Health inspection·February 1, 2023

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of a nurse note, dated 01/05/23, indicated Resident #378 was admitted to the facility with a central venous catheter. There was no documentation from 01/05/23 to present in the medical record to indicate the resident's midline catheter dressing had been changed until 01/30/23, after state surveyor intervention. During an interview on 02/01/23 at 8:30 a.m., the MDS Coordinator said Resident #378 had no MD order for a central line dressing or other interventions related to antibiotic therapy and central line care due to his Dx. of Osteomyelitis to trigger the assessment. He said he missed capturing Section M skin conditions indicated, application of nonsurgical dressings during the admission assessment, because the admission nurse had failed to obtain an order for the care of the central line. During an interview on 02/01/23 at 2:00 p.m., the Interim Admin said the DON informed him Resident #378 had not received a central venous dressing change since admission from the hospital. The interim Admin said his expectations were for the resident's assessment to be completed correctly. He said the ADON and the DON are responsible for ensuring staff are assessing residents needs and obtaining orders. He said if the assessment was not accurate, the resident may not receive the appropriate care. He said the MDS assessments were completed according to the RAI (Resident Assessment Instrument) guidance. Record review of Nursing Policies and Procedures, dated 10/01/2019, revealed Policy Minimum Data Set (MDS) . 3. Interview, observe and physically assess the resident to obtain validation of items identified on the medical record and to collect information for items where no documentation exists. Documentation of participation must include direct observation and communication with the resident, as well as communication with licensed and non-licensed direct care staff members on all shifts. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676362 If continuation sheet Page 2 of 19 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 676362 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bridgecrest Rehabilitation Suites 14100 Karissa Court Houston, TX 77049 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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that met professional standards of quality care for 2 of 16 residents (Residents #76 and #378) reviewed for baseline care plans. 1. The facility failed to develop a baseline care plan or comprehensive care plan to address person-centered care for Resident #76. 2. The facility failed to develop a baseline care plan with interventions and goals for Resident #378's Central [NAME] Catheter (CVC) care. These failures could place residents at risk of not receiving care and services to meet their needs. Findings include: 1.Record review of a face sheet, dated 02/01/23 revealed Resident #76 was an [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included bacterial infection, hyperlipidemia (high fat in the blood) and edema (fluid retention-swelling). He was discharged on 1/3/23. Record review of Resident #76's closed clinical record revealed no baseline care plan or comprehensive care plan. During an interview on 02/01/23 at 11:09 a.m., the Interim Admin said there was no baseline care plan for Resident #76 in his chart and he was unable to produce one. He said residents could be at harm because staff may not be able to meet the needs of the residents due to not having a baseline care plan available to staff. 2. Physician orders, dated January 2023, indicated Resident #378 was admitted to the facility on [DATE]. Resident #378 was a [AGE] year-old male with diagnoses which included osteomyelitis (infection to the bone), diabetes mellitus (high blood glucose) with diabetic neuropathy (nerve damage). The resident was ordered cefepime 1000 mg give 1 gm IV (intravenously) TID (three times every day). Record review of the baseline care plan, dated 01/09/23, indicated Resident #378 had no interventions on his baseline care plan related to antibiotic therapy and central line care due to his Dx. of Osteomyelitis. Record review of the comprehensive care plan, dated 01/26/23, indicated Resident #378 had no interventions related to antibiotic therapy and central line care due to his Dx. of Osteomyelitis During an interview on 02/01/23 at 9:00 a.m., the DON said her expectations were for all residents to have an accurate baseline care plan. She said residents could be at harm because staff may not be able to meet the needs of the residents due to not having a baseline care plan available to staff. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676362 If continuation sheet Page 3 of 19 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 676362 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bridgecrest Rehabilitation Suites 14100 Karissa Court Houston, TX 77049 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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete During an interview on 02/01/23 at 2:00 p.m., the Interim Admin said the DON informed him Resident #378 did not have an accurate baseline care plan. He said residents could be at harm because staff may not be able to meet the needs of the residents due to not having a baseline care plan available to staff. Record Review of Person Centered Care Plan Process policy, dated 07/01/2016, indicated . Procedures: 1. Develop and implement the baseline care plan within 48 hours of a resident's admission. 