Health inspection·July 6, 2023

F 0836 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure that the governing body failed to operate and provide services in compliance with all applicable Federal, State and local laws, regulations and codes for 1 of 1 facility reviewed for Administrator. and there was no licensed nursing Facility administrator appointed as required by state regulation. This failure could place residents at risk of administrative duties not being carried out or maintained at the highest practicable physical, mental, and psychosocial well-being of the residents. Findings Included: During an entrance interview with Operations Manager on 6/16/2023 at 10:10am, he stated that he is the Operations Manager because he is still working on getting his Administrator's license. He stated that he had experience sitting a building (acting as Manager of the facility) in [NAME], Texas. Observation of the Operation Manager's office on 6/16/2023, revealed no Licensed Facility Administrator's license was observed. During an interview on 6/26/2023 at 4:54pm, the former Administrator, she stated she was no longer employed by the facility. She said her last day working at the facility was on 5/19/2023. During a subsequent interview with the Operations Manager on 7/6/2023 at 11:15am, he stated that the VPO would be sending him a copy of his license to post. He said that he worked under the VPO at another facility and had been appointed to manage the building until he is fully licensed. He stated that he had completed an AIT program and all of the required hours. However, he said that he was unsuccessful at passing the test to be a licensed Nursing Facility Administrator. He was unaware of who would be responsible for contacting HHS to notify them that the former Administrator was no longer working there. He said he understands why HHS would be notified to ensure facilities have experienced administration to manage the building. An interview conducted with BOM on 7/6/2023 at 12:45pm, revealed her to state that the Operations Manager was introduced the day that the former Administrator was terminated. She said that the Operations Manager is the manager of the building. Page 1 of 4 676208 676208 07/06/2023 Eagle Crest Rapid Recovery 9602 Huffmeister Rd Houston, TX 77095

F 0836 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview with VPO on 7/6/2023 at 1:45pm, revealed him to state that he was supervising the Operations Manager on a weekly basis in-person and was available via telephone if he should have any questions. He said that he recently started working for the company two weeks ago and said that he believed that they had 30 days to have a licensed Administrator in place. He said that he believed that owner must contact HHS to inform them of Administrator changes. He said he has not notified HHS about the Administrator change. Record review of staff listing revealed a list of staff names by department, date of hire and position revealed that the Operations Manager was listed as the Administrator and hired on 5/8/2023. Record review of Texas Unified Licensure Information Portal (TULIP), NFA license search revealed that the Operations Manager was not currently licensed as a Nursing Facility Administrator. Under the status it had Prospective. Further review of TULIP revealed that the former Administrator and license was still listed for the facility. Record review of personnel record for the Operations Manager revealed that his pre-employment checklist had under the licensure verification listed a NFA license number as #111718 and expiring on 6/30/2023. This was checked and verified by a former HR representative. Record review of Job description for the Executive Director/Administrator revealed in part: Position Summary states the Executive Director leads and directs the overall operations of the facility in accordance with patient/resident needs, government regulations and company policies to maintain quality care for the patients/residents while achieving the facility's business objectives. Minimum Qualifications knowledge, skills and abilities): College degree or the equivalent in related work experience, current, valid Nursing Home Licensing specific to the state of practice and 2+ years of management experience in a long-term care setting. The Executive Director reports to the VPO. During an attempt to interview the new HR representative on 7/6/2023 at 3:47pm, revealed that he was not at work. Record review of TAC §554.1902(a) revealed .The governing body must: (2) ensure that a person designated as being in authority notifies HHSC immediately when the facility does not have an administrator. 676208 Page 2 of 4 676208 07/06/2023 Eagle Crest Rapid Recovery 9602 Huffmeister Rd Houston, TX 77095

