Inspection·December 22, 2025

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few stand up to get in the chair on her own so she stood up and her [left] knee gave out so she lowered her to the floor before the other CNA could answer the emergency light. I notified the nurse taking care of the resident of the fall. [Resident #2] was assessed and placed back into wheelchair. No apparent injuries were noted at that time.Record review of a statement dated 12/08/25 by CNA E reflected, on Dec. 8th [ 2025] I assisted the resident onto the toilet with another CNA and waited for the emergency light to come on. The other CNA went to go help another resident in the meantime and when the bathroom light came on, I went inside and the resident was ready to get in the wheelchair, so she stood up before the other CNA came back and then her leg gave out and I was forced to lower the resident to the floor. I them immediately went to get help did notify hall 4 nurse. Record review of an interview taken by the Administrator from Resident #2 reflected, On 12/16, I spoke with the resident [Resident #2], about the incident that occurred on 12/8 [2025], the resident raised her two fingers and stated there should have been two people. Record review of an interview taken by the Administrator from Resident #2's RP reflected, On 12/16 [2025], I spoke with the [RP] who mentioned that [Resident #2] was assisted out from the toilet by one staff member instead of two. I stated that I was informed that she was attempting to get out of the commode and her knee gave out, so the CNA assisted her to the floor. [RP] mentioned that [Resident #2] would not attempt to get up without assistance. The [RP] stated that the nurse mentioned exactly what I stated, but there is no way [Resident #2] will attempt to get up without assistance. I told the family that I will investigate. Review of Resident #2's progress note dated 12/15/25 by the DON reflected Resident #2 had a witnessed fall resulting in a fracture to her left femur. After assessment by the nurse and NP in the facility, no immediate injuries were observed. The NP recommended no x-ray at that time. The resident was offered as needed pain medication and accepted at the time of the incident. The facility MD was making rounds the next day and ordered an x-ray of the left hip with results that showed a fracture of the left femur. Resident #2's care escalated to the emergency room per the RP request. Resident #2's statement, I fell in the bathroom. Review of Resident #2's hospital records dated 12/10/25 revealed chief complaint: fall/left femur fracture, mechanism fall, [AGE] year-old female presented to emergency room with a complaint of left hip pain, ground-level fall when the resident was being moved into the bathroom at the nursing facility when she lost her balance and fell. Review of Resident #2's hospital records dated 12/12/25 revealed Resident #2 was postop day 1 from trochanteric femoral nail on the left (an orthopedic implant used to fix hip fractures, particularly those extending down the femur (thigh bone), by stabilizing the broken bone from within, using a metal rod (nail) inserted down the marrow canal and secured with screws). Review of video received from Resident #2's RP reflected Resident #2 transferred on 11/04/25 by CNA M by mechanical lift from her wheelchair to her bed by 1 staff member. Review of video received from Resident #2's RP reflected Resident #2 transferred on 11/05/25 by mechanical lift from her wheelchair to her bed by 1 staff member (name of staff member unknown). Review of video received from Resident #2's RP reflected Resident #2 transferred on 11/07/25 by CNA M by mechanical lift from her wheelchair to her bed by one staff member. Review of video received from Resident #2's RP reflected Resident #2 transferred on 11/07/25 by CNA N by mechanical lift from her wheelchair to her bed by one staff member. Review of video received from Resident #2's RP reflected Resident #2 transferred on 12/07/25 by CNA M alone, no mechanical lift, from her wheelchair to her bed by one staff member. Review of video received from Resident 2's RP reflected Resident #2 transferred on 12/09/25 by mechanical lift from her wheelchair to her bed by one staff member (name of staff member unknown). Review of video received from Resident #1's RP reflected Resident #2 transferred on 12/16/25 by mechanical lift from her wheelchair to her bed by one staff member (name of staff (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 745051 If continuation sheet Page 2 of 12 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 12/22/2025 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few member unknown). Interview on 12/21/25 at 7:42 am with the ADON revealed CNA D came to get the ADON when Resident #2 was on the floor in the bathroom. When the ADON arrived at Resident #2's restroom, CNA E was with Resident #2. The ADON assessed Resident #2 who complained of pain. The ADON said that CNA E was in the restroom with Resident #2 alone when Resident #2 fell. The ADON said Resident #2 was care planned for 2 people to be in the restroom with her. The ADON said that CNA D and CNA E were both present and assisted Resident #2 to the toilet. The ADON said CNA D left Resident #2's room after Resident #2 got on the toilet. The ADON said Resident #2's knees buckled and Resident #2, on the way down to the floor, bumped her knee on the toilet paper dispenser. The ADON said the videos that reflected CNAs operating a mechanical lift to transfer a resident were because of staffing issues. The ADON said they had staffing issues, especially in the evenings, for several months. She said the facility needed a minimum of 7 CNAs in the building