a safe and appetizing temperature for one of one meal (lunch on 02/14/24) reviewed for food and nutrition services. Residents Affected - Some The facility failed to deliver food at an appetizing taste and temperature for the lunch meal on 02/14/24. The deficient practice could place residents at risk of poor intake of nutrition, weight loss, and illness. Findings included: Interview on 02/13/24 at 10:19 AM with Resident #54 revealed his food was always so salty for every meal and he was concerned because he was supposed to be on a heart healthy diet with low salted foods. Interview on 02/13/24 at 10:53 AM with Resident #9 revealed his food was always cold for every meal. Interview on 02/13/24 at 11:00 AM with Residents #10 and #60 revealed their food was always cold for every meal. Confidential group interview with residents revealed the food was salty and cold for every meal served. Review of the facility's menu for the lunch meal on 02/14/24 revealed pork chops, pinto beans, turnip greens, banana pudding, and cornbread. Observation on 02/14/24 revealed the last hall cart left the kitchen at 12:35 PM and made it to the 200-hall at 12:43 PM. The last tray was served at 12:56 PM to the last resident. Observation and interview on 02/14/24 at 12:59 PM with [NAME] Z revealed she brought a sample tray to the conference room. The sample tray consisted of pork chops, pinto beans, turnip greens, banana pudding, and cornbread. [NAME] Z and the surveyors tasted the sample tray and found the food to be lukewarm and room temperature and the pinto beans tasted very salty. [NAME] Z said she felt the food should be much hotter than what it was. [NAME] Z said she used chicken bouillon paste which was what probably made the pinto beans salty but was not sure why the food was not served hot. [NAME] Z said the importance of residents receiving palatable food was that they wouldn't eat it if it was not warm or seasoned well and that could lead to weight loss. Interview on 02/14/24 at 2:15 PM with the DM revealed he wanted the food to be at least warm to a resident's palate but not burning hot in their mouth. The DM said the taste needs to have full flavor but cautious about the salt because a lot of residents are on a low salt or not salt diet. The DM said he was responsible for everything that comes out of the kitchen, and he did taste the food before it left the kitchen but did not note food being too salty. The DM said [NAME] Z uses chicken bouillon paste and a chicken seasoning that has salt in it too to flavor the food. The DM said he wanted the food to be enjoyed and if it was cold or too salty the resident may not eat it all which could (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676408 If continuation sheet Page 15 of 22 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 676408 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bear Creek Nursing and Rehabilitation 3729 Ira E Woods Avenue Grapevine, TX 76051 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 0804 lead to weight loss. Level of Harm - Minimal harm or potential for actual harm Review of the facility's Menus policy, dated October 2017, reflected the following: .1. Menus meet the nutritional needs of residents in accordance with the recommended dietary allowances of the Food and Nutrition Board (National Research Council and National Academy of Sciences) Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676408 If continuation sheet Page 16 of 22 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 676408 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bear Creek Nursing and Rehabilitation 3729 Ira E Woods Avenue Grapevine, TX 76051 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 0809 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that each resident received at least three meals daily at regular times comparable to normal mealtimes in the community for one of three Residents (Resident #2) reviewed for meals. The facility did not provide Resident #2 with a meal or snack when going to dialysis on Mondays, Wednesdays, and Fridays. This failure could place residents who received dialysis services at risk for decreased intake, unplanned weight loss, and diminished quality of life. Findings included: Record review of Resident #2's Face Sheet, dated 02/14/24, revealed Resident #2 was an [AGE] year-old male who was admitted to the facility on [DATE] and initially on 10/8/23. Resident #2's diagnoses included End Stage Renal Disease, Dependence on Renal Dialysis, Anemia in Chronic Kidney Disease, and dementia. Record review of Resident #2's February 2024 Physician orders revealed Resident #2 had admitting diagnoses of End Stage Renal Dialysis and Dependence on Renal Dialysis. Resident #2 Physician Orders indicated Resident #2 went to dialysis on Mondays, Wednesdays, and Fridays. Record review of Resident #2's Care Plan indicated that facility would make transportation arrangements for dialysis. The care plan stated that resident will be offered choice of foods per dietary restrictions, which is a limitation on what a person can eat. The Care Plan also revealed that the Schedule for Resident #2's dialysis coordination indicated he went to dialysis on Mondays, Wednesday, and Fridays. Record review of