Health inspection·December 9, 2025

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few review of Resident #1's Weekly Non-Ulcer Wound Assessment, dated 09/30/2025, reflected Resident #1 had a wound on right shin (lower leg). The type of wound was skin tear. The measurement of the skin tear was length- 2.5 cm, width 1.0 cm, depth 0.1 cm. The skin tear exudate (a fluid, rich in cells and proteins, that leaks from blood vessels into nearby tissues due to inflammation) amount was moderate, color was yellow, and exudate character was clear. There was no odor. Record review of Resident #1's Weekly Non-Ulcer Wound Assessment, dated 10/09/2025, reflected Resident #1 had a wound on right shin (lower leg). The type of wound was skin tear. The measurement of the skin tear was length- 3.0 cm, width 1.0 cm, depth 0.1 cm. The skin tear exudate amount was moderate, exudate color was yellow, and exudate character was clear. Resident #1's skin tear did not have any odor. Record review of Resident #1's treatment record reflected Resident #1 received treatment to his right leg on 10/02/2025, 10/03/2025, 10/06/2025,10/08/2025 and 10/10/2025. Interview on 10/28/2025 at 8:35 AM Treatment Nurse LVN A stated the treatment records was not correct. She stated LVN B documented she completed treatment to Resident #1's right shin on the following dates: 10/06/2025, 10/08/2025, and 10/10/2025 on the treatment administration record by mistake and LVN B did not provide any type of treatment on these dates to Resident #1 right shin. Treatment Nurse LVN A stated Resident #1 did not receive treatment to his right shin from 10/02/2025 until 10/10/2025. She stated she entered the order for Resident #1 on 09/30/2025 and it was the wrong order. Treatment Nurse LVN A stated she made a mistake and entered for Resident #1 to receive treatment to his shin Monday, Wednesday and Friday at night. She stated the order was for him to receive treatment Monday, Wednesday, and Friday once a day, but not at night. She stated Resident #1's family called the facility on 10/09/2025 and reported Resident #1 had a bandage on his right shin with the date 10/02/2025. She stated she immediately reviewed Resident #1's medical record and realized she made a mistake when she entered the order in Resident #1's physician orders in the medical record. Treatment Nurse LVN A stated she immediately called the doctor and the family. She entered the correct order on 10/09/2025. She stated on 09/30/2025 Resident #1 measurement for skin tear to his right shin was 2.5 length, 1.0 width, and 0.1 depth. Treatment Nurse LVN A stated on 10/09/2025 his measurement for skin tear to his right shin was 3.0 length, 1.0 width, and 0.1 depth. She stated if a resident did not receive the appropriate treatment to any skin concerns there was a risk for an infection to the resident's skin. She stated there was also a potential the area of the skin tear, or wound may become larger. The treatment nurse LVN A stated she was responsible to ensure all treatments are completed to all residents with any type of skin concerns. She stated it was the DON and ADON responsibility to monitor treatments. She stated she had been in-serviced on treatments including documenting the correct orders and monitoring treatments. Interview on 10/28/2025 at 8:54 AM Resident #1's Primary Care Physician stated there was no adverse effect of Resident #1 not receiving treatment to skin tear from 10/02/2025 until 10/09/2025. He stated if the measurement increased length .25, he would not have any concerns about Resident #1's skin tear. The Physician stated there was no harm to Resident #1. Interview on 10/28/2025 at 11:45 AM, LVN B stated she accidentally clicked on the treatment form in the electronic medical records that she did treatment on Resident #1's right shin. She stated that was a mistake. She thought she was documenting something else, and she did not give Resident #1 treatment on 10/06/2025, 10/08/2025 or 10/10/2025. She stated she did receive one on one in-service on documentation and completing treatments to skin concerns on residents. LVN B stated she did not recall the exact date; however, she stated it was either 10/11/2025 or 10/12/2025. She stated she worked the night shift, and the night shift nurses did not do routine treatments on skin concerns unless it was a new skin concern. Interview on 10/28/2025 at 2:15 PM ADON stated if a resident did not receive treatment to skin concerns there was a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 745051 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 745051 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/09/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Five Points Nursing & Rehabilitation of College St 3105 Corsair Drive College Station, TX 77845 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete possibility a resident may develop an infection or sepsis ( a life-threatening medical emergency where an infection triggers a dangerous and extreme inflammatory response from the body). She stated the Treatment Nurse was responsible for all treatment orders and to enter the orders into