and half the time only 4 - 5 CNAs showed up. The ADON said residents fell all the time. She said the lack of staff had gone on for months and a lack of staff had made 1 person transfers a reality. The ADON said the possible negative effect of not having 2 people when transferring a resident who was a 2 person assist and 2 people when transferring a resident by mechanical lift was possible injury to the resident. Interview on 12/21/25 8:47 am with LVN L revealed that she was the facility scheduler. She said they had trouble scheduling nurses and MAs but they did pretty good with CNAs except that CNAs called in a lot. She said she did not feel 2 nurses and 5 CNAs were a sufficient number to staff a shift and address the residents' needs. She said the reason why residents were being transferred by 1 person instead of 2 people was because of lack of staffing. She said the possible negative effect of having 1 person doing a 2 person transfer was the resident could get hurt. She said it was the responsibility of all staff to make sure the residents were being transferred appropriately. Interview via phone on 12/21/25 9:13 am with CNA M revealed that when they were transferring a resident using a mechanical lift, there should always be two staff members transferring the resident. He said residents could get hurt if they only use 1 person when transferring a person with a mechanical lift. He said he sometimes transferred residents by himself using a mechanical lift because of staffing issues. He said they could wait for a second person to come and help with a mechanical lift transfer, but residents had specific requests, and they ere not able to meet them if you had to wait for a 2nd staff member. He said it was the responsibility of everyone to make sure that residents were transferred safely but specifically it was the responsibility of the staff who worked directly with the residents. Interview via phone on 12/21/25 at 9:24 am with the facility MD revealed Resident #2 was wheelchair bound and non-ambulatory. Resident #2 had osteopenia (bones that are weaker than average and residents have an increased risk of developing osteoporosis (a bone disease causing bones to become weak, porous, and brittle, making them prone to fractures) and fracturing bones, especially with age or minor injury). Resident #2's bones were significantly weaker and more prone to fractures and the trauma to her knee when she fell could have caused the fracture because the knee is located at the bottom of the femur. Interview via phone on 12/21/25 at 9:35 am with CNA N revealed that if they ere transferring a resident by mechanical lift or if the resident required 2 people for a transfer, they needed to have 2 people in case anything happened to the resident. CNA N said he had transferred residents who were 2 person transfers by himself multiple times because of the shortage of staff. He said one night (date unknown) he was the only staff member in his hallway. He said there was definitely a shortage of staff at the facility. Interview via telephone on 12/21/25 at 11:02 am with RN C reflected that generally 1 person could transfer a resident operating a mechanical lift, it depended on the resident. RN C said the policy might state that 2 people were needed to operate a mechanical lift but policy was one thing, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 745051 If continuation sheet Page 3 of 12 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 12/22/2025 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few reality was another thing. She said it was too much for Resident #2's family to expect 2 people to take Resident #2 to the restroom, but that was what the family wanted. She said it was her directive for her staff to follow policy. RN C said she had no control over staffing. Interview via telephone on 12/2125 at 11:19 am with CNA E revealed she and CNA D transferred Resident #2 to the toilet and CNA D left Resident #2 in the care of CNA E. CNA D said she was not in the bathroom at the time Resident #2 fell. CNA D said she had access to the Kardex (an electronic a quick-reference patient care system that included the resident's transfer status) and Resident #2 was a 2 person transfer both on and off the toilet. CNA D said she told CNA E to call her if she needed assistance transferring Resident #2 off the toilet. CNA D said they had multiple call lights on and after Resident #2 was transferred to the toilet, CNA D left to respond to other resident call lights. CNA D said CNA E found her and told her Resident #2 had fallen. CNA D said she had transferred residents who were 2 person assist by herself multiple times because of staffing issues. She thought 100% the incident with Resident #2 could had have been prevented if the facility had more staff. Interview via telephone on 12/21/25 at 1:05 pm with CNA E revealed she did not know that Resident #2 was a 2 person transfer in the bathroom. She said she did not know how to look at the Kardex. CNA E said she helped Resident #2 in the bathroom the week before by herself and it was fine. She said she was in the bathroom with CNA D and together they transferred Resident #2 to the toilet. She said CNA D left, and CNA D said to call her when Resident #2 was ready to be transferred off the toilet. CNA E said she pulled the light for CNA D to come, but CNA D did not come. She said Resident #2 had been waiting a while and because CNA E transferred Resident #2 the week before with no problem she tried it again. CNA E said when Resident #2 was standing up Resident #2 was a little shaky and Resident #2 was too heavy for her. CNA E said she was behind Resident #2 and when Resident #2 was lowered to the floor, Resident #2's knee