Inspection·October 10, 2025

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few not feeling well while she was helping other residents in the hallway. She said she heard Resident #2 tell Nurse A that CR #1 was asking for her to come to his room because he was not feeling well, but she said she told Resident #2 not to worry about it and that she would take care of it. She said she went back to his room, and CR #1 was on his bed, sitting up but slouched all the way over and throwing up. She said she took his temperature with her personal thermometer, and he had a fever of 103 F. She said CR #1 was saying his chest hurt, and to please call the ambulance. She said he told her his pain level was a 10 out of 10. She said over an hour had passed and she never saw Nurse A go into his room to check on him. She said she called 911 from her cell phone at 8:46 p.m. and yelled out for Nurse A. She said Nurse A went to CR #1's room and asked him how he was feeling. She said the resident could barely talk, and that he just kept saying to call the ambulance. She said she left CR #1's room and went to the hallway to give 911 the address to the facility, and they arrived maybe within 5 minutes. She said Nurse A denied being told that something was wrong with CR #1. During an observation and interview on 09/17/25 at 10:09 a.m., revealed CR #1 was at the hospital lying in bed, watching television. He said he did not remember what time he started feeling bad on Sunday, 09/14/25. He said he was in a lot of pain from his waist down, he was vomiting, his chest was also hurting, and his pain level was at a 10. He said he told the nurse aide he was feeling bad but said he did not remember when he told her. He said he did not get a chance to ask the nurse for anything because she never came and checked on him. He said he pressed his call light, waited for about an hour, but the nurse did not go to his room until about 2-3 minutes before the ambulance got to the facility. He said the nurse aide said she was going to call the ambulance. He said he heard the nurse at the facility tell the ambulance driver he had a fever but did not remember the nurse's name. He said the hospital had yet to tell him what was wrong with him but said they told him they were going to admit him. He said the doctor told him he was not going to be discharged today, 9/17/25. He said the facility did not call his family member/RP/emergency contact #1 and she did not know he was in the hospital. During a telephone interview on 09/17/25 at 11:41 a.m., Nurse A said she called the NP/physician listed on the CR #1's Face Sheet after EMTs took the resident. She said she did not speak to them and probably left them a message. She said she did not contact the resident's RP/emergency contact and that she had no reason for not making the contact. During a telephone interview on 09/17/25 at 1:23 p.m., the NP said he was notified via text (does not know by who) on Monday, 09/15/25, that on Sunday, 09/14/25, CR #1 had nausea, was throwing up, complaining about chest pain, and that the nurse aide had called 911. He said had he been notified when symptoms had been occurring, he could have done some kind of intervention. He said each case was different and he still did not know all the details about what happened on Sunday with the resident. He said he did not know if the on-call service was notified on Sunday. During an interview on 09/18/25 at 9:48 a.m., the DON said the family and physician should be notified immediately once the resident was stable and safe. He said Nurse A did not document that she contacted CR #1's RP/emergency contact #1 in her progress note. He said he gave both emergency contacts a courtesy call on Monday, 09/15/25, to see if they had any concerns or if they needed him to do anything but both of their phones had a message saying they were not taking calls at that time. He said not contacting a resident's RP/emergency contact would not have an ill effect on the resident. During a follow-up telephone interview on 09/18/25 at 11:35 a.m., the NP said he checked with the on-call service and with the physician and the physician said he was not notified and there was no record that the on-call service was called. During a telephone interview on 09/18/25 at 4:03 p.m., with CR #1's family member/RP/emergency contact #1 she said the facility did not call her to tell her CR #1 was sent to the hospital. She said CR #1 called her on 09/16/25 and told (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455815 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 455815 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fallbrook Rehabiliation and Care Center 10851 Crescent Moon Dr Houston, TX 77064 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 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete her he was in the hospital. Record review of the facility's Notification of Changes policy, date reviewed/revised 12/08/24, revealed