Health inspection·December 21, 2025

F 0755 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Glargine) inject 15 units subcutaneously in the evening for diabetes. The medication was administered to Resident #1 at 8:00 p.m. on 12/03/2025 and at 8:00 p.m. on 12/04/2025. Farxiga Oral Tablet 10 MG, (Dapagliflozin Propanediol) give 1 tablet by mouth one time a day for diabetes. The medication was administered to Resident #1 at 8:00 a.m on 12/02/2025, 8:00 a.m. on 12/03/2025, 8:00 a.m. on 12/04/2025, 8:00 a.m. on 12/05/2025, and 8:00 a.m. on 12/06/2025. Lasix Oral Tablet 40 MG (Furosemide) give 1 tablet by mouth two times a day for fluid overload. The medication was administered to Resident #1 at 6:00 p.m. on 12/01/2025, 8:00 a.m. and 6:00 p.m. on 12/02/2025, 8:00 a and 6:00 p.m. on 12/03/2025, 8:00 a.m. and 6:00 p.m. on 12/4/2025, 8:00 a.m. and 6:00 p.m. on 12/5/2025, and 8:00 a.m. on 12/06/2025. Insulin Lispro Injection Solution 100 UNIT/mL (Insulin Lispro) inject as per sliding scale:If 0-150 = 0; 151-200 = 2; 201-250 = 4; 251-300 = 6; 301-350 = 8; 351-400 = 10; 401 + = 12 units and notify the doctor, subcutaneously before meals for diabetes. Resident #1 was administered 8 units at 11:00 a.m. on 12/02/25 with a blood sugar reading of 312. Record review of Resident #1's Physician's Orders, dated 12/20/25, reflected the resident was currently prescribed Topiramate. The Black Box Warning (the most serious warning issued by the U.S. Food and Drug Administration (FDA) to alert patients and healthcare providers about the potential for serious or life-threatening side effects associated with certain medications) for the incorrectly administered Metformin HCI (hydrochloride) specifically identified the use of Topiramate (a carbonic anhydrase inhibitor) as a clinical risk factor. According to the manufacturer's warning, the use of these two medications at the same time was associated with an increased risk for the development of lactic acidosis (a medical condition characterized by the accumulation of lactic acid in the bloodstream, leading to a decrease in blood pH and potential health complications). Further review of the Order Summary reflected a Black Box warning for the incorrectly administered Lasix Oral Tablet. The warning stated if given in excessive amounts, could lead to a profound diuresis (process of formation and excretion of urine from the body through the kidneys) with water and electrolyte depletion. Therefore, careful medical supervision was required, and dose schedule must be adjusted to the individual patient's needs. Record Review of Resident #1's Care Plan, dated 12/01/25, reflected the resident was receiving insulin. The Care Plan did not specify the diagnosis associated with insulin use. The Care Plan interventions included monitoring blood glucose, monitoring for hypoglycemia, and notifying the physician as needed. Record Review of Resident #1's Patient Discharge Instructions from the resident's previous rehabilitation facility reflected four pages of another resident's medication action plan mixed in with Resident #1's records. The four pages of the medication action plan each identify the incorrect resident by first, middle initial, last name, MRN number, and date of birth . Record Review of Resident #1's Change in Condition Evaluation, dated 12/06/2025 at 10:02 p.m., reflected the resident had abnormal vital signs and listed the other change as Unresponsive. The resident's most recent blood pressure reading was 92/48, pulse of 78, respiration 18, body temperature of 97.7, oxygen saturation at 94.0, and blood glucose of 134.0 mg/dL. The evaluation further reflected Resident #1's neurological status changed. It reflected Resident #1 had an altered level of consciousness and the level of change stated sudden change in the level of consciousness or responsiveness. Record review of Resident #'1 Nursing Note, dated 12/10/2025 reflected, Received phone call from MD [name] stating that he'd received a call from son stating, that he was receiving medication to treat diabetes and patient is not a diabetic. Writer looked into patient records and noted that mixed in with patient records were orders for another patient that was sent with Resident #1 clinicals from [name of rehabilitation facility]. MD [name] was made aware and stated he will follow up with the son. Record review of Resident #1's Nursing Facility to Hospital Transfer Form, dated 12/06/2025 at 9:30 p.m., reflected the resident was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676408 If continuation sheet Page 2 of 10 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 12/21/2025 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 0755 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some transported to the hospital due to unresponsive. Record review of Resident #1's hospital