hit the bottom of the toilet paper dispenser. CNA E said that CNA D had transferred Resident #2 by herself. She said it would have been better if CNA D had been in the bathroom with her when she transferred Resident #2. CNA E said she and CNA D were the only CNAs who worked that hallway that day and CNA D left after they got Resident #2 on the toilet to answer other resident call lights. She said the facility was sometimes short staffed. She said every CNA and MA transferred residents who were a 2 person transfer with 1 person all the time except when a state surveyor was in the building. Interview on 12/21/25 at 1:18 pm with the DON revealed there was 1 CNA in the bathroom with Resident #2 when she fell. She said that was absolutely a problem because Resident #2 was care planned for a 2 person assist in the bathroom and it posed a risk to Resident #2 for only one person to be in the bathroom with her. She said that there was not a staffing issue every day, but a lot of times they had to send a nurse manager home for the day to come back and work the floor in the evening because they did not have enough staff. She said that staffing was not where it should have been and facility policy was to always follow the residents' care plans. Interview on 12/22/25 at 4:10 pm with the ADON revealed she told the Administrator about the lack of staff availability when mechanical lifts needed to be used for residents. The ADON said multiple staff members were doing 1 person mechanical lift transfers. Interview on 12/22/25 at 5:51 pm with the RNC revealed she did not think the facility had a lack of staff problem that caused Resident #2 to have 1 staff person in the bathroom when Resident #2 needed to transfer from the toilet to her wheelchair. The RNC said it was a lack of staff education about 2 person assist transfers. She said that if there was not someone available to help with a resident transfer that required 2 staff members, staff needed to wait until a 2nd staff member was available before the transfer was made. Interview on 12/22/5 at 6:50 pm with the DON revealed she believed a communication issue caused the problem with Resident #2 not being transferred by 2 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 745051 If continuation sheet Page 4 of 12 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 12/22/2025 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few people when she was in the bathroom. The DON said the CNAs should have communicated with each other better. She said CNAs should know how to read the resident Kardex. She said it was the responsibility of the ADON, DON, and Administrator to make sure residents were transferred property. She said the possible negative effect of not transferring a resident properly, using the correct number of staff, was the resident could be injured. She said, it would not be ideal, but if there was only one other person in the facility to assist with a 2 person transfer, staff should wait until there were 2 people available to perform the transfer. Interview on 12/22/25 at 7:02 pm with the Administrator revealed Resident #2 stood up in the bathroom and she was assisted to the floor by CNA E. The Administrator said at the time of the incident, there was just a skin tear to Resident #2's knee from where her knee hit the toilet paper dispenser. The Administrator said Resident #2 was care planned for a 2X assist, and there was one person in the bathroom and there should have been two people in the bathroom. Review of the facility policy, undated, Lifting Machine, Using a Mechanical -F689 - Lifting Machine, Using a Mechanical Purpose: The purpose of this procedure is to establish the general principles of safe lifting using a mechanical lifting device. It is not a substitute for manufacturer's training or instructions. General Guidelines:at least two (2) nursing assistants are needed to safely move a resident with a mechanical lift, or assistance required per manufacturer recommendationsReview of facility policy, undated, Moving A Resident, Bed To Chair/Chair To BedPurpose: The purposes of this procedure are to allow the resident to be out of his or her bed as much as possible and to provide for safe transferring of the resident. Steps in the Procedure: Note: This procedure may require two (2) persons The Administrator was notified on 12/21/2025 at 2:07 pm that an IJ had been identified. An IJ template was provided and a POR was requested. The following POR was approved on 12/22/2025 at 9:50 am and indicated: Date: 12/21/25Plan of Removal F689 Free of Accident Hazards/Supervision/DevicesResident #1 fell during a 1 person assist (CNA E) in the bathroom. Which resulted in Resident #1 landing on her knee and fracturing her femur. Resident #1 was seen on video being transferred with a mechanical lift with 1 person assist instead of 2 person assist. All residents requiring 2 person assist with transfers could have been affected by the deficient practice. Interventions:Action: All residents requiring 2 person assist during transfer were assessed by the ADONs and Charge Nurses for any injuries. No additional injuries from an improper transfer were assessed on any residents. Completion date 12/21/25. Inservice Action: The CNA was provided with 1:1 in-service for the following:Abuse and Neglect Policy: to include failure to provide the proper number of staff needed to perform a transfer could result in an injury to a resident and result in neglect. If a staff member is observed performing a mechanical lift transfer without a second staff member, the Administrator and DON should be notified immediately. Mechanical Lifts Transfer: includes 2 certified or licensed staff members who are mandatory to perform a mechanical