in part .The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, resident's representative when there is a change requiring notification.2. Significant change in the resident's physical, mental or psychological condition such as deterioration in health, mental or psychosocial status. This may include: a. Life-threatening conditions, or b. Clinical complications.Additional considerations: 1. Competent individuals.c. When a resident is mentally competent, such a designated family member should be notified of significant changes in the resident's health status because the resident may not be able to notify them personally, especially in the case of sudden illness or accident. Event ID: Facility ID: 455815 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 455815 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fallbrook Rehabiliation and Care Center 10851 Crescent Moon Dr Houston, TX 77064 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 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice for 1 (CR #1) of 6 residents reviewed for quality of care. -On 09/14/25, CNA A failed to tell Nurse A specifically what was wrong with CR #1. Nurse A failed to assess or provide medical care for CR #1 for approximately two hours, after CNA A asked her to check on CR #1 around 6:30 p.m. CNA A called 911 on 09/14/25 around 8:46 p.m. after CR #1 was noted to have a fever of 103 F, nausea/vomiting, doubled over with pain of 10/10, and was grayish in color. CR #1 was diagnosed at the hospital with fever, left heel wound infection, complicated UTI, and AKI. An Immediate Jeopardy (IJ) was identified on 10/07/25. The IJ Template was provided to the facility on [DATE] at 2:05 p.m. While the IJ was removed on 10/09/25, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal (POR). This failure could place residents at risk of not receiving necessary medical care, a decline in health, and/or experiencing emotional and physical distress. The findings included: Record review of CR #1's admission Record, dated 09/16/25, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included type 2 diabetes mellitus (high levels of blood sugar in the blood) with chronic kidney disease, degenerative disease of nervous system (conditions that affect the nerve cells in the brain and spinal cord), other chronic pancreatitis (long-standing inflammation of the pancreas), depression, and muscle weakness. Record review of CR #1's Quarterly MDS Assessment, dated 08/28/25, revealed a BIMS score of 13, indicating intact cognition. Further review revealed the resident required the assistance of 2 or more helpers with toileting and chair/bed-to-chair transfer, and partial assistance with showering/bathing. Record review of CR #1's Care Plan, undated, revealed he had an ADL self-care performance deficit and required hands on assistance bathing/showering, bed mobility, dressing, and transferring. Record review of CR #1's progress notes, dated 09/14/25 at 20:50 (8:50 p.m.), entered by Nurse A, revealed in part CNA called 911 resident complaining of vomiting and chest pain.Blood pressure 143/84, pulse 81, respiration 18, temp 102.2, and O2 sat 99. As nurse was leaving room EMT and police coming in hallway with CNA stating she called them. 2105 [9:05 p.m.] time on stretcher to ambulance. Record review of the hospital report, ADM DT: 09/15/25, Note Date: 00:34 (12:34 a.m.), admission Date: 09/14/2025, revealed in part .presented from [nursing facility name] with complaints of flu-like symptoms, nausea, vomiting, chest pain associated with vomiting, and abdominal pain. The patient reports the abdominal pain as severe, rated 10/10 (pain scale used for assessing pain intensity, where 0 indicates no pain and 10 represents the worst pain imaginable) and similar to his previous h/o pancreatitis.On exam the patient is AAOx4 [patient is fully aware of their identity, location, time, and situation, reflecting a high level of cognitive function], in no apparent distress. Record review of hospital report, ADM DT: 09/15/25, note dated 09/15/25 at 15:24 (3:24 p.m.), revealed in part .Assessment: #Fevers, #L heel wound, #complicated UTI w/ suprapubic catheter, #AKI. Further review, note date: 09/21/25 22:16 [10:16 p.m.], revealed in part .09/19/2025: Echogram with pelvic angiogram [diagnostic procedure that uses X-ray images to visualize blood vessels and identify any blockages or narrow spots], bilateral lower extremity angiogram, spur retrieval stent of left peroneal artery [self-expanding stent with integrated balloon dilation technology, allowing for temporary support of the artery and improved blood flow], IVUS [minimally invasive procedure that uses sound waves to assess blood vessels from the inside]. During a telephone interview on 09/16/25 at 7:27 a.m., CNA A said she did not know what time she Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455815 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 455815 