Health inspection·November 19, 2025

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Resident #1 passed away. She stated she was in route to the facility to visit Resident #1 and submit the grievance when she go the call she had passed away. She stated as of [DATE] she had still not received a call from the facility about her filed grievances. In an interview with the DON on [DATE] at 2:11 PM, she stated the SW received all grievances. She revealed the SW received the grievance form from Resident #1's RP on [DATE]. She also revealed she received Resident #1's RP, filed grievances and started investigating. The DON stated shortly after she started her investigation, she had to go out for surgery and handed it off the ADON. She stated she did not know how far the ADON had gotten into the grievance process. The DON stated as of [DATE] she had not followed up with a resolution call to Resident #1's RP. She stated she had completed the investigations into the filed concerns in the grievance. The DON stated it was the responsibility of the DON or ADON to investigate any concern that dealt with the nursing side. She stated she, ADON or SW were responsible for providing an update of progress to a resident, a resident's RP or family member. She stated she thought the call to Resident #1's RP was completed by ADON or SW while she was on leave. In an interview on [DATE] at 2:45 PM, the SW stated she attempted to contact Resident #1's RP to discuss the grievance. SW stated she did not document the attempt to contact. The SW also stated she did not remember if she left a message on the Resident #1's RP voicemail. She stated she did not know what days she attempted to contact the resident's RP, but she felt it was the same day she saw the grievance. She stated as of [DATE] she had not updated Resident #1's RP about resolution of the grievances she filed. In an interview on [DATE] at 4:06 PM, the ADON stated she had not investigated the concerns in the grievance submitted by Resident #1's RP. She stated she knew the DON had started investigating but was not aware of how far she had gotten. She stated she had not received the task of completing the grievance from the DON. She stated she was not aware that she had to keep Resident #1's RP apprised of the resolution. She stated she thought it was the DON or SW that would contact resident's RP. The DON stated they had failed to keep Resident #1's RP apprise of the findings and resolutions of investigation regarding her grievance. Record review of the facility's policy, implemented and revised on [DATE], titled Resident Rights, reflected in part the following: 9. Grievances. The resident has the right to: a. Voice grievances to the facility or other agency or entity that hears grievances without discriminationor reprisal. Such grievances include those with respect to care and treatment which has been furnishedas well as that which has not been furnished; and the behavior of staff and of other residents; andother concerns regarding their LTC facility stay.b. The resident has the right to and the facility must make prompt efforts by the facility to resolve Event ID: Facility ID: 676408 If continuation sheet Page 2 of 4 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 11/19/2025 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 - Few 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, in accordance with State and Federal laws, to store all drugs and biologicals in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys for 1 of 6 residents (Resident #1) reviewed for medication storage. The facility failed to secure all medications in a locked storage area when Resident #1's Labetalol HCl and Pantoprazole Sodium medications were found on the floor approximately 2-3 inches from resident's bed on [DATE]. This failure could place residents at risk of access to medications not approved for administration by their physician. Findings included: Record review of Resident #1's admission record, initially admitted on [DATE], reflected the resident was an [AGE] year old female with diagnoses that included hypertension and irritable bowel syndrome. Record review of Resident #1's admission MDS assessment, dated [DATE], reflected the resident had a BIMS score of 2 out of 15, which indicated severe cognitive impairment. In the MDS assessment Section GG-Functional Abilities, it revealed Resident #1 needed partial and maximum assistance with ADLs. Resident #1 required partial assistance with mobility. In the MDS assessment Section J Health Condition, it revealed no for scheduled pain medication regimen, PRN pain medications or offered and declined, and received non-medication intervention for pain. There was no information about medication types. Record review of Resident #1's care plan, dated [DATE], reflected to administer medications per orders. Record review of Resident #1's order summary report, reflected may crush meds or open capsules as needed unless contraindicated. Record review of Resident #1's medication administration on [DATE], reflected LVN A administered the following medications:*Bactrium DS Tablet 800-160 MG, *Pantoprazole Sodium Oral Tablet Delayed Release 40 MG, *Prostat 30ml, *MiraLax Oral Pack 17 GM (Polyethylene Glycol 3350) 17 GM,Labetalol HCl Oral Tablet 200 MG,Juven andIpratropium-Albuterol Solution 0.5-2.5 (3) MG/3M In an interview with Resident #1's RP on [DATE] at 11:42 AM, she stated on [DATE] Resident #1's friend visited and upon arrival, she found two pills on Resident #1's floor. She stated their friend