records, dated 12/06/25, reflected the following: .Acute Kidney failure creatinine 0.8 on 11/18/25 - had been getting Lasix, farxiga at nursing home - Creatinine 2.52 to 2.62 after contrast. During an interview on 12/20/2025 at 11:20 a.m., the Administrator and DON stated Resident #1 was administered five incorrect medications that were not prescribed to him. The DON reported that based on their internal investigation, it was determined Resident #1 was admitted to the facility from a short-term care facility and the records provided by the short-term care facility had another resident's MAR mixed in with Resident #1's records. The DON stated the records also contained Resident #1's MAR, so it appeared to be a long list of medications that were all prescribed for Resident #1. The DON reported Resident #1 was transferred to the emergency room on [DATE] because he was unresponsive. During an interview on 12/20/2025 at 10:09 a.m., Resident #1's family member reported on 12/06/25 at approximately 8:42 p.m. they were notified by the facility that the resident was unresponsive and they wanted to transfer him to the hospital. Resident #1's family member reported the family requested the facility wait until they arrived to transfer the resident. Resident #1's family member stated a nurse informed the family she was scheduled to administer insulin but that the resident was not eating. Resident #1's family member questioned why insulin was ordered, as the resident was not diabetic and the nurse provided a copy of the MAR, which noted orders for insulin, metformin, farxiga, and furosemide, medications the family member stated Resident #1 was not prescribed prior to admission. Resident #1's family member reported Resident #1 was transferred to the hospital, admitted to the ICU, and treated for acute renal failure, aspiration pneumonia, and sepsis. Resident #1's family member stated the resident required oxygen and IV fluids and later developed significant weakness and inability to swallow, resulting in a decision to transition Resident #1 to hospice care. Resident #1's family member reported the family received copies of the resident's medication lists, MAR, and prior rehabilitation records and stated the medications at the previous rehabilitation facility and hospital were correct. Resident #1's family member reported the facility later informed him another resident's medical records were mixed into Resident #1's paperwork. During an interview on 12/20/2025 at 12:02 p.m., the facility MD reported he was notified on 12/06/2025 that Resident #1 was unresponsive and had been transferred to the hospital, where he was later informed the resident was diagnosed with severe sepsis. He stated he did not have access to the resident's hospital records and could not determine whether the medications contributed to the resident's decline without reviewing additional clinical data. The MD reported the medication orders were transcribed from faxed transfer records and entered into the system by the admitting nurse, verified by the DON, and then routed to him for signature. He stated he relied on nursing staff to accurately enter and reconcile medication orders and acknowledged that he trusted the information presented to him when signing off. He reported that during this process the residents' diagnoses were not reviewed or verified with the nurse prior to signing the orders and stated this step was missed due to multiple moving parts in the admission process. The physician reported that during his follow-up review he learned a document from another resident was mixed into Resident #1's transfer paperwork, which resulted in incorrect medications being ordered. He stated the medications were entered as new orders and reported insulin was administered once due to elevated blood glucose levels. He stated medication reconciliation was completed per facility workflow by nursing staff and verified by the DON prior to his review. Record review of the facility's Abuse, Neglect, and Exploitation Policy, dated 07/2025, reflected, .failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. This was determined to be an Immediate (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676408 If continuation sheet Page 3 of 10 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 12/21/2025 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 0755 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Jeopardy (IJ) on 12/20/25 at 5:45 p.m. The Administrator was notified. The Administrator was provided with the IJ template on 12/20/25 at 6:21 p.m.; an updated version of the IJ template was provided on 01/08/26 at 10:40 a.m.The following Plan of Removal submitted by the facility was accepted on 12/21/25 at 12:21 p.m: .Interventions:The resident was transferred to the hospital and no longer resides in