2. The baseline care plan will include the minimum healthcare information necessary to properly care for the resident including, but limited to initial goals on admission orders, residents' goals, physician orders, dietary orders, therapy services, and PASARR recommendations, if applicable. 3. Following the RAI Guidelines and implement a comprehensive assessment. 4. Provide the resident and their legal representative a copy of the baseline care plan summary by completion of the comprehensive assessment. Event ID: Facility ID: 676362 If continuation sheet Page 4 of 19 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 676362 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bridgecrest Rehabilitation Suites 14100 Karissa Court Houston, TX 77049 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment and failed to ensure the comprehensive care plan described services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 16 residents (Resident #378) reviewed for care plans. The facility failed to ensure Resident #378's comprehensive person-centered care plan addressed the resident's risk, interventions or goals for dressing and care of a central line. This failure could place residents at risk of not receiving appropriate treatment and services. The findings were: Record review of physician orders, dated January 2023, indicated Resident #378, admitted to the facility on [DATE]. Resident #378 was a 63-year--old male with diagnoses which included osteomyelitis (infection to the bone), diabetes mellitus (high blood glucose) with diabetic neuropathy (nerve damage). The resident was ordered cefepime 1000 mg, give 1 gm IV (intravenously) TID (three times every day). Record review of an order, dated 1/30/23, indicated the catheter dressing was to be changed, once weekly every Sunday. The order was obtained after state surveyor intervention. Record review of an admission MDS assessment for Resident #378, dated 01/10/23, indicated DX of Acute Osteomyelitis, with treatment of IV Cefepime. Resident #378 was cognitively intact and required extensive assistance for ADL care. In Section M skin conditions indicated; application of nonsurgical dressings was not captured. Record review of the comprehensive care plan, dated 01/26/23, indicated Resident #378 had no interventions related to antibiotic therapy and central line care due to his Dx. of Osteomyelitis. During an interview on 02/01/23 at 8:30 a.m., the MDS Coordinator stated he was responsible for developing and revising the comprehensive person-centered care plan. The MDS Coordinator said the comprehensive person-centered care was important because it contained information on how to care for Resident #378 and identified what kind of services the resident needed. The MDS Coordinator said Resident #378 interventions and goals for central line care had been left off his care plan because there was no order for dressing changes obtained upon admission. He said he missed capturing Section M skin conditions indicated, application of nonsurgical dressings during the admission assessment, if he would have included the CVC dressing, the assessment would have trigger care and interventions to the care plan. He said he was responsible for making a physical assessment and review of orders of Resident #378 to capture interventions on the MDS that would flow to the care plan, but he missed the CVC for infusing the antibiotics. During an interview on 02/01/23 at 9:00 a.m., the DON said her expectations were for the admitting nurse to review all orders and initiated a baseline care plan. The MDS Coordinator would complete (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676362 If continuation sheet Page 5 of 19 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 676362 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bridgecrest Rehabilitation Suites 14100 Karissa Court Houston, TX 77049 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 0656 Level of Harm - Minimal harm or potential for actual harm the MDS, and the assessment would flow to the comprehensive care plan. She said residents could be at harm because staff may not be able to meet the needs of the residents due to not having a comprehensive care plan available to staff. Record Review of Person Centered Care Plan Process policy, dated 07/01/2016, Residents Affected - Few Indicated the Interdisciplinary Team (IDT) will review for effectiveness and revise the care plan after each assessment. The includes both the comprehensive and quarterly assessments .10.Thru ongoing assessment, the facility will initiate care plans when the resident's clinical status or change in condition dictates the need of such .12. The person-centered care plan will include A. Date B. Problem C. Residents goals for admission and desired outcomes. D. Time frames for achievement. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676362 If continuation sheet Page 6 of 19 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 676362 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bridgecrest Rehabilitation Suites 14100 Karissa Court Houston, TX 77049 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure a resident received care consistent with professional standards of practice, to prevent pressure ulcers and did not develop pressure ulcers unless the individual's clinical condition demonstrated it was unavoidable and residents with pressure ulcers received necessary treatment and services consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 of 3 residents (Resident #38) reviewed for pressure ulcers. Residents Affected - Few The facility failed to ensure Resident #38 received wound care treatments to prevent the development of or worsening of pressure ulcers. This failure could place residents at risk for improper wound management, the development of new pressure ulcers and deterioration in existing pressure ulcers/injuries. The findings include: Record review of an undated face sheet for Resident #38 indicated a female who admitted to the facility on [DATE] and was [AGE] year-old. Resident #38 had diagnoses which included systolic congestive heart failure (heart not able to pump efficiently), pressure of left heel, stage 4 (wound on left heel that is deep reaching muscles, ligaments, or bones), vascular dementia (brain damage caused by multiple strokes), and major depressive disorder (persistent feeling of sadness and loss of interest). Record review of a Quarterly MDS for Resident #38, dated 11/4/2022, indicated she was rarely/never understood and at risk of developing pressure ulcers/injuries but did not have any unhealed pressure ulcers/injuries at that time. Record review of a physician order for Resident #38 indicated an order start date of 1/8/2023 for an order to cleanse stage 4 left heel with normal saline, Santyl, Bactroban, and foam dressing (may secure with Kerlex as needed) once a day on Sunday and Saturday. Record review of a licensed administration history dated 1/1/2023 to 1/31/2023, for Resident #38 indicated an order to cleanse stage 4 left heel with normal saline, Santyl, Bactroban, foam dressing once a day on Sunday and Saturday. On 1/28/2023 was initialed by LVN I and on 1/29/2023 by LVN J which indicated the treatment was completed by them. Record review of a Wound Treatment Administration history dated 1/1/2023 to 1/31/2023, for Resident #38 indicated an order for daily wound treatment to cleanse stage 4 left heel with normal saline, Santyl, Bactroban, foam dressing once a day on Monday, Tuesday, Wednesday, Thursday, and Friday with a start date of 1/7/2023 indicated no initials were present on dates 1/9, 1/19 and 1/25 which indicated the treatment was not completed. Record review of a Wound Physician Report dated 1/3/2023, for Resident #38 indicated a pressure ulcer to left heel that measured 4 cm x 4 cm x 1.3 cm and it was an initial exam for stage 4 pressure injury that had moderate serous drainage and 76-100% of moist black eschar. Wound was debrided and orders given to cleanse wound to left heel with normal saline, apply Santyl, apply Bactroban, apply alginate, cover wound with dry absorptive dressing, change dressing daily. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676362 If continuation sheet Page 7 of 19 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 676362 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bridgecrest Rehabilitation Suites 14100 Karissa Court Houston, TX 77049 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of a Care plan for Resident #38, dated 1/4/2023, indicated she had a stage 4 pressure ulcer to left heel. Measurement 3.5 cm x 3.2 cm with an approach to notify md of any signs and symptoms of infection. Keep clean and dry as possible. Minimize skin exposure to moisture. Provide daily wound care as ordered. Record review of a physician order for Resident #38 indicated an order, dated 1/7/2023, for daily wound treatment to clean stage 4 left heel with normal saline, Santyl, Bactroban, and foam dressing (may secure with kerlix as needed) once a day on Monday, Tuesday, Wednesday, Thursday, Friday. Record review of a facility action plan, dated 1/25/2023 indicated, .The facility has self-identified a concern with skin management/pressure ulcer prevention and processes related to the skin system with a root cause analysis of lack of key positions to ensure follow up and a stable system including no full-time wound nurse; lack of consistent direct staff. Baseline data indicated an audit revealed missing weekly skin assessments; inconsistent/incorrect skin assessments, wound management documentation is inconsistent/not present/not updated. Interventions included: clinical morning meeting process to be implemented with treatment nurse present and daily follow-up and communication regarding pressure ulcers and wounds/wound management with a date of completion 2/6/2023 . Record review of a medication/treatment error investigation worksheet dated 2/1/2023 for Resident #38 indicated on 1/28/2023 the nurse (no name indicated) failed to complete treatment per order to left heel over the weekend, falsified documentation by signing off on the treatment order that wound care was provided to Resident #38. Follow up/steps taken skilled nurse will perform wound treatment as ordered/assigned by ADON/DON or other designee to validate treatment. On 2/1/2023 treatment performed and completed. Daily wound care performed. No distress noted during wound care when performed. During an observation and interview on 