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fallbrook Rehabiliation and Care Center 10851 Crescent Moon Dr Houston, TX 77064 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 - Immediate jeopardy to resident health or safety Residents Affected - Few told Nurse A to check on CR #1 on 09/14/25 but when she told her she said okay she was going to get to him, but she never checked on him. She said CR #1 was normally grumpy and aggressive but on this day, 09/14/25, he was doubled over, his skin color was grayish, he looked tired and just did not look like himself at all. She said she also heard CNA B, and Residents #2 and #3, tell Nurse A (did not know what time) about CR #1 not feeling well while she was helping other residents in the hallway. She said she heard Resident #2 tell Nurse A (did not know what time) that CR #1 was asking for her to come to his room because he was not feeling well, but she said she told Resident #2 not to worry about it that she would take care of it. She said she went back to his room, and CR #1 was on his bed, sitting up but slouched all the way over and throwing up. She said she took his temperature with her personal thermometer, and he had a fever of 103 F. She said CR #1 was saying my chest hurts, my chest hurts, please call the ambulance. She said he told her his pain level was a 10 out of 10. She said over an hour had passed and she never saw Nurse A go into his room to check on him but said she was helping other residents during this time but heard them tell the nurse that he did not feel well. She said she called 911 from her cell phone at 8:46 p.m. and yelled out for Nurse A. She said Nurse A went to CR #1's room and asked him how he was feeling. She said the resident could barely talk, and that he just kept saying call the ambulance. She said she left CR #1's room and went to the hallway to give 911 the address to the facility, and they arrived maybe within 5 minutes. She said Nurse A denied being told that something was wrong with CR #1. During an interview on 09/16/25 at 11:17 a.m., the DON said Nurse A called him on 09/14/25 and said she did not have the chance to reassess CR #1 because the CNA (he said he could not remember CNA's name and would have to look at the schedule) told her she had called 911. He said the CNA should have let the nurse know the resident was not feeling well so the nurse could have assessed and taken proper clinical action. He said he spoke to Nurse A and she said CNA A never told her that CR #1 was not feeling well. During an interview on 09/16/25 at 1:09 p.m., Resident #2, said on 09/14/25 she heard and saw CNA A tell Nurse A that she needed to go and check on CR #1 between 7:00/8:00 p.m. She said Nurse A was at the nurse's station on the computer and told CNA A she would check on CR #1 in a minute. She said about 1-1 1/2 hours later the ambulance arrived at the facility. During an interview on 09/16/25 at 9:50 a.m., Resident #3 said He said he never heard anyone tell the nurse that CR #1 needed to be checked on. He said he saw a nurse (did not know her name) come out of CR #1's room around 9:00 p.m. on 09/14/25. During an observation and interview on 09/17/25 at 10:09 a.m., revealed CR #1 was at the hospital lying in bed, watching television. He said he did not remember what time he started feeling bad on Sunday, 09/14/25. He said he was in a lot of pain from his waist down, he was vomiting, his chest was also hurting, and his pain level was at a 10. He said he told the nurse aide he was feeling bad but said he did not remember when he told her or what her name was because she was new. He said he did not get a chance to ask the nurse for anything because she never came and checked on him. He said he pressed his call light, waited for about an hour, but the nurse did not go to his room until about 2-3 minutes before the ambulance got to the facility. He said the nurse aide said she was going to call the ambulance. He said he heard the nurse at the facility tell the ambulance driver he had a fever but did not remember the nurse's name. He said the hospital had yet to tell him what was wrong with him, but said they told him they were going to admit him. He said the doctor told him he was not going to be discharged today, 9/17/25. He said the facility did not call his family member/RP/emergency contact #1 and she did not know he was in the hospital. During a telephone interview on 09/17/25 at 11:41 a.m., Nurse A said someone, a CNA, (she did not know who) approximately right before 9:00 p.m. on 09/14/25, said that girl called 911 . She said at that point she did not know who the CNA was referring (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455815 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 455815 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fallbrook Rehabiliation and Care Center 10851 Crescent Moon Dr Houston, TX 77064 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 - Immediate jeopardy to