Resident #2's EMAR revealed his weight on 10/08/23 was 151.4 pounds. His record also revealed on 02/05/24 that he weighed 149.8 pounds which was a 1.06 % loss in 4 months. Interview on 02/15/24 at 1:50 PM, the DM stated he was unaware that Resident #2 was on dialysis. The DM revealed he had never sent a lunch or snack with Resident #2 to dialysis because he was unaware the resident was on dialysis. Interview on 02/15/24 at 2:28 PM, Resident #2 said he had never received a snack or a meal to take with him to dialysis. Interview on 02/15/24 at 2:30 PM, Resident #2's responsible party stated Resident #2 had never been offered a snack or meal to take with him to dialysis. The Responsible Party also stated she came to the facility every day and took Resident #2 to dialysis on the scheduled days. The Responsible Party stated they left at 10:00 AM and returned the facility between 3:30 PM and 4:00 PM. The Responsible Party stated the facility served the resident lunch and left it on the bedside table. When they returned from dialysis, the resident took a few bites of the cold lunch that was left sitting on his bedside table. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676408 If continuation sheet Page 17 of 22 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 676408 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bear Creek Nursing and Rehabilitation 3729 Ira E Woods Avenue Grapevine, TX 76051 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 0809 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 02/15/24 at 2:50 PM, LVN B stated residents were supposed to be given a snack or something to eat to take with them when they went to dialysis. Interview on 02/15/24 at 2:52 PM, LVN A stated Resident #2 left after he had eaten breakfast at 10:00 AM. LVN A also revealed Resident #2 did not take anything to eat when he went out to dialysis. LVN A stated the resident's lunch tray was left in his room for him, and the resident had not complained of not having enough food to eat. Interview on 02/25/24 at 3:37 PM, the ADON stated Resident #2 had a lunch sent with him to dialysis. Interview on 02/15/24 at 4:29 PM, the DON revealed residents should be provided something to eat while they were out to dialysis. The DON also revealed a resident's well-being, such as dehydration or energy, could be affected if they did not receive a snack or meal. The DON concluded by stated that not receiving a nourishing snack or meal was not safe for them. The facility's Frequency of Meals Policy Statement revealed each resident shall receive at least three meals daily, at times comparable to typical mealtimes in the community, or in accordance with resident needs, preferences, requests, and the plan of care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676408 If continuation sheet Page 18 of 22 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 676408 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bear Creek Nursing and Rehabilitation 3729 Ira E Woods Avenue Grapevine, TX 76051 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 3 (Residents #45, #50, and #232 ) of 5 residents reviewed for treatment administration. 1. The facility failed to ensure staff accurately documented on Resident #45's MAR/TAR after performing wound care on Resident #45. 2. The facility failed to document wound care treatments on Resident #50's February 2024 TAR. 3. The facility failed to document wound care treatments on the Treatment Administration Record for Resident #232 indicated by blanks on Resident #232's February 2024 TAR. These failures could put residents at risk for treatment errors and errors in care. Findings included: 1. Review of Resident #45's face sheet, dated 02/15/24, revealed the resident was an [AGE] year-old female who originally admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included a Stage 4 pressure ulcer of sacral region. Review of Resident #45's physician's orders, dated 01/30/24, reflected the following: Sacrum: clean area with dakins, pat dry. Apply santyl [NAME] calcium Alginate and cover with dry dressing. Every day shift. Review of Resident #45's quarterly MDS Assessment, dated 01/19/24, reflected a BIMS score of 00 indicating the resident was unable to complete the interview. Review of Resident #45's care plan, dated 02/07/24, reflected the following: Pressure ulcer actual or at risk due to: Diagnosis of diabetes, Pressure Ulcer Present stage 4 pressure wound to sacrum Pressure Ulcer will heal without complication , treatments as ordered. Review of Resident #45's February 2024 MAR revealed the following dates: 02/01/24, 02/02/24, 02/05/24, 02/06/24, 02/07/24, 02/08/24, 02/09/24, 02/12/24, 02/13/24, and 02/14/24 were not checked to show wound care was performed. Observation and interview on 02/13/23 at 11:14 AM revealed Resident #45 in her bed in her room. Resident #45 was not able to answer any questions or seem to recognize that questions were being asked. She could not tell whether staff performed wound care. Interview on 02/14/24 at 11:34 PM with Resident #45's family member revealed the family member visited Resident #45 every day, and the resident's wound care was performed each day. Observation on 02/15/24 at 11:08 AM revealed the DON provided Resident #45 with wound care. He explained the procedure, washed his hands, put on gloves, disinfected the table, and left it to dry. He removed his gloves, washed his hands, and put his supplies together. He wheeled the table to the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676408 If continuation sheet Page 19 of 22 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 676408 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bear Creek Nursing and Rehabilitation 3729 Ira E Woods Avenue Grapevine, TX 76051 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some room. He positioned the resident, washed hands, and put on gloves. He removed the old dressing that was dated 02/14/24, discarded it in the biohazard bag, removed gloves and washed hands. The DON then cleansed the sacrum area with gauze soaked in Dakin's solution (a diluted bleach solution used to prevent and treat skin and tissue infections), patted it dry, removed the gloves, washed hands, and put on clean gloves. He then applied Santyl cream (used to remove dead tissue from wounds) and then calcium alginate and covered with a dry dressing dated 02/15/23. Interview on 02/15/24 at 1:10 PM with ADON revealed he was the wound care nurse. He stated he was aware he was supposed to document on treatment administration record every time he performed wound care, but he was forgetting due to having a lot of work to do .ADON stated the risk of not documenting after the wound care was done would mean treatment not administered. He stated the facility policy was to sign the treatment administration record after wound care was performed. ADON stated he had another nurse he was orienting, and he was performing wound care and he was responsible of ensuring he signed on the treatment record after wound care. He stated he had done training with the nurse on signing of MAR and TAR and he had not documented the training . He stated he had done in-services with all other nurses on documenting treatment after administration. Interview on 02/15/24 at 2:05 PM with the DON revealed her expectations were that staff to document accurately on the resident's MAR/TAR. The DON said wound care nurse should have documented on Resident #45's MAR that he had performed wound care. She stated ADON was the one responsible of ensuring the wound care was done and documented on TAR/MAR. She stated the facility was training another nurse to help with wound care and she suspended him when she noticed the MAR and TAR were not being documented accurately but she was expecting the ADON to have rectified the problem after taking over wound care .The DON said the purpose of documenting accurately was to make sure orders were completed correctly. The DON said the risk of staffs not documenting care accurately could lead to care not being provided and the wounds would deteriorate. The DON state she had done in-service on documentation in December 2023. Review of the in-services on 02/15/23 it was revealed the facility offered in-service on 12/20/23 on wound treatments stating all staffs are responsible for signing the MAR/TAR after treatments was completed. Review of the facility's policy charting and documentation, revised 07/2017, revealed: Documentation in the medical records may be electronic, manual or a combination. 3. Documentation in the medical record will be objective(not opinionated or speculative),complete and accurate . 2. Review of Resident #50's face sheet, dated 02/15/24 reflected he was a [AGE] year-old male who originally admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included osteomyelitis (an infection in the bone caused by bacteria or fungi) of vertebra, pressure ulcer of sacral region, and quadriplegia (dysfunction or loss of motor and/or sensory function in the cervical area of the spinal cord). Review of Resident #50's quarterly MDS Assessment, dated 12/22/23, reflected he had a BIMS score of 02 which indicated severe cognitive impairment. Review of Resident #50's physician's orders reflected the following: Sacrum: clean open area with dakins cleanser pad dry apply santyl and calcium alginate and draw tex [a specific type of dressing] (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676408 If continuation sheet Page 20 of 22 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 676408 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bear Creek Nursing and Rehabilitation 3729 Ira E Woods Avenue Grapevine, TX 76051 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 0842 secure with dry dressing every day shift. Level of Harm - Minimal harm or potential for actual harm Review of Resident #50's February TAR reflected blank spots with no check mark or initial for the following dates and order: 02/01/24, 02/02/24, 02/04/24, 02/05/24, 02/06/24, 0207/24 for the order Sacrum: clean open area with dakins cleanser [antiseptic solution] pad dry apply santyl and calcium alginate and draw tex secure with dry dressing every day shift. Residents Affected - Some Observation on 02/13/24 at 10:50 AM of Resident #50 revealed he was in his room laying in his bed. Resident #50 did not respond to any questions being asked. Interview on 02/15/24 at 1:34 PM with the ADON revealed he took over providing wound care treatments for Residents #45, #50, and #232 last Friday and all other residents with wounds in the building after the last wound care nurse resigned. The ADON said he was responsible for all wound treatments in the building and had been completing them daily as ordered. The ADON said during the month of February 2024 he was helping to train the previous wound care nurse and was still responsible for completing wound care treatments. The ADON said since he was currently providing wound care treatments, he was also responsible for documenting on the residents' TAR's that the care was provided. The ADON said he had not had the chance to document on each resident's TAR that he had provided the wound care because he was busy. The ADON said he knew the importance of making sure the wound care provided was documented on the resident's TAR because that way others would know the wound care had been done. The ADON said the risk of not documenting on the resident's TAR that wound care was provided was that it could indicate it had not been done unless someone went to check. The ADON said he as a nurse manager would normally follow-up and ensure that staff were documenting on the resident's TAR's but he had not had the time to do so. The ADON said he was supposed to document on the resident's TAR after he provided the treatment. Interview on 02/15/24 at 4:07 PM with the DON revealed she saw on the residents' (Residents #45, #50, and #232) TARs that the ADON had failed to document that wound care had been provided during February 2024. The DON said the previous wound care nurse was training with the ADON and he eventually resigned so the ADON had been providing wound care for residents. The DON said staff knew to document as they went along providing care to residents on the resident's TAR. The DON said the ADON was responsible for documenting on the TAR that he provided the wound care to each resident. The DON said she knew the ADON had been overwhelmed with a lot of things going on so that was why he had not been documenting on the resident's TAR. The DON said all staff had been trained on documenting on the resident's TAR after they provided the care. The DON said the responsibility of following-up and checking that staff documented on the resident's TAR was normally her, but she had been away from the facility for a few weeks and just recently returned. The DON said the concern with staff not documenting on the resident's TAR was that if it wasn't documented there was no proof it was actually provided. 3. Record review of face sheet for Resident #232 reflected the resident was a [AGE] year-old male admitted on [DATE] with diagnoses of pneumonitis due to inhalation of food and vomit, acute respiratory failure with hypoxia, pressure ulcer of sacrum, pressure induced deep tissue wound of left heel, and pressure induced deep tissue wound of right heel. Record Review of Resident #232's quarterly MDS dated [DATE] reflected that Resident #232's BIMS score was 12, which means that Resident #232 had moderate cognitive impairment. Record Review of Resident #232's Care Plan dated 02/7/24 reflected that wound treatments as ordered (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676408 If continuation sheet Page 21 of 22 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 676408 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bear Creek Nursing and Rehabilitation 3729 Ira E Woods Avenue Grapevine, TX 76051 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some and weekly wound assessments. Further Care Plan review also reflected that Resident #232 was at risk for pain. Record Review of Resident #232's physician orders dated 02/06/24 reflected for left heel: clean area with normal saline, pad dry, apply betadine, and cover with foam dressing everyday shift and as needed. Physician orders also reflected for Resident #232's right heel: clean area with normal saline, pad dry, apply skin prep, leave open to air everyday shift. Physician orders also reflected for Resident #232's sacrum: clean open with normal saline, pad dry, apply Santyl and calcium alginate, cover with foam dressing everyday shift and as needed. Record review of Resident #232 revealed no records were recorded of Resident #232 receiving wound care treatment on sacrum wound on 02/11/24, 02/12/24, 02/13/24, and on 02/14/24 as indicated by blanks on the TAR. Record review of Resident #232 revealed no records were recorded of Resident #232 receiving wound care treatment on left heel wound on 02/11/2024, 02/12/24, 02/13/24, and on 02/14/24 as indicated by blanks on the TAR. Record review of Resident #232 revealed no records were recorded of Resident #232 receiving wound care treatment on right heel wound on 02/11/24, 02/12/24, 02/13/24, and on 02/14/024 as indicated by blanks on the TAR. Record Review of Resident #232 progress notes for February 2024 did not reflect alternative documentation of wound treatments of the sacrum, left heel, or right heel. Review of the facility's Charting and Documenting policy, dated July 2017, reflected: .2. The following information is to be documented in the resident medical record .c. Treatments or services performed FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676408 If continuation sheet Page 22 of 22