1/30/2023 at 3:30 PM, in Resident #38's room, LVN E pulled the linens back to reveal a dressing to Resident #38's left foot, dated 1/27/2023. LVN E said wound care was supposed to be done daily to her knowledge to Resident #38's left heel and said her last day of work at the facility was on 1/27/2023 and she was off over the weekend. She said wound care on the weekends was performed by the nurses or the treatment nurse. During an interview on 1/31/2023 at 9:00 AM, LVN F said she was employed at the facility full time but had only been there for a month. She said she only worked Monday-Friday. She said the charge nurses were responsible for doing wound care treatments until the new treatment nurse started on 2/06/2023. She said she did not work this past weekend but would be doing treatments this week. She did not know who was responsible for treatments the past weekend. During an interview on 1/31/2023 11:50 AM, the DON said LVN H was the treatment nurse at the facility and left in December 2022. She said the Wound Care Physician came to the facility on Mondays and sometimes the nurses would forget to document on the TAR because the Wound Care Physician did the wound care on those days. She said if the TAR had a blank on the date indicated for wound care treatment, then it meant the wound care was not performed. She said Resident #38 had an order for wound care to her left heel for treatments to be done daily that started on 1/7/2023. She said when the facility had a full-time treatment nurse they did not have any issues with wound care not being performed. She said the facility put an action plan in place, dated 1/25/2023, regarding skin management/pressure ulcer prevention and processes related to the skin system. She said the action plan had not been taken to QAPI yet and they had meetings monthly. She said on 1/25/2023 when the action plan was put in place by the Clinical Nurse, she was off and today was her first day back. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676362 If continuation sheet Page 8 of 19 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 676362 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bridgecrest Rehabilitation Suites 14100 Karissa Court Houston, TX 77049 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 2/1/2023 at 8:10 AM, the DON said she was not aware Resident #38 did not receive wound care this past weekend (1/28/2023-1/29/2023). She said this past weekend agency staff worked. She said she was not aware the nurses that worked this past weekend (1/28/2023-1/29/2023) signed off on the TAR to indicate the wound care was done on 1/28/2023 and 1/29/2023 when the dressing to Resident #38's left heel was dated 1/27/2023 on 1/30/2023. She said the Clinical Nurse came to the facility on 1/25/2023 and she was off that day. The DON said the Clinical Nurse created the action plan after conducting an audit and found issues with wound care. The DON said yesterday she conducted an in-service on wound management/treatments and said if the wound care nurse was not present then she would designate someone to complete the wound care treatments. The DON said on the weekends she would specifically assign someone to complete the wound care treatments and would have the RN supervisor on the weekends to provide oversight to ensure wound treatments were done. She said if a resident did not receive wound care treatments daily as ordered by the physician, the wound could worsen, deteriorate, get infected or develop sepsis. She said her expectation going forward would be for the DON to run the missed administration report every morning to see what was not done by the nurse and would have the weekend RN to run the same report on the weekends. During an interview on 2/1/2023 at 8:20 AM, the Clinical Nurse said on 1/25/2023 she created an action plan when she noticed some assessments and wound documentation was inconsistent, so she emailed the Administrator because the DON was leaving her position and returning to being a floor nurse at the facility. She said she was unaware Resident #38 did not receive wound care this past weekend (1/28/2023-1/29/2023). She said the facility had hired a new DON and she started this week. During a phone interview on 2/1/2023 at 9:23 AM, LVN I (agency nurse) said she had only worked three times at the facility. She said she worked a double last Saturday 1/28/2023 from 6 AM to 2 PM and 2 PM to 10 PM on hall 200. She said she had a couple of residents who required preventative measures such as applying barrier cream and she changed the dressings on residents who had showers. She said she was not able to recall who the residents were. She said she did get a full report from the nurse prior to her shift starting and it was very thorough but was not told anything specific about wound care or who needed to do the wound care treatments. She said she was under the impression the facility had someone designated to provide wound care treatments. She said if a resident had a wound dressing that was soiled, she did change it. Record review of a facility policy titled Wound Care Policies and Procedures, dated 2017, indicated, .All treatments should be in conjunction with a physician's orders, Wound evaluation: the facility should have a system in place for daily observation of pressure ulcers/wounds which may include: an evaluation of