lift transfer. The staff members will NOT perform the task under any circumstance until the proper number of staff is available. Electronic Medical Record for ADL Care Plan: the resident Kardex is how staff determine the appropriate number of staff needed to perform an ADL including transfers on a resident. If a staff member can't locate a second staff member, the DON or Administrator should be notified immediately to assist with locating and providing the appropriate number of staff to perform the task. The staff members will NOT perform the task under any circumstance until the proper number of staff is available.CNA Retention Checks: CNA was provided with written in-service cheat sheets to place in name badge for quick reference, signature and verbal acknowledgements were obtained. Return demonstration was received from CNA with all transfers with rehab director.Provided by: Director of NursingStart Date: 12/21/2025Completion Date: 12/21/2025 The administrator, DON, and ADONs were 1:1 in-serviced by the Regional Compliance Nurse (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 745051 If continuation sheet Page 5 of 12 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 12/22/2025 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few and ADO on the following topics below. Competency was determined by correctly answering a post test. Completed 12/21/25.Abuse and Neglect Policy: to include failure to provide the proper number of staff needed to perform a transfer could result in an injury to a resident and result in neglect. If a staff member is observed performing a mechanical lift transfer without a second staff member, the Administrator and DON should be notified immediately. Mechanical Lift Transfers: includes 2 certified or licensed staff members are mandatory to perform a mechanical lift transfer. The staff members will NOT perform the task under any circumstance until the proper number of staff is available. Electronic Medical Record for ADL Care Plan: the resident Kardex is how staff determine the appropriate number of staff needed to perform an ADL including transfers on a resident. If a staff member can't locate a second staff member, the DON or Administrator should be notified immediately to assist with locating and providing the appropriate number of staff to perform the task. The staff members will NOT perform the task under any circumstance until the proper number of staff is available. New Process: The administrator and DON will assess and determine staffing levels daily in accordance with the census and facility assessment. If needed, the facility will offer full-time and PRN staff extra shift bonuses to meet any staffing needs. Sign on bonuses will be provided if needed to attract new employees. Company sister facilities will be contacted for assistance with staffing needs if needed. The Administrator/DON will be responsible for building out the schedule at a minimum of 1 week in advance. Open shifts will then be able to be reviewed timely to determine the need for extra shift bonuses or assistance from sister facilities. Training on this new process was provided by the Area Director of Operation. Completion date: 12/21/25.Employee Retention Checks: Administrator and DON were provided with written in-service cheat sheets to place in name badge for quick reference, signature and verbal acknowledgements were obtained.Start Date: 12/21/2025Completion Date: 12/21/2025The Regional Compliance Nurse, Administrator, DON, and ADON will in-service all certified and licensed staff on the following topics below. All staff not present for the in-services will not be allowed to work their next shift until the in-services are complete. All new hires will be in-serviced during orientation prior to working their shift. Staff will sign the in-service sheet to verify that they acknowledge and understand the facility directive. All agency staff will be in-serviced prior to assuming scheduled shift. A posttest will be provided by the Regional Compliance Nurse, DON, and ADON to confirm understanding. Completed 12/21/25.Abuse and Neglect Policy: to include failure to provide the proper number of staff needed to perform a transfer could result in an injury to a resident and result in neglect. If a staff member is observed performing a mechanical lift transfer without a second staff member, the Administrator and DON should be notified immediately. Mechanical Lift Transfers: includes 2 certified or licensed staff members are mandatory to perform a mechanical lift transfer. If a staff member can't locate a second staff member, the DON or Administrator should be notified immediately to assist with locating and providing the appropriate number of staff to perform the task. The staff members will NOT perform the task under any circumstance until the proper number of staff are available. Return demonstration by each staff member will be required for the mechanical transfer check-off. Electronic Medical Record for ADL Care Plan: the resident Kardex is how staff determine the appropriate number of staff needed to perform an ADL, including transfers on a resident. If a staff member can't locate a second staff member, the DON or Administrator should be notified immediately to assist with locating and providing the appropriate number of staff to perform the task. The staff member will NOT perform the task under any circumstance until the proper number of staff is available. Employee Retention Checks: All staff were provided with written in-service cheat sheets to place in name badge for quick reference, signature and verbal acknowledgements were obtained. Post (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 745051 If continuation sheet Page 