resident health or safety Residents Affected - Few to. She said she stopped passing medications, locked the cart, and went around the corner to the nurse's station on hall 200. She said she looked to her right, out the window, and saw flashing lights coming from the ambulance. She said CNA A said she called 911 because CR #1 was projectile vomiting. She said she went to CR #1's room and asked him what was going on and he said he was vomiting. She said she told him she needed to take his vital signs. She said she started taking his vitals and told him she could call the doctor to get some medication for nausea. She said CR #1 said it was not going to help because he was going to throw it back up. She said by the time she finished taking his vital signs, EMTs were coming in the room. She said she then left the room. She said another set of EMTs came in with police officers and they went to CR #1's room, and she stayed at the nurse's station. She said less than 5 minutes after EMTs arrived, they took the resident. She said CNA A did not tell her that CR #1 was not feeling well, and/or she needed to check on him. She said there was one little puddle of vomit on the floor, and said he was not projectile vomiting, but said she did not actually see him vomit. She said he had a fever of 102 F but everything else was okay. She said no residents reported to her that CR #1 was feeling unwell. During an interview on 09/17/25 at 1:04 p.m., Nurse B said she worked the 6:00 a.m. to 6:00 p.m. shift on 09/14/25 and was assigned to CR #1. She said she left her shift around 6:30 p.m. She said when she was grabbing her bag to leave, CNA A came around the corner toward the 200-hall nurse's station and said out loud (she said CNA A did not say anyone's name) when you have a moment can you check on CR #1?. She said Nurse A acknowledged the fact that CNA A said to check on CR #1 by saying ok out loud. She said CNA A did not give any details. She said she saw CR #1 throughout the day on 09/14/25 for blood sugar checks, but he was fine throughout her shift. She said no one ever asked her to check on him and the resident never voiced any concerns to her. During an interview on 09/18/25 at 8:52 a.m., the Administrator said he tried contacting CNA A to find out what happened and why she decided to call 911 instead of letting the nurse initiate the call. He said CNA A texted him that Nurse A was mad at her because she called 911 and that she told Nurse A CR #1 was projectile, and Nurse A did nothing. He said he asked CNA A what she meant by projectile, but she did not respond. He said he checked the resident's room on Monday morning, 09/15/25, around 10:00 a.m. and did not see any signs of projectile vomiting and he checked the resident's clothes, which were still in his room because the resident sent his laundry out to be washed, and he did not see any signs or vomit on his clothes. He said he talked to Nurse B, and she said she did not see anything abnormal during her shift. He said Nurse B, said she went and checked CR #1's blood sugar around 5:30 p.m. and tried to flush his catheter but he refused. He said he talked to the night nurse, Nurse A, and she said she received a report from Nurse B, and there was no change in condition for CR #1. He said Nurse B said she was told the resident was in and out of the facility as usual. During a follow-up interview on 09/30/25 at 2:43 p.m., the DON said when a resident was complaining of pain, they assessed the resident by asking them how much pain they were in on a scale of 1 to 10. He said if the resident was non-verbal, they looked for facial grimacing or assessed through touch. He said pain was a priority, but he said he could not assign an amount of minutes to when it should be addressed by the nurse but said they should respond as soon as possible. During a follow-up interview on 09/30/25 at 4:30 p.m., the NP said he would have directed the staff to give the resident Mylanta because it could have been due to GERD, and they could have done nitroglycerin (nitrate medicine that relaxes blood vessels and prevents or treats chest pain), and a baby aspirin. He said 9 times out of 10 symptoms would be relieved. He said it was hard to tell what negative effects could result from waiting for 1-1 1/2 hours. He said the resident had prostate issues, got UTIs, and those could cause a lot of symptoms. During a follow-up telephone interview on 09/30/25 at (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455815 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 455815 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fallbrook Rehabiliation and Care Center 10851 Crescent Moon Dr Houston, TX 77064 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 - Immediate jeopardy to resident health or safety Residents Affected - Few 4:39 p.m., CNA A said she did not tell Nurse A CR #1 had a fever or was throwing up. She said later (she could not provide a time) after she told