the ulcer, an evaluation of the status of the dressing, status of the skin surrounding the ulcer that can be observed FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676362 If continuation sheet Page 9 of 19 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 676362 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bridgecrest Rehabilitation Suites 14100 Karissa Court Houston, TX 77049 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 0694 Provide for the safe, appropriate administration of IV fluids for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure parenteral fluids were administered consistent with professional standards of practice and in accordance with physician orders, the comprehensive person-centered care plan, and the residents' goals and preferences for one of one resident (Resident #378) reviewed for parenteral IV fluids. Residents Affected - Few The facility failed to ensure the dressing covering for Resident #378's central venous (CVC) site to the right chest was changed after the resident admitted from the hospital on [DATE]. Resident #378's dressing was undated and had not been changed for 25 days and failed to apply an end cap, to prevent contamination to the intravenous tubing line when not in use. This failure could place residents at risk of the intravenous site becoming infected and the line becoming unusable. Findings include: During an observation and interview on 01/30/23 at 10:45 a.m., revealed Resident #378 was lying in bed. The resident had a central venous catheter (CVC [a catheter placed in a large vein for medication infusion]) to the right chest covered with a clear non- occlusive dressing with no date or initials and insertion site appeared clean with no redness or drainage. An empty bag labelled Cefepime 1000 mg give 1 gm IV in 50 ml dextrose 5% was hung from an IV pole with the connected port open with no protective cap. During an interview, LVN A said the resident received cefepime 1GM three times daily through the CVC line catheter for osteomyelitis. During observation and interview on 01/30/23 at 11:10 a.m., revealed Resident #378 was lying in bed, awake and alert. Resident #378 said he did not remember his dressing being removed and the site being cleaned, or a new dressing being applied. Observation of the central venous catheter dressing to the resident's right chest was undated. LVN A said she was not sure how often the dressing needed to be changed usually weekly and the RNs were responsible for changing the central venous dressings. LVN A said the LVNs were responsible for reporting newly admitted or readmitted residents with midlines, PICC lines, central lines, etc. to the RN on duty. She said she thought the dressing was supposed to be changed every week and agreed the site should be dated. She said the dressing needed to be changed and would call the RN. She said the normal process was to place a cap at the end of the IV tubing to prevent infection. LVN A said she would discard the tubing now, since she had not capped the end when she discontinued the infusion. She said not changing the dressing and capping the line could cause septicemia (poisoning of the blood caused by bacteria). Record review of Physician orders, dated January 2023, indicated Resident #378 was admitted to the facility on [DATE]. Resident #378 was a [AGE] year-old male with diagnoses which included osteomyelitis (infection to the bone), diabetes Mellitus (high blood glucose) with diabetic neuropathy (nerve damage to lower extremities). The resident had an order dated 01/05/23 for cefepime 1000 mg give 1 gm IV (intravenously) TID (three times every day) with Normal saline flushes before and after. There was no order for a central line dressing change. Record review of an admission MDS assessment, dated 01/10/23, indicated Resident #378 was cognitively intact. The resident required extensive assistance for ADL care. In section M skin conditions (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676362 If continuation sheet Page 10 of 19 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 676362 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bridgecrest Rehabilitation Suites 14100 Karissa Court Houston, TX 77049 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 0694 indicated; application of nonsurgical dressings was not captured. Level of Harm - Minimal harm or potential for actual harm Record review of the baseline care plan, dated 01/09/23, indicated Resident #378 had no interventions related to antibiotic therapy and central line care due to his dx. of osteomyelitis. There were no interventions to administer the antibiotic three times daily, assess for complications of localized infection, systemic infection, dislodgement, infiltration, phlebitis (infection of a vein), etc., or discontinue IV at first sign of infiltration or local inflammation and change dressing. Residents Affected - Few Record review of the comprehensive care plan, dated 01/26/23, indicated Resident #378 had no interventions related to antibiotic therapy and central line care due to his Dx. of Osteomyelitis. Record review of the TAR, dated 01/05/23 to 01/29/23, had no documentaion of an order or documentation of a dressing change had been completed since admission. Resident #378 received a dressing change to the midline catheter until 01/30/23, after state