the electronic medical record in the physician orders. The ADON stated it was the DON's and her responsibility to monitor all treatments. She stated she had been in-serviced on monitoring treatments and documenting in the physician orders of the correct treatment including time of the treatment to be completed by nursing staff. She stated Resident #1 did not receive treatment to his right shin between 10/02/2025 and 10/09/2025. She stated LVN B did not treat Resident #1's right shin between the dates 10/02/2025 and 10/09/2025. ADON stated the Treatment Nurse A entered the wrong time for the treatment to be given and this was the reason the treatment for Resident #1 was missed. She stated all nurses were in-serviced on documentation and to double-check new orders entered into the electronic medical records. Record review of the facility's policy on Pressure Injury: Prevention, Assessment and Treatment, dated 05/05/2025, reflected Nursing Personnel will continually aim to maintain the skin integrity, tone, turgor and circulation to prevent breakdown, injury and infection. Upon assessment and identification of a pressure sore the staff nurse will notify the treatment nurse/designee. The treatment nurse/designee will notify the physician or pressure sore and obtain and follow any new orders as directed by the physician. Event ID: Facility ID: 745051 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 745051 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/09/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Five Points Nursing & Rehabilitation of College St 3105 Corsair Drive College Station, TX 77845 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 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. Based on observations, interviews, and record review, the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keysfor 1 of 3 medication carts (Medication Cart #1) reviewed for medication storage. The facility failed to prevent Medication Cart #1 was locked and medications were secure and not accessible to other staff, residents, or visitors. This failure could place residents at risk of having unauthorized access to prescriptions, biologicals, and over-the counter medications. Findings included: Observation on 10/28/2025 at 2:37 AM revealed an unlocked medication cart #1 in front of one of one nurses' station. RN C was sitting behind the nurse's station. Interview on 10/28/2025 at 2:40 AM RN C stated she did not realize the medication cart was unlocked. She stated all medication carts were to be locked except when a nurse was obtaining medications from the cart. RN C stated if a resident did ingest medications the resident was allergic to there was a possibility the resident may have a reaction and possibly die. She stated a resident also had a potential of overdosing on medications or give the medications to another resident. RN C stated she had been in-serviced on locking medication carts; however, she did not recall the date of this in-service. Observation on 10/28/2025 at 3:58 AM revealed an unlocked medication cart #1 in front one of one nurses' station. There was not a nurse around the medication cart or around the nurse's station. RN C walked from 300 hall toward the nurses' station approximately 10 minutes after the medication cart was found unlocked by the surveyor. Interview on 10/28/2025 at 4:15AM RN C stated she walked away from the cart to assist a resident down the hall. She stated she thought she locked the medication cart. RN C stated this is second time today I forgot to lock the medication cart. She stated she did not have an explanation of why she did not lock the medication cart. She stated a resident, staff or visitor had access to the medications and anyone could have taken the medications, and no one would have known a resident, staff or visitor had taken the medication. She stated if a resident was allergic to the medication they may need to be hospitalized and possibly could die from an overdose. She stated she did not recall the date she was in-service on locking medication cart. RN C stated the ADON informed her earlier she would be in-serviced today (10/28/2025) on locking medication cart. Interview on 10/28/2025 at 4:35 AM the ADON stated her expectation was for all medication carts to be locked when the nurse was not administering medications. She stated the staff had been in-serviced on securing the medication carts when not in use. ADON stated she was starting an in-service today and she did not recall the last time the facility had in-service on locking medication carts with the nurses and medication aides. She stated it was the nurse's responsibility to ensure the medication cart was locked when not dispensing a resident's medication. Record review of the Facilities Policy on Medication Storage in the Facility, not dated, reflected Medications and biologicals are stored safely, securely and properly following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to license nursing personnel, or staff members lawfully authorized to administer medications. Event ID: Facility ID: 745051 If continuation sheet Page 4 of 4