6 of 12 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 12/22/2025 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few test were conducted and returned to Administrator and DON. Start Date: 12/21/2025Completion Date: 12/21/2025 Involvement of the Medical Director: The Medical Director was notified of the immediate jeopardy citation on 12/21/25 by the Administrator. Completed 12/21/25. ADHOC QAPI: This meeting was conducted on 12/21/25 to include the IDT Team and the Medical Director to review the immediate jeopardy citation and plan of removal. Completed 12/21/25.Please accept this letter as our plan of removal for the determination of immediate jeopardy issued on 12/21/2025. Monitoring: Record review on 12/22/25 of documentation by the ADON and charge nurses that all residents requiring 2 person assist during transfer were assessed for any injuries and no additional injuries from an improper transfer were determined. Record review on 12/22/25 of in-services and interviews on 12/22/25 at 4:24 pm with CNA E reflected she received 1:1 in-service for: Abuse and Neglect Policy: to include failure to provide the proper number of staff needed to perform a transfer could result in an injury to a resident and result in neglect. If a staff member is observed performing a mechanical lift transfer without a second staff member, the Administrator and DON should be notified immediately. Mechanical Lifts Transfer: includes 2 certified or licensed staff members who are mandatory to perform a mechanical lift transfer. The staff members will NOT perform the task under any circumstance until the proper number of staff is available. Electronic Medical Record for ADL Care Plan: the resident Kardex is how staff determine the appropriate number of staff needed to perform an ADL including transfers on a resident. If a staff member can't locate a second staff member, the DON or Administrator should be notified immediately to assist with locating and providing the appropriate number of staff to perform the task. The staff members will NOT perform the task under any circumstance until the proper number of staff is available.Review on 12/22/25 of the written in-service cheat sheet CNA E was to place in her name badge for quick reference. Interview on 12/22/25 at 4:24 pm with CNA E confirmed she received training from the therapy department on transfers for both mechanical lift and gait belt and demonstration she was competent in safe resident transfers. Interview with the Regional Compliance Nurse on 12/22/25 at 4:30 pm and review of an in-service reflected she in-serviced the Administrator, DON, and ADONs on Abuse and Neglect Policy: to include failure to provide the proper number of staff needed to perform a transfer could result in an injury to a resident and result in neglect. If a staff member is observed performing a mechanical lift transfer without a second staff member, the Administrator and DON should be notified immediately. Mechanical Lift Transfers: includes 2 certified or licensed staff members are mandatory to perform a mechanical lift transfer. If a staff member can't locate a second staff member, the DON or Administrator should be notified immediately to assist with locating and providing the appropriate number of staff to perform the task. The staff members will NOT perform the task under any circumstance until the proper number of staff are available. Return demonstration by each staff member will be required for the mechanical transfer check-off. Electronic Medical Record for ADL Care Plan: the resident Kardex is how staff determine the appropriate number of staff needed to perform an ADL, including transfers on a resident. If a staff member can't locate a second staff member, the DON or Administrator should be notified immediately to assist with locating and providing the appropriate number of staff to perform the task. The staff member will NOT perform the task under any circumstance until the proper number of staff is available.Interview with the ADO 12/22/25 at 5:35 pm and review of an in-service reflected she in-serviced the Administrator, DON, and ADONs on Abuse and Neglect Policy: to include failure to provide the proper number of staff needed to perform a transfer could result in an injury to a resident and result in neglect. If a staff member is observed performing a mechanical lift transfer without a second staff member, the Administrator and DON should be notified immediately. Mechanical Lift Transfers: includes 2 certified or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 745051 If continuation sheet Page 7 of 12 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 12/22/2025 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete licensed staff members are mandatory to perform a mechanical lift transfer. If a staff member can't locate a second staff member, the DON or Administrator should be notified immediately to assist with locating and providing the appropriate number of staff to perform the task. The staff members will NOT perform the task under any circumstance until the proper number of staff are available. Return demonstration by each staff member will be required for the mechanical transfer check-off. Electronic Medical Record for ADL Care Plan: the resident Kardex is how staff determine the appropriate number of staff needed to perform an ADL, including transfers on a resident. If a staff member can't locate a second staff member, the DON or Administrator should be notified immediately to assist with locating and providing the appropriate number of staff to perform the task. The staff member will NOT perform the task under any circumstance until the proper number of staff is available. Interview with the Administrator