F 0837 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure that the governing body appointed an Administrator who was licensed by the State, where licensing was required; responsible for management of facility and reports to and is accountable to the governing body, in that: The governing body did not appoint a licensed Nursing Home Administrator who was licensed by the State. This deficient practice could have resulted in the facility not being managed in a responsible manner, which could affect the health and safety of all residents. Findings Included: During an entrance interview with Operations Manager on 6/16/2023 at 10:10am, he stated that he is the Operations Manager because he is still working on getting his Administrator's license. He stated that he had experience sitting a building (act as manager of the facility) in [NAME], Texas and was a Speech Pathologist by trade. Observation of the Operations Manager's office on 6/16/2023, revealed no Licensed Facility Administrator's license was observed. During an interview on 6/26/2023 at 4:54pm, the former Administrator stated that she was no longer employed by the facility. She said her last day working at the facility was on 5/19/2023. During a subsequent interview with the Operations Manager on 7/6/2023 at 11:15am, he stated that the VPO would be sending him a copy of his license to post. He said that he worked under the VPO at another facility and had been appointed to manage the building until he is fully licensed. He stated that he had completed an AIT program and all of the required hours. However, he said that he was unsuccessful at passing the test to be a licensed Nursing Facility Administrator. He said that he would be re-taking the test soon. According to him, the VPO supervises him weekly and was in the building on 7/5/2023. The VPO resides in Dallas, Texas area. An interview with the SW on 7/6/2023 at 11:46am, she stated that the Operations Manager was introduced to the management team on or about 5/8/2023 and was said to be sitting the building(act as the manager of the facility). She stated that the VPO was at the community with the Operations Manager on 7/5/2023. An interview with the Medical Records Coordinator on 7/6/2023 at 12:19pm, revealed that the Operations Manager was the Administrator. She said she did not recall if she was here for his formal introduction but she knowns him as the Administrator. An interview conducted with BOM on 7/6/2023 at 12:45pm, revealed her to state that the Operations Manager was introduced the day that the former Administrator was terminated. She said that the Operations Manager is the manager of the building. 676208 Page 3 of 4 676208 07/06/2023 Eagle Crest Rapid Recovery 9602 Huffmeister Rd Houston, TX 77095

F 0837 Level of Harm - Minimal harm or potential for actual harm During an interview with VPO on 7/6/2023 at 1:45pm, revealed him to state that he is supervising the Operations Manager on a weekly basis in-person and is available via telephone if he should have any questions. He said that he recently started working for the company as well and said that he believed that they had 30 days to have a licensed Administrator in place. He said he would send any documentation of the supervision/training provided. Residents Affected - Few Record review of staff listing revealed a list of staff names by department, date of hire and position revealed that the Operations Manager was listed as the Administrator and hired on 5/8/2023. Record review of Texas Unified Licensure Information Portal (TULIP), NFA license search revealed that the Operations Manager is not currently licensed as a Nursing Facility Administrator. Under status it had Prospective. Further review of TULIP revealed that the former Administrator and license was still listed for the facility. Record review of personnel record for the Operations Manager revealed that his pre-employment checklist had under the licensure verification of application listed the NFA license number as #111718 and expiring on 6/30/2023. This was checked and verified by HR representative. The operations Manager signed the checklist on 5/1/2023. There was no record of AIT documentation or copy of the license listed on this checklist. Record review of Job description for the Executive Director revealed in part: Position Summary states the Executive Director leads and directs the overall operations of the facility in accordance with patient/resident needs, government regulations and company policies to maintain quality care for the patients/residents while achieving the facility's business objectives. Minimum Qualifications knowledge, skills and abilities): College degree or the equivalent in related work experience, current, valid Nursing Home Licensing specific to the state of practice and 2+ years of management experience in a long-term care setting. The Executive Director reports to the VPO. During an attempt to interview the new Human Resource representative on 7/6/2023 at 3:47pm, revealed that he was not at work. Review of supervisory documentation/training was not provided for the Operations Manager prior to exit. Record review of TAC §554.1902(a) revealed .The governing body must: (2) ensure that a person designated as being in authority notifies HHSC immediately when the facility does not have an administrator. 676208 Page 4 of 4