Nurse A that CR #1 was not feeling well, she heard CNA B tell Nurse A Mr. [CR #1's last name] is asking for you. He is not feeling very well. During an interview on 09/30/25 at 5:00 p.m., CNA B said she was not assigned to CR #1's hall on 09/14/25 but saw his light on around 8:00/8:30 p.m. She said she went inside his room, and he asked her to get the nurse and that maybe she needed to call the ambulance, but he did not say why, and she said she did not ask why. She said she told CR #1 okay and she went to Nurse A and told her CR #1 had his light on and he needed her to call the ambulance. She said Nurse A said okay. She said she went back to her assigned hall and about 10 minutes later, she saw EMS coming out of his room. She said CNA A said the resident had been asking for the nurse, he needed an ambulance, so she called 911. During a telephone interview on 10/02/25 at 4:18 p.m., the Physician said complicated UTI symptoms would be vague and could maybe range from a fever, chills, and/or blood in the urine. He said he would have ordered a CBC, CMP, a similar panel to what they would order at the hospital, and EKG. He said if the resident had a fever of 102 F, he would also get a chest x-ray, urinalysis, and blood culture. He said he would have ordered that first and start the resident on antibiotics and have the nurse call him back within 30 minutes to an hour with an update. He said AKI did not have any symptoms and was based on a blood test. He said it was a broad term and did not present symptoms. He said it could be caused from dehydration but most likely from the resident being anemic. During a follow-up telephone interview on 10/03/25 at 7:58 a.m., the Physician said from what he gathered, CR #1's symptoms were vague, and he said he did not believe there would be any negative effects resulting from staff waiting for 1-2 hours to address resident's change in condition. Record review of the facility's Notification of Changes policy, date reviewed/revised 12/08/24, revealed in part .The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, resident's representative when there is a change requiring notification.2. Significant change in the resident's physical, mental or psychological condition such as deterioration in health, mental or psychosocial status. This may include: a. Life-threatening conditions, or b. Clinical complications.Additional considerations: 1. Competent individuals.c. When a resident is mentally competent, such a designated family member should be notified of significant changes in the resident's health status because the resident may not be able to notify them personally, especially in the case of sudden illness or accident. Record review of the facility's Registered Nurse Job Description, undated, revealed in part .follows the nursing model to promote holistic care for the residents.assesses for changes in residents' status. The DON was notified on 10/07/25 at 2:05 p.m. that an IJ was identified due to the above failures and the IJ template was provided. The following Plan of Removal (POR) was accepted on 10/08/25 at 11:01 a.m.: Immediate Jeopardy Removal Plan F-684 - Quality of Care 10/8/2025 Tag Cited: F-684Quality of Care Issue Cited: The facility failed to ensure treatment and care was provided to Resident #1 [resident name/CR#1] consistent withprofessional standards of practice. Nurse A [nurse's name] failed to assess or provide medical care for CR #1 [resident's name] for approximately two hours on 09/14/25, after CNA A [aide's name] notified that CR #1 [resident's name] experienced a change of condition around 6:30 p.m. CNA A [aide's name] called 911 on 09/14/25 around 8:45 p.m. after CR #1 [resident's name] was noted to have a fever of 103 [degrees Fahrenheit], nausea/vomiting, doubled over with pain of 10/10, and was grayish in color. CR #1 [resident's name]was diagnosed at the hospital with fever, left heel wound infection, complicated UTI, and AKI This immediate jeopardy removal plan is submitted as the facility's immediate actionable plan to remove the likelihood that serious harm to a resident will occur or recur from (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455815 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 455815 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fallbrook Rehabiliation and Care Center 10851 Crescent Moon Dr Houston, TX 77064 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 - Immediate jeopardy to resident health or safety Residents Affected - Few alleged deficient practice. The facility failed to ensure treatment and care was provided to Resident #1 consistent with professional standards of practice 1. Identification of Residents Affected or Likely to be Affected:The facility took the following actions to address the citation and prevent any additional residents from suffering an adverse outcome. (Completion/ Date: 10/7/2025) Resident #1 [CR#1] returned to facility on 9/24/2025 with orders for