on 12/22/25 at 7:13 pm, the DON 6:56 pm, the ADON 3:39 pm and ADON F at 4:11 pm who confirmed they received a 1:1 in-serviced by the Regional Compliance Nurse and ADO on the following topics below. Competency was determined by correctly answering a post test. a. Abuse and Neglect Policy: to include failure to provide the proper number of staff needed to perform a transfer could result in an injury to a resident and result in neglect. If a staff member is observed performing a mechanical lift transfer without a second staff member, the Administrator and DON should be notified immediately. b. Mechanical Lift Transfers: includes 2 certified or licensed staff members are mandatory to perform a mechanical lift transfer. If a staff member can't locate a second staff member, the DON or Administrator should be notified immediately to assist with locating and providing the appropriate number of staff to perform the task. The staff members will NOT perform the task under any circumstance until the proper number of staff are available. Return demonstration by each staff member will be required for the mechanical transfer check-off. c. Electronic Medical Record for ADL Care Plan: the resident Kardex is how staff determine the appropriate number of staff needed to perform an ADL, including transfers on a resident. If a staff member can't locate a second staff member, the DON or Administrator should be notified immediately to assist with locating and providing the appropriate number of staff to perform the task. The staff member will NOT perform the task under any circumstance until the proper number of staff is available. During interviews on 12/22/25 from 3:10 pm - 7:13 pm one RN, seven LVNs, three MAs, and six CNAs from different shifts all stated they were in-serviced before working their shift onAbuse and Neglect Policy: to include failure to provide the proper number of staff needed Event ID: Facility ID: 745051 If continuation sheet Page 8 of 12 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 12/22/2025 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate administering of all drugs and biologicals) to meet the needs of each resident for one (Resident #1) of two residents reviewed for medication administration, in that: The facility failed to ensure they administered Resident #1 a one-time order, dated 12/10/25, of 500 ml of Sodium Chloride 0.9%. Resident #1 instead received approximately 900 ml of Sodium Chloride 0.9%. Resident #1 was sent to the hospital for SOB, and returned the same day with a diagnosis of pneumonia, no fluid overload. The failure placed residents at risk for fluid overload, shortness of breath, blood pressure issues, physical injury to organ failure. Findings included: Record review of Resident #1's face sheet, dated 12/18/25, revealed a seventy-six-year-old female who was admitted to the facility on [DATE] and readmitted on [DATE]. Her admitting diagnoses included acute combined systolic (congestive) and diastolic (congestive) heart failure (the heart struggles to both contract forcefully and relax properly, leading to fluid backup (congestion) in the lungs and body, causing severe symptoms like shortness of breath and swelling), chronic obstructive pulmonary disease (a progressive lung condition making it hard to breathe, characterized by inflamed airways and damaged air sacs (emphysema/bronchitis) leading to persistent cough, wheezing, and shortness of breath), and morbid (severe) obesity due to excess calories (a serious chronic condition defined by a BMI (a measure of body fat based on height and weight) of 40+ or 35+ with severe health issues, often stemming from consistently consuming more calories than the body burns, leading to excess fat storage). Record review of Resident #1's MDS (clinical assessment to determine resident's strength and needs) Quarterly Assessment Section C - Cognitive Patterns dated 12/02/25 revealed a score of 14 indicating no cognitive issues. Record review of Resident #1's care plan revealed a focus dated 12/11/25 that Resident #1 had congestive heart failure and was at risk for fluid volume overload with an intervention dated 01/03/25 to report to the charge nurse any new or increased swelling, breathing problems, change in skin color, or increased difficulty performing tasks. Record review of Resident #1's order dated 12/10/25 reflected Sodium Chloride Solution 0.9% use 500 ml intravenously one time only for dehydration for 1 day; run at 75ml/hour, reassess at 250ml and 500ml. Record review of Resident #1's nurses progress note by the DON dated 12/11/25 reflected, The resident received the wrong dose of IV fluid. Record review of Resident #1's nurses progress note by RN B dated 12/11/25 reflected, [Resident #1] was transferred to a hospital on [DATE] 12:00 AM related to SOB, O2 sat 85% while pt is on 4L o2 [sic]. Record review of Resident #1's hospital records dated 12/11/25 reflected Resident #1's chief complaint was SOB. The hospital visit diagnoses was a cough and pneumonia. Review of the Provider Investigation Report dated 11/11/25 reflected, The nurse administered 900 ml of sodium chloride 0.9% instead of 500 ml. Resident [#1] was assessed and transferred to the ER. The nurse received an order to administered [sic] 500 ml sodium chloride 0.9% to the resident [#1] for dehydration. The nurse hung a 1000 ML bag. According to the nurse, he reported to the incoming nurse who was assigned to another Hall about the order and treatment plan, since his relieve [sic] was running late. The nurse assigned to the resident stated she was not informed, and did not read the order. During her last round, she noted 450-550 ml and was instructed by the incoming nurse to continue the infusion. Incoming