told her there was a white and yellow pill on the floor next to the resident's bed. She stated the nurse informed Resident #1's neighbor/friend that one pill was for the resident's stomach and the other pill found was identified as blood pressure. RP stated she was concerned as she did not know if Resident #1 received her medications on the morning of [DATE]. Resident #1's RP revealed she had attempted to contact management at the facility over that weekend but to no avail. She stated she submitted her concerns in a grievance. She stated she wanted the facility to investigate her concerns and inform her of the findings. In an interview on [DATE] at 4:06 PM, the ADON revealed she was not in the facility on [DATE]. She stated she received information from one of the nurses that Resident #1's friend had seen medications at resident's bedside. She stated she spoke with the nurse and had her told her to document the incident. She also stated she told the nurse to assess the resident. On [DATE] at 2:55 PM and (second time) attempts were made to contact staff LVN but phone was disconnected. In an interview with Resident #1's friend on [DATE] at 3:12 PM, she stated on [DATE] she visited Resident #1. She stated when she walked in the resident's room, she noticed two pills on the resident's floor. She stated it was a white and yellow pill approximately 2-3 inches on the right side of resident's bed on the floor. She also stated she picked the medications off the floor and sat them on the resident's tray table. She stated afterwards, she walked to the nurse's station and informed LVN B. She stated LVN B told her that she had just come onto her shift for the day, so she was not aware of the medications. She stated LVN B told her she would come (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676408 If continuation sheet Page 3 of 4 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 11/19/2025 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 - Few FORM CMS-2567 (02/99) Previous Versions Obsolete to get the medications. Resident #1's friend stated shortly after LVN B went into Resident #1's room and retrieved the medications. Resident #1's friend also stated that LVN B told her she would check the computer to find out which pills it was. Resident #1's friend stated LVN B came back into the room and informed her it was Resident #1's Protonix (treat conditions that cause too much stomach acid) and Labetalol HCl (lower high blood pressure). She stated the LVN told her one was for Resident #1's stomach and the other for the resident's blood pressure. She stated the LVN stated the resident record showed she had taken two medications in the morning and did not want to give it to her if she had already taken them. Resident #1's friend stated LVN B stated she would document the medications on the floor in the system. Resident #1's friend stated she did not know how long it had been on the floor and was concerned. Interview with LVN B, she stated she had worked for agency. She stated she worked with Resident #1 on [DATE] on 2nd shift. She stated she worked from 2:00pm-10:00pm. LVN B stated Resident #1's friend came out and got her from the nurse's station. She stated it was shortly after she got on shift that day. She stated she and Resident #1's friend went back to the resident's room where two pills lay on the tray table. LVN B stated she picked up the two pills and took them to the nurse's station to investigate. She stated she found that it was Resident #1's Protonix and Labetalol HCI. LVN B stated she went back to Resident #1's room and informed resident's friend of her findings. She stated it was two pills that Resident #1 took in the morning. LVN B revealed it had shown on the MARs the medications were given to the resident, so she did not want to double her more pills. LVN B stated she checked Resident #1's blood pressure which was good. The LVN stated she told resident's friend she would give her the evening medications. LVN B stated she reported it to the DON or the ADON but she was not aware of who it was as she spoke to the person over the phone. She stated she was told to document it on the 24-hour log report. She stated she documented the incident in the 24-hour report and later administered Resident #1's evening medications. In an interview with DON on [DATE] at 2:11 PM, she stated she was made aware that Resident #1's friend told one of her nurse's she had found two pills on the resident's floor. She stated she started an investigation to investigate how the pills got on the floor. She stated her belief was maybe the nurse tried to throw the pills in the trash. The DON stated her staff was not aware of any medication being on Resident #1's floor until it was brought to their attention by the resident's friend. In an interview with ADON on [DATE] at 4:06 PM, she stated Resident #1's friend told one of the nurse's she had found some medication at the resident's bedside. She stated she spoke with the nurse and told her to document and assess the resident. Record review of 24-hour report book did not have any documentation 24-hour report of Resident #1's medications on the floor. Record review of the facility's policy, implemented and revised on [DATE], titled Destruction of Unused Drugs, reflected in part the following: Policy: All unused, contaminated, or expired prescription drugs shall be disposed of in accordance with state laws and regulations (refer to any state-specific requirements). Event ID: Facility ID: 676408 If continuation sheet Page 4 of 4