the facility. The Director of Nursing (DON) or designee conducted an immediate facility-wide review of all residents admitted or readmitted within the past 30 days to ensure medication orders were accurately reconciled with hospital discharge instructions and physician orders. Also, to include any transfers from other facilities. Nursing supervisors verified MAR accuracy, medication availability, and physician clarification as needed. Any discrepancies identified were corrected immediately. The Administrator reviewed the audit findings and confirmed that no additional residents were at risk. The Director of Nursing (DON) or designee will implement the following systemic changes and education on 12-21-25. The staff member who input the orders was terminated by the DON on 12-10-25. All staff will be in-serviced by the DON/designee on abuse, neglect, and misappropriation. Staff members who are not present will be in serviced prior to working their next shift and before providing resident care. Completion will be verified and documented. Revised the admission and readmission medication reconciliation process to require dual verification confirming that admit orders/discharge Summary matches the orders entered in the EMR by the admitting nurse and another licensed nurse. The DON/designee established a requirement for immediate physician notification, clarification, and documentation when discrepancies are identified. Updated the admission checklist to include MD verification, dual nurse verification, and DON/designee verification to be completed for every admission and readmission. The DON/Designee will verify that the admission checklist is completed for all admissions. Required DON or designee review of all new admissions and readmissions by next business day The Director of Nursing (DON) or designee will provide re-education to all licensed nursing staff on proper medication reconciliation, verification of physician orders prior to medication administration, escalation procedures, and documentation requirements. Education will be provided by the DON/designee through in-service training, with staff competency validated through verbal review. Staff members who are not present will be in serviced prior to working their next shift and before providing resident care. Completion will be verified and documented. Nursing management will notify the Regional Nurse of any significant medication error requiring physician intervention or hospitalization. The Regional nurse notified the administrator to in-service nurse management regarding notification of the regional nurse of any significant medication error requiring physician intervention or hospitalization. The Director of Nursing (DON) or designee will conduct weekly audits of all new admissions and readmissions for four weeks, then monthly thereafter, to ensure continued compliance with medication reconciliation requirements. Audit results will be reviewed by the Administrator and incorporated into the facility's QAPI program. Any identified noncompliance will result in immediate corrective action and re-education. The facility's implementation of the Plan of Removal was verified through the following: In an interview on 12/21/2025 at 3:20 PM with the hospital social worker, she reported Resident #1 had been a patient at the hospital admitted on [DATE] and was discharged to inpatient hospice. Record review of Admission, Discharge, and Transfer Report dated 11/20/2025 through 12/20/2025, reflected 8 residents were selected for residents admitted within the last 30 days to ensure medication orders were accurately reconciled with hospital discharge instructions and physician orders. In part of the review of the 8 residents, the following records were reviewed to ensure medication accuracy: Interim Medication Regimen Review, discharge orders/instructions, order summary report, MAR, and progress notes. Record review of terminated staff member's employee file reflected a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676408 If continuation sheet Page 4 of 10 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 12/21/2025 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 0755 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Termination of Employment letter dated 12/10/2025. Record review of in-service logs, dated 12/20/25 and 12/21/2025, reflected that facility staff members had been in-serviced on areas including abuse/neglect and new admission process. During interviews with multiple staff members who represented all assigned shifts (MDS Nurse, Staffing Coordinator, CNA A, CNA B, CNA C, CNA D, CNA E, CNA F, CNA G, CNA H, RN I, RN J, LVN K, and LVN L) on 12/21/25 between 2:10PM and 4:15PM, they each reported being in-serviced on topics including abuse/neglect, new admission processes, medication regimen