surveyor intervention, which was 25 days after the last dressing change. There was no documentation to indicate the resident received an assessment of the central vascular insertion site. Record review of a nurse note dated 01/05/23, indicated Resident #378 was admitted to the facility with a central venous catheter. There was no documentation from 01/05/23 to 01/30/23 to indicate the resident's midline catheter dressing had been changed until documentation on nurses note dated 01/30/23 indicated an order had been obtained and the dressing to the CVC site was changed by the ADON. Record Review of an order obtained by the ADON dated 1/30/23, indicated the catheter dressing was to be changed, once weekly every Sunday. The order was obtained after state surveyor intervention. During interview on 01/30/23 at 12:22 p.m., ADON B said the central venous dressing change for Resident #378 was missed and should have been changed every 7 days. She said the resident was at risk for infection and complications to the midline catheter if the dressing was not changed as ordered. Record review of an incident report dated 01/31/23 completed by the ADON indicated resident #378 had not received CVC dressing change. CVC line dressing order omitted.MD and RP notified orders and dressing addressed. During an interview on 02/01/23 at 8:30 a.m. the MDS/Care plan nurse said Resident #378 had no MD order for a central line dressing or other interventions related to antibiotic therapy and central line care due to his dx. of Osteomyelitis to trigger the assessment. He said he missed capturing Section M skin conditions indicated, application of nonsurgical dressings during the admission assessment. During an interview on 02/01/23 at 9:00 a.m., the DON said her expectations were for the admitting nurse to review all orders, notify the physician for order clarification, document all orders and give 24-hour report to the 2 ADONs and the DON and to notify the RN on duty so they would be aware of the required dressing change. The DON and ADONs then need to review the 24-hour report to ensure orders were followed up on. The DON said not obtaining an order and changing the dressing and not capping the line could cause septicemia (poisoning of the blood caused by bacteria). She said that the doctor had been notified of the error and an incident report created. During an interview on 02/01/23 at 2:00 p.m., the Interim Admin said the DON informed him Resident #378 had not received a central venous dressing change since admission from the hospital. He said (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676362 If continuation sheet Page 11 of 19 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 676362 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bridgecrest Rehabilitation Suites 14100 Karissa Court Houston, TX 77049 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 0694 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few his expectations were for the new residents to receive a head-to-toe assessment from the floor nurse and for the nurse to capture all aspects of the resident's care needs, then give 24-hour report to the ADONs and DON. He said there was a break in communication. Record review of the Nursing Policies and Procedures, Physician Orders policy, dated 2017, indicated .2. A call is placed to the physician to confirm the orders and request any additional orders needed . 3. Upon admission, the Facility has physician orders for the resident's immediate care to include but not limited to: A. Dietary orders, B. Medications, if necessary, and C. Routine care orders to maintain or improve the resident's functional abilities until staff can conduct a comprehensive assessment and develop appropriate care plan. Record review of the Peripherally Inserted Central Catheter Line, Insertion of and Site Care policy, dated 2018, indicated . 40. After the first twenty-four hours, replace the 2x2 gauze dressing with a sterile, transparent, occlusive dressing. This dressing can be left in place for 3 to 7 days or per physician's orders unless it becomes damp, loose, soiled or if the patient develops a problem at the insertion site .42. Dressing change should be labeled with date . 44. Assess insertion site for phlebitis, leaking, clotting, catheter breakage and document FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676362 If continuation sheet Page 12 of 19 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 676362 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bridgecrest Rehabilitation Suites 14100 Karissa Court Houston, TX 77049 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences for 4 of 12 residents (Residents #24, #25, #35 and #46) reviewed for respiratory care. Residents Affected - Some 1. The facility failed to ensure Resident #24's nasal cannula tubing was dated and prefilled humidifier was dated. 2. The facility failed to ensure Resident #25's nasal cannula tubing was changed according to physician orders and the prefilled humidifier was dated. 3. The facility failed to ensure Resident #35's oxygen nasal cannula was changed according to physician orders. 