nurse denied being given such direction. He went to the room and discontinued the IV. Around 8:01 am on 12/11 [2025] the resident complained of shortness of breath. The provider was notified and order [sic] oxygen therapy. Resident symptoms didn't improve and was transferred to the ER. The resident had a diagnosis of pneumonia. Record review of a statement by LVN A undated reflected, During (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 745051 If continuation sheet Page 9 of 12 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 12/22/2025 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few my shift on 12/10/25, I arrived to the facility for my NOC shift at 1830. There was on the NOC nurse for 300/400. During my round, upon assessment, it was observed at 0650 that resident had approximately 800 - 700 ml of Normal Saline in the bag. During my mid early morning rounds, I went to get the U/A that was ordered and also to administer the resident's Synthroid, there still was alot of fluid left in the bag. I had to take care of a resident on 200 for quite some time. When I made my last rounds, the resident had approx. 450-550 ml remained [sic] at around 0551. The dayshift RN advised meto [sic] allow the infusion to continue until he was able to consult with the Nurse Practitioner (NP) citing concern regarding the resident Systolic BP [the top number in a blood pressure reading, measuring the pressure in your arteries when your heart beats and pushes blood out], which was noted to be I the [sic] high 90s. Resident was stable @ 0600. Report given to [RN B]. This nurse left the facility @ or around 0647. Record review of a statement by RN B dated 12/11/25 reflected, report to night nursing staff to end NS drip for patient [Resident #1] at 500 ml and reassess. In am when I returned to work and rounded I saw that the whole 1000 ml bag was nearly gone. I immediately stopped IV and reported to the ADON. Interview on 12/18/25 at 9:57 am with the DON revealed the PPHP NP wrote the order for Resident #1 to receive Sodium Chloride Solution 0.9% 500 ML intravenously. The DON said that the PPHP NP spoke with the MDS nurse about the order who relayed the information to the charge nurse, RN B. The DON said they did not have a Sodium Chloride Solution 0.9% bag of 500 ML, only a 1,000 ML fluid bag. The MDS nurse relayed the order to the charge nurse, RN B, who pulled the 1,000 ML fluid bag from the emergency kit and hung the fluid. RN B gave report to LVN C, the oncoming charge nurse. The DON said he told LVN C to stop the fluids 500 ML. The DON said that when RN B returned the following morning and checked Resident #1, it was evident that Resident #1 had received more than 500 MLs of Sodium Chloride Solution 0.9%. She said RN B said the bag was almost empty and it was estimated she received 900 MLs of Sodium Chloride Solution 0.9%. The DON said RN B told her he stopped the IV and assessed Resident #1. The DON said RN B said that Resident #1's O2 saturation was a little low and she had SOB. The DON said RN B told her he notified the facility practitioner who recommended Resident #1 be sent to the hospital for evaluation. The DON said the hospital diagnosed Resident #1 with pneumonia and Resident #1 returned to the facility the same day. The DON said the resident receiving approximately 900 MLs of Sodium Chloride Solution 0.9% instead of the prescribed 500 MLs was a medication error. The DON said it was the responsibility of nursing management, that consisted of the DON, ADON, and charge nurse to have made sure there were no medication errors. The DON said the possible negative effects of a medication error were that residents could have an unneeded hospital transfer. The DON said the nurse on duty should have rounded on Resident #1 every two hours and calculated the IV flow rate for the time that the IV would have been lowered to 500 MLs. The DON said she did not feel that Resident #1 suffered harm, and the facility took the right action when the error was discovered. The DON said Resident #1 returned stable from the hospital that same day with no significant changes to her orders except for antibiotics for Resident #1's diagnoses of pneumonia. Interview on 12/18/25 at 10:32 am with Resident #1 revealed that the facility did not tell her that she was given too much IV fluid and she did not remember why she went to the hospital. She thought it was because of her cough and she was spitting up green stuff. Interview on 12/18/25 at 10:46 am with the facility NP revealed there was an order for Resident #1 to receive 500 MLs of Sodium Chloride Solution 0.9% that was given by the PPHP NP. The facility NP said that when Resident #1 received approximately 900 MLs of Sodium Chloride Solution 0.9% that was communicated to the PPHP NP. The NP for the facility said Resident #1 received too much fluid and had SOB that could present as fluid overload. The NP for the facility said SOB was a classic symptom of fluid overload. The facility (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 745051 If continuation sheet Page 10 of 12 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 12/22/2025 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few NP said the chest x-ray from the hospital reflected Resident #1 had pneumonia. She said Resident #1 receiving approximately 500 MLs more Sodium Chloride Solution 0.9% than prescribed was a medication error and a huge snafu. The facility NP said that RN B marked with a pen on the outside of Resident #1's fluid bag at the 500 ML mark to indicate where to stop the fluid. She said the nurse on duty should have calculated the flow rate and the time to stop the bag when it reached 500 MLs. Interview via phone on 12/28/25 