intravenous antibiotics. All other orders were to resume as previously prescribed. The DON/ADON reviewed the 24-hour report for the last 72 hours to ensure all changes of conditions including nausea, vomiting and fever were assessed and the provider notified appropriately to ensure residents receive proper and quality care to prevent infections and diminished health. The DON/ADON audited nursing progress notes from 9/14-9/16/2025 for current residents. No new changes in condition that did not already have physician notification and intervention were identified. The Attending Physician and Medical Director were notified of IJ on 10/7/2025 at 2:49 pm. 2. Actions to Prevent Occurrence/Recurrence:The facility took the following actions to prevent an adverse outcome from reoccurring. (Completion Date: 10/7/25) The facility policy and procedures related to change of condition were reviewed by the Director of Nursing, Administrator, Regional Nurse Consultant on 10/7/2025, no revisions deemed necessary at this time. Nurse A is no longer employed by the facility. The facility separated with Nurse A on 9/19/2025 due to failure to complete 90-day introductory phase. The DON/ADON/Corporate Nurse will provide education to Nursing Staff in person, via phone, via facility messaging platform, or prior to next shift. Nursing staff will not be permitted to provide resident care until education is received. This education will include definitions of what a change of condition is including signs and symptoms of infection including nausea, vomiting and fever, circumstances where the clinical teams must be notified, when staff must notify nurses of changes in condition and when the nurse must notify medical providers and when to notify responsible parties. This education emphasizes that CNAs are to report observations and resident concerns to the nurse. They will then recheck with the resident to see if their concerns have been addressed, and then reconfirm with the nurse on duty if the resident still has concerns. If the resident or CNA have concerns that their notification has not been addressed, the CNA will call the DON/ADON/NHA to report the concern so that facility leadership may address the situation to ensure timely follow up and notification to the MD. The facility has posted a Call with Concern sheet with the appropriate numbers that may be contacted listed at the nursing stations. This education will emphasize notification to the nurse on resident concerns, and follow up assessment by the licensed nurse, with follow up notification to the medical provider. Licensed Nurses will validate their understanding of education by reviewing and demonstrating the use of the E-Interact Change in Condition Evaluation tool in Point Click Care [cloud-based healthcare software platform that helps manage clinical, financial, and administrative tasks] with the DON/ADON/Designee prior to working their next scheduled shift. The Director of Nursing or designee will continue to monitor/audit Changes of Condition and Signs and Symptoms of infection including fever by reviewing the 24-hour report during morning clinical meetings three times weekly for four weeks, then weekly for eight weeks. A QAPI PIP has been initiated to report on the above monitoring and auditing procedures. All findings from the PIP will be presented at the monthly QAA meeting. Monitoring/auditing and reporting will continue for a minimum of three months. Quality of CarePurpose: To ensure that all changes of condition are addressed immediately and appropriate action taken.Instructions: Review 24-hour reports in clinical meetings for all changes of condition as well as any signs or symptoms of infection including nausea, vomiting and fever and ensure that they are addressed immediately.Date of 24-hour report reviewAudit/Monitoring?Resident Name?Change of Condition/ Signs and Symptoms of infection including nausea, vomiting, fever (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455815 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 455815 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fallbrook Rehabiliation and Care Center 10851 Crescent Moon Dr Houston, TX 77064 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 - Immediate jeopardy to resident health or safety Residents Affected - Few Identified?Actions taken to address Change of ConditionComments/Corrective Action. On 10/08/25-10/09/25, surveyors confirmed the facility implemented their plan or removal (POR) to sufficiently remove the IJ by the following: Observation on 10/09/25 at 3:25 p.m., revealed Call with Concern sheets posted with the Administrator's, DON's, and ADON's phone numbers. Record review of a 24-hour report, dated 10/07/25 and 10/08/25, revealed 5 recorded changes of condition for residents that were addressed. Record review of the eInteract Change in Condition Evaluation tool used by Licensed Nurses to demonstrate and validate their understanding of education