reviews, and discharge orders/instructions. These staff members were able to verbalize the facility's policies and procedures related to the aforementioned areas. Staff members appeared knowledgeable on the facility's policies and procedures. These interviews were conducted without incident or concern regarding the trainings provided. The Administrator was notified the IJ was removed on 12/21/25 at 5:40PM, however the facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm and a scope of pattern due to the facility still monitoring the effectiveness of their Plan of Removal. Event ID: Facility ID: 676408 If continuation sheet Page 5 of 10 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 12/21/2025 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 0760 Ensure that residents are free from significant medication errors. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents were free from significant medication errors for one (Resident #1) of five residents reviewed for medication accuracy. The facility failed to ensure they had processes in place to ensure accurate verification and reconciliation of physician's orders and medications upon admission. The admitting nurse for Resident #1 entered medications into Resident #1's medical record without verifying them against an accurate and current medication list, and the facility's physician subsequently signed the medication orders as entered. This resulted in Resident #1 being administered multiple doses of medications that were not prescribed to him. Resident #1 was found unresponsive and was subsequently sent to the hospital. On 12/20/25 at 6:10 p.m. an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 12/21/25, the facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm and a scope of pattern due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. This failure could place residents at risk of health decline, allergic reactions, hospitalization, and death.Findings included: Record review of Resident #1's MDS Assessment, dated 12/20/25, reflected he was an [AGE] year-old male, admitted [DATE] with a BIMS score of 9, which indicated moderate cognitive impairment characterized by impaired short-term memory and inconsistent orientation, requiring cueing or assistance to understand, retain, and follow instructions. The resident's diagnoses included Parkinson's disease (a brain disorder that causes tremors, stiffness, and slow movement), dysphagia (difficulty speaking or understanding language, usually due to brain injury or stroke), vascular dementia (brain damage from reduced blood flow that affects memory, judgment, and understanding), hypothyroidism (underactive thyroid gland that did not make enough hormone), bradycardia (the heart is beating slower than normal, can cause fatigue, dizziness, confusion, or fainting, the brain and body may not get enough blood and oxygen), hyperlipidemia (too much fat like cholesterol or triglycerides in the blood, which can raise the risk of heart disease and stroke), presence of cardiac pacemaker (a small device implanted in the chest to help the heart beat at a regular pace), anemia (the body has too few red blood cells or not enough hemoglobin), cognitive communication deficit (trouble understanding, processing, or expressing information) and encounter for surgical aftercare following surgery. Record Review of Residents #1 Medication Administration Review (MAR), dated 12/01/2025 through 12/06/2025, reflected the resident was administered the following incorrect medications: Metformin HCI oral tablet, 500 mg, 2 tablets administered by mouth 2 times a day for diabetes. The medication was administered to Resident #1 at 6:00 p.m. on 12/01/2025, 8:00 a.m. and 6:00 p.m. on 12/02/2025, 8:00 a.m. and 6:00 p.m. on 12/03/2025, 8:00 a.m. and 6:00 p.m. on 12/04/2025, 8:00 a.m. and 6:00 p.m. on 12/05/2025, and at 8:00 a.m. on 12/06/2025. Insulin Glargine subcutaneous solution 100 UNIT/mL (Insulin Glargine) inject 15 units subcutaneously in the evening for diabetes. The medication was administered to Resident #1 at 8:00 p.m. on 12/03/2025 and at 8:00 p.m. on 12/04/2025. Farxiga Oral Tablet 10 MG, (Dapagliflozin Propanediol) give 1 tablet by mouth one time a day for diabetes. The medication was administered to Resident #1 at 8:00 a.m on 12/02/2025, 8:00 a.m. on 12/03/2025, 8:00 a.m. on 12/04/2025, 8:00 a.m. on 12/05/2025, and 8:00 a.m. on 12/06/2025. Lasix Oral Tablet 40 MG (Furosemide) give 1 tablet by mouth two times a day for fluid overload. The medication was administered to Resident #1 at 6:00 p.m. on 12/01/2025, 8:00 a.m. and 6:00 p.m. on 12/02/2025, 8:00 a and 6:00 p.m. on 12/03/2025, 8:00 a.m. and 6:00 p.m. on 12/4/2025, 8:00 a.m. and 6:00 p.m. on 12/5/2025, and 8:00 a.m. on 12/06/2025. Insulin Lispro Injection Solution 100 UNIT/mL (Insulin Lispro) inject as per sliding