at 4:58 with LVN A revealed that she arrived late for her shift on 12/10/25. Her shift began at 6:00 pm and she arrived closer to 7:00 pm. She said it was very busy when she arrived. She said she did not receive report from the nurse who worked prior to her shift and did not know Resident #1 was on an IV bag. She said when she sat down at the computer, she did see the order for Resident #1's IV bag but got distracted and did not check Resident #1's IV. She said when the day shift started RN B asked her if anyone gave her report and she said no. RN A told her the IV should have been stopped at 500 MLs. She said she was informed by the DON that Resident #1 received too much fluid and the facility suspended her. She said she did not receive either a written report or a verbal report from a nurse during her shift beginning on 12/10/25 and ending 12/11/25. She said she should have asked the nurse on shift if there was anything additional she should have know or called RN A and asked him to give her report from his shift. She said she made a mistake and learned her lesson. She said it was her responsibility to review any new resident orders. She said if a resident got too much fluid, it could result in fluid overload. Interview on 12/18/25 at 5:24 pm via phone with the facility MD revealed he knew that Resident #1 received approximately 400 MLs too much fluid. The facility MD said Resident #1 did not have fluid overload and Resident #1's hospital BNP (a hormone that helps regulate blood pressure and fluid balance) of 227 did not indicate that Resident #1 had fluid overload and BNP was chronically elevated in a person with CHF. He said Resident #1 probably had SOB because she had pneumonia which was what was revealed in the hospital chest x-ray. Interview on 12/19/25 at 12:42 pm with RN A revealed an order was written on 12/10/25 for Resident #1 for Sodium Chloride Solution 0.9% IV not to exceed 500 MLs. RN A said his shift ended and LVN A was late for her shift, and he gave report to LVN C to give to LVN A and he told LVN C to not let LVN A forget to stop Resident #1's IV fluids. RN A said he did not know if LVN C gave LVN A the report. RN A said he came in on 12/11/25 and checked on Resident #1 and her IV had not been stopped. He said he immediately stopped the bag and assessed Resident #1. He said Resident #1 complained of wheezing and he spoke with the NP who said to send Resident #1 to the hospital. RN A said it was the responsibility of the residents' primary nurse had made sure orders were followed. He said that was a medication error. He said there was a breakdown in the communication between LVN A and LVN C. He said the possible negative effect of this medication error would be fluid overload. Interview via phone on 12/21/25 at 2:43 pm with LVN C reflected RN B told her about Resident #1's IV order. LVN C said she told RN B to write it down and leave the information on the cart so it would not be missed. LVN C said she was busy, and on 12/10/25 she did not speak with LVN A about Resident #1's IV fluids. The next day, on 12/11/25, LVN A said no one told her about the IV fluids for Resident #1 and LVN C said she told RN A to write the information down for LVN A to see. LVN C said Resident #1 receiving fluid exceeded the amount that was ordered was a medication error. She said the charge nurse for that resident was responsible for making sure the resident received medication according to the provider's order. Interview on 12/22/25 at 4:13 pm with the ADON revealed the order for Resident #1's IV fluids was not communicated to the nurse who came on duty. The ADON said anything that was not done in accordance with a provider's order was a medication error. The ADON said it was charge nurses responsibility to have made sure the resident received medications according to what the provider wrote in the order. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 745051 If continuation sheet Page 11 of 12 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 12/22/2025 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete The ADON said the possible negative effect of giving someone too much fluid was death. She said that all errors can possibility lead to death. Interview on 12/22/15 at 5:15 pm with the RCN revealed Resident #1 receiving too much IV fluid was a communication error that ended up being a medication administration error. The RCN said it was the responsibility of both charge nurses to have made sure that the IV fluids order was communicated. The RCN said RN B should have put the information in writing and LVN C should have tended to the order when she saw it. She said the possible negative effect of giving too much fluid to a resident was fluid overload, which can cause death. Interview on 12/22/25 at 7:02 pm with the Administrator revealed Resident #1 did not get the proper amount of fluids because of a communication problem. The Administrator said there was an IV on the resident and it needed to be checked. The Administrator said if you have any questions about an order or resident care, then you needed to call the prior nurse. She said it was the responsibility of the charge nurse for that resident to have checked report, records, and the computer for new orders. She said providers order was not followed and Resident #1 was given too much fluid. The possible negative effect of giving a resident too much fluid was that the resident could have SOB and be sent to the hospital for evaluation. Review of facility policy Medication Administration and General Guidelines undated reflected, Medications are administered in accordance with written orders of the attending physician. Event ID: Facility ID: 745051 If continuation sheet Page 12 of 12