was completed. Record review of the In-Service Summary / Report of Education, dated 10/07/25, reflected 34 staff members were educated on reporting and following up on what a change of condition is including signs and symptoms of infection including nausea, vomiting and fever, circumstances where the clinical teams must be notified, when staff must notify nurses of changes in condition and when the nurse must notify medical providers and when to notify responsible parties. Education included finding the nurse on duty immediately, being clear and specific on what was seen or heard, when and where it happened, any changes from resident's usual condition, and checking back with the nurse to confirm the concern was addressed. In addition, it included reporting to another nurse or the nurse supervisor/DON/ADON the change in condition if the nurse was busy and that resident safety is a shared responsibility. Record review of the In-Service Summary / Report of Education, dated 10/07/25, reflected 12 nurses were educated on addressing any significant deviation from a patient's baseline health status, which could by physical, cognitive, behavioral, or functional. The nurse must identify, assess and report changes to the MD/NP immediately to prevent complications, improve safety, and guide treatment. Changes in condition included but were not limited to: Nausea and vomiting, pain, new behavior, lack of behavior, headache, dizziness, diarrhea, abnormal vitals, needing extra help with ADL, decrease mobility, resident expressing I don't feel good, and/or seizures. Record review of the In-Service Summary / Report of Education, dated 10/07/25, reflected 37 staff members were educated on being alert for signs of a change in a resident's condition, such as unusual behavior (like confusion, agitation, or withdrawal), changes in mobility (moving slower, limping, or needing more help), noticeable skin issues (paleness, flushing, bruising, or swelling), changes in appetite or refusal to eat, increased sleepiness or trouble waking up, vomiting and nausea, complaints of feeling unwell, dizzy, or in pain, chest pain and any signs of incontinence or changes in bathroom habits; the resident expressing concerns about illness or sadness. Ensuring to report any of these symptoms to the nurse in charge. Record review of the Change of Condition Demonstration Audit Tool, dated 10/08/25, reflected 8 staff members received demonstration, return demonstration, and notification MD/NP/RP/Progress Note. Record review of the In-service Tracking form, dated as of 10/07/25, reflected 117 staff members were contacted in-person, by telephone, or through voicemail, for in-service training over being alert for signs of a change in a resident's condition, such as unusual behavior, changes in mobility, changes in appetite or refusal to eat, increased sleepiness or trouble waking up, vomiting and nausea, resident complaints of feeling unwell, dizzy, or in pain, chest pain and any signs of incontinence or changes in bathroom habits; the resident expressing concerns about illness or sadness; and/or ensuring to report any of these symptoms to the nurse in charge. Record review of the 24-hour report for the last 72 hours, dated 10/05/25 to 10/08/25, reflected all changes in conditions were assessed and provider was notified appropriately. Record review of nursing progress notes from 09/14/25 to 09/16/25, reflected no new identified changes in condition that did not already have physician notification and intervention. Record review of the QAPI Ad-HOC Meeting sign-in sheet, dated 10/08/25, reflected the meeting was held at 11:30 a.m. and 14 staff members were in attendance. Interviews were conducted on 10/08/25 between (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455815 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 455815 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fallbrook Rehabiliation and Care Center 10851 Crescent Moon Dr Houston, TX 77064 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 - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete 11:53 a.m. and 12:09 p.m. and on 10/09/25, between 2:01 p.m. and 3:30 p.m., with staff from all shifts (6:00 a.m.to 6:00 p.m., 6:00 p.m. to 6:00 a.m., 6:00 a.m. to 2:00 p.m., 2:00 p.m. to 10:00 p.m., and 10:00 p.m. to 6:00 a.m.). Staff interviewed included the following: Nurses D, E, and F, MAs A and B, and CNAs C, D, E, F, G, and H. All staff interviewed verbalized an understanding of being alert for signs of a change in a resident's condition, signs and changes to look for, reporting and following up with the nurse, and following chain in command when there is a concern. The DON was informed that the Immediate Jeopardy was removed on 10/09/25 at 3:34 p.m. The facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm that was not immediate jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. Event ID: Facility ID: 455815 If continuation sheet Page 10 of 10