scale:If 0-150 = 0; 151-200 = 2; 201-250 = 4; 251-300 = 6; 301-350 = 8; 351-400 = 10; 401 + = Residents Affected - Some (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676408 If continuation sheet Page 6 of 10 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 12/21/2025 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 0760 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some 12 units and notify the doctor, subcutaneously before meals for diabetes. Resident #1 was administered 8 units at 11:00 a.m. on 12/02/25 with a blood sugar reading of 312. Record review of Resident #1's Physician's Orders, dated 12/20/25, reflected the resident was currently prescribed Topiramate. The Black Box Warning (the most serious warning issued by the U.S. Food and Drug Administration (FDA) to alert patients and healthcare providers about the potential for serious or life-threatening side effects associated with certain medications) for the incorrectly administered Metformin HCI (hydrochloride) specifically identified the use of Topiramate (a carbonic anhydrase inhibitor) as a clinical risk factor. According to the manufacturer's warning, the use of these two medications at the same time was associated with an increased risk for the development of lactic acidosis (a medical condition characterized by the accumulation of lactic acid in the bloodstream, leading to a decrease in blood pH and potential health complications). Further review of the Order Summary reflected a Black Box warning for the incorrectly administered Lasix Oral Tablet. The warning stated if given in excessive amounts, could lead to a profound diuresis (process of formation and excretion of urine from the body through the kidneys) with water and electrolyte depletion. Therefore, careful medical supervision was required, and dose schedule must be adjusted to the individual patient's needs. Record Review of Resident #1's Care Plan, dated 12/01/25, reflected the resident was receiving insulin. The Care Plan did not specify the diagnosis associated with insulin use. The Care Plan interventions included monitoring blood glucose, monitoring for hypoglycemia, and notifying the physician as needed. Record Review of Resident #1's Patient Discharge Instructions from the resident's previous rehabilitation facility reflected four pages of another resident's medication action plan mixed in with Resident #1's records. The four pages of the medication action plan each identify the incorrect resident by first, middle initial, last name, MRN number, and date of birth . Record Review of Resident #1's Change in Condition Evaluation, dated 12/06/2025 at 10:02 p.m., reflected the resident had abnormal vital signs and listed the other change as Unresponsive. The resident's most recent blood pressure reading was 92/48, pulse of 78, respiration 18, body temperature of 97.7, oxygen saturation at 94.0, and blood glucose of 134.0 mg/dL. The evaluation further reflected Resident #1's neurological status changed. It reflected Resident #1 had an altered level of consciousness and the level of change stated sudden change in the level of consciousness or responsiveness. Record review of Resident #'1 Nursing Note, dated 12/10/2025 reflected, Received phone call from MD [name] stating that he'd received a call from son stating, that he was receiving medication to treat diabetes and patient is not a diabetic. Writer looked into patient records and noted that mixed in with patient records were orders for another patient that was sent with Resident #1 clinicals from [name of rehabilitation facility]. MD [name] was made aware and stated he will follow up with the son. Record review of Resident #1's Nursing Facility to Hospital Transfer Form, dated 12/06/2025 at 9:30 p.m., reflected the resident was transported to the hospital due to unresponsive. Record review of Resident #1's hospital records, dated 12/06/25, reflected the following: .Acute Kidney failure creatinine 0.8 on 11/18/25 - had been getting Lasix, farxiga at nursing home - Creatinine 2.52 to 2.62 after contrast. During an interview on 12/20/2025 at 11:20 a.m., the Administrator and DON stated Resident #1 was administered five incorrect medications that were not prescribed to him. The DON reported that based on their internal investigation, it was determined Resident #1 was admitted to the facility from a short-term care facility and the records provided by the short-term care facility had another resident's MAR mixed in with Resident #1's records. The DON stated the records also contained Resident #1's MAR, so it appeared to be a long list of medications that were all prescribed for Resident #1. The DON reported Resident #1 was transferred to the emergency room on [DATE] because he was unresponsive. During an (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676408 If continuation sheet Page 7 of 10 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 12/21/2025 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 0760 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some interview on 12/20/2025 at 10:09 a.m., Resident #1's family member reported on 12/06/25 at approximately 8:42 p.m. they were notified by the facility that the resident was unresponsive and they wanted to transfer him to the hospital. Resident #1's family member reported the family requested the facility wait until they arrived to transfer the resident. Resident #1's family member stated a nurse informed the family she was scheduled to administer insulin but that the resident was not eating. Resident #1's family member questioned why insulin was ordered, as the resident was not diabetic and the nurse provided a copy of the MAR, which noted orders for insulin, metformin, farxiga, and furosemide, medications the family member stated Resident #1 was not prescribed prior to admission. Resident #1's family member reported Resident #1 was transferred to the hospital, admitted to the ICU, and treated for acute renal failure, aspiration pneumonia, and sepsis. Resident #1's family member stated the resident required oxygen and IV fluids and later developed significant weakness and inability to swallow, resulting in a decision to transition Resident #1 to hospice care. Resident #1's family member reported the family received copies of the resident's medication lists, MAR, and prior rehabilitation records and stated the medications at the previous rehabilitation facility and hospital were correct. Resident #1's family member reported the facility later informed him another resident's medical records were mixed into Resident #1's paperwork. During an interview on 12/20/2025 at 12:02 p.m., the facility MD reported he was notified on 12/06/2025 that Resident #1 was unresponsive and had been transferred to the hospital, where he was later informed the resident was diagnosed with severe sepsis. He stated he did not have access to the resident's hospital records and could not determine whether the medications contributed to the resident's decline without reviewing additional clinical data. The MD reported the medication orders were transcribed from faxed transfer records and entered into the system by the admitting nurse, verified by the DON, and then routed to him for signature. He stated he relied on nursing staff to accurately enter and reconcile medication orders and acknowledged that he trusted the information presented to him when signing off. He reported that during this process the residents' diagnoses were not reviewed or verified with the nurse prior to signing the orders and stated this step was missed due to multiple moving parts in the admission process. The physician reported that during his follow-up review he learned a document from another resident was mixed into Resident #1's transfer paperwork, which resulted in incorrect medications being ordered. He stated the medications were entered as new orders and reported insulin was administered once due to elevated blood glucose levels. He stated medication reconciliation was completed per facility workflow by nursing staff and verified by the DON prior to his review. Record review of the facility's Abuse, Neglect, and Exploitation Policy, dated 07/2025, reflected, .failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. This was determined to be an Immediate Jeopardy (IJ) on 12/20/25 at 5:45 p.m. The Administrator was notified. The Administrator was provided with the IJ template on 12/20/25 at 6:21 p.m.; an updated version of the IJ template was provided on 01/08/26 at 10:40 a.m.The following Plan of Removal submitted by the facility was accepted on 12/21/25 at 12:21 p.m: .Interventions:The resident was transferred to the hospital and no longer resides in the facility. The Director of Nursing (DON) or designee conducted an immediate facility-wide review of all residents admitted or readmitted within the past 30 days to ensure medication orders were accurately reconciled with hospital discharge instructions and physician orders. Also, to include any transfers from other facilities. Nursing supervisors verified MAR accuracy, medication availability, and physician clarification as needed. Any discrepancies identified were corrected immediately. The Administrator reviewed the audit findings and confirmed that no additional residents were (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676408 If continuation sheet Page 8 of 10 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 12/21/2025 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 0760 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some at risk. The Director of Nursing (DON) or designee will implement the following systemic changes and education on 12-21-25. The staff member who input the orders was terminated by the DON on 12-10-25. All staff will be in-serviced by the DON/designee on abuse, neglect, and misappropriation. Staff members who are not present will be in serviced prior to working their next shift and before providing resident care. Completion will be verified and documented. Revised the admission and readmission medication reconciliation process to require dual verification confirming that admit orders/discharge Summary matches the orders entered in the EMR by the admitting nurse and another licensed nurse. The DON/designee established a requirement for immediate physician notification, clarification, and documentation when discrepancies are identified. Updated the admission checklist to include MD verification, dual nurse verification, and DON/designee verification to be completed for every admission and readmission. The DON/Designee will verify that the admission checklist is completed for all admissions. Required DON or designee review of all new admissions and readmissions by next business day The Director of Nursing (DON) or designee will provide re-education to all licensed nursing staff on proper medication reconciliation, verification of physician orders prior to medication administration, escalation procedures, and documentation requirements. Education will be provided by the DON/designee through in-service training, with staff competency validated through verbal review. Staff members who are not present will be in serviced prior to working their next shift and before providing resident care. Completion will be verified and documented. Nursing management will notify the Regional Nurse of any significant medication error requiring physician intervention or hospitalization. The Regional nurse notified the administrator to in-service nurse management regarding notification of the regional nurse of any significant medication error requiring physician intervention or hospitalization. The Director of Nursing (DON) or designee will conduct weekly audits of all new admissions and readmissions for four weeks, then monthly thereafter, to ensure continued compliance with medication reconciliation requirements. Audit results will be reviewed by the Administrator and incorporated into the facility's QAPI program. Any identified noncompliance will result in immediate corrective action and re-education. The facility's implementation of the Plan of Removal was verified through the following: In an interview on 12/21/2025 at 3:20 PM with the hospital social worker, she reported Resident #1 had been a patient at the hospital admitted on [DATE] and was discharged to inpatient hospice. Record review of Admission, Discharge, and Transfer Report dated 11/20/2025 through 12/20/2025, reflected 8 residents were selected for residents admitted within the last 30 days to ensure medication orders were accurately reconciled with hospital discharge instructions and physician orders. In part of the review of the 8 residents, the following records were reviewed to ensure medication accuracy: Interim Medication Regimen Review, discharge orders/instructions, order summary report, MAR, and progress notes. Record review of terminated staff member's employee file reflected a Termination of Employment letter dated 12/10/2025. Record review of in-service logs, dated 12/20/25 and 12/21/2025, reflected that facility staff members had been in-serviced on areas including abuse/neglect and new admission process. During interviews with multiple staff members who represented all assigned shifts (MDS Nurse, Staffing Coordinator, CNA A, CNA B, CNA C, CNA D, CNA E, CNA F, CNA G, CNA H, RN I, RN J, LVN K, and LVN L) on 12/21/25 between 2:10PM and 4:15PM, they each reported being in-serviced on topics including abuse/neglect, new admission processes, medication regimen reviews, and discharge orders/instructions. These staff members were able to verbalize the facility's policies and procedures related to the aforementioned areas. Staff members appeared knowledgeable on the facility's policies and procedures. These interviews were conducted without incident or concern regarding the trainings provided. The Administrator was notified the IJ was removed on 12/21/25 at 5:40PM, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676408 If continuation sheet Page 9 of 10 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 12/21/2025 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 0760 Level of Harm - Immediate jeopardy to resident health or safety however the facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm and a scope of pattern due to the facility still monitoring the effectiveness of their Plan of Removal. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676408 If continuation sheet Page 10 of 10