4. The facility failed to ensure Resident #46's nebulizer face mask was bagged, labeled and tubing was changed according to physician orders. These deficient practices could place residents at risk of developing respiratory infections and complications. Findings include: 1. Record review of Resident #24's face sheet, dated 01/31/2023, indicated Resident # 24 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included acute and chronic respiratory failure and pneumonia (lung infection). Record review of Resident #24's physician orders, dated 01/31/2023, indicated oxygen at 3-5 liters per nasal cannula with start date of 11/04/2022 and change oxygen tubing every week on Sunday with start date of 11/04/2022. Record review of the admission MDS, dated [DATE], indicated Resident # 24 required oxygen therapy. Record review of Resident #24's care plan, dated 11/22/2022, indicated Resident # 24 had acute and chronic respiratory failure with hypoxia (low blood oxygen) and required oxygen and oxygen setup per facility protocol. During an observation on 01/30/2023 at 11:54 AM revealed Resident # 24 was receiving oxygen at 3 liters per nasal cannula and the oxygen tubing was not dated and the prefilled humidifier (bubbler) was dated 01/18/2023. 2. Record review of Resident #25's facility face sheet, dated 01/31/2023, indicated Resident #25 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included hyponatremia (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676362 If continuation sheet Page 13 of 19 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 676362 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bridgecrest Rehabilitation Suites 14100 Karissa Court Houston, TX 77049 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 0695 (low sodium) and shortness of breath. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #25's physician orders, dated 01/31/2023, indicated oxygen 2 liters per nasal cannula with a start date of 12/01/2022 and change oxygen tubing weekly on Sunday start date 12/01/2022. Residents Affected - Some Record review of Resident #25's care plan, dated 11/09/2022, indicated Resident # 25 with ineffective breathing pattern and required oxygen therapy. Record review of annual MDS, dated [DATE], indicated Resident # 25 required oxygen therapy. During an observation on 01/30/23 at 10:58 AM revealed Resident # 25 had oxygen in place at 2 liters per nasal cannula connected to a prefilled humidifier bottle (bubbler). The Nasal cannula tubing was dated 01/21/2023 and the prefilled humidifier was undated. During an interview on 01/30/2023 at 11:00 AM, Resident # 25 stated she wore her oxygen all the time and was not sure when her oxygen supplies were changed. 3. Record review of Resident #35's face sheet, dated 01/31/2023, indicated Resident #35 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included diabetes (high blood sugar), shortness of breath, and wheezing. Record review of Resident #35's physician orders, dated 01/31/2023, indicated oxygen at 2-4 liters per nasal cannula at bedtime with start date of 09/19/2022 and change oxygen tubing weekly on Sunday with start date of 07/28/2021. Record review of Resident #35's quarterly MDS, dated [DATE], indicated oxygen therapy. Record review of Resident #35's care plan, dated 12/07/2022, indicated Resident #35 had shortness of breath related to respiratory disease and required oxygen therapy with intervention to administer oxygen via nasal cannula. During an observation on 01/30/23 at 10:38 AM revealed Resident # 35's oxygen tubing was dated 01/21/2023. During an interview on 01/30/2023 at 10:40 AM, Resident # 35 stated he wore his oxygen at night. He was unsure how often the tubing was changed. 4. Record review of Resident #46's face sheet, dated 01/31/2023, indicated Resident # 46 was a [AGE] year-old female admitted to facility on 08/20/2022 with diagnoses which included dementia (memory loss) and shortness of breath. Record review of Resident #46's physician orders, dated 01/31/2023, indicated Resident #46 received budesonide nebulization suspension two times a day with a start date of 08/24/2022 and formoterol fumarate nebulization solution two times a day with start date of 08/24/2022. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676362 If continuation sheet Page 14 of 19 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 676362 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bridgecrest Rehabilitation Suites 14100 Karissa Court Houston, TX 77049 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of Resident #46's care plan, dated 11/23/2022, indicated Resident # 46 had ineffective breathing related to chronic obstructive pulmonary disease (lung disease) and nebulized medications ordered. During an observation on 01/30/2023 at 10:30 AM revealed Resident #46 had a nebulizer face mask laying across the bedside table and was unbagged or labeled and the tubing was dated 01/17/2023. During an interview on 01/30/2023 at 10:32 AM revealed Resident #46 was not sure when the nurses changed out her nebulizer supplies and could not recall if she ever had a bag. During an interview on 01/30/2023 at 09:50 AM, LVN A stated oxygen tubing and nebulizer setups were changed on the night shift each week but each nurse was responsible for their patients on each shift. She stated she was not aware any tubing was out of date and the risk could be infections. During an interview on 01/30/2023 at 11:48 AM, LVN D stated every nurse was responsible for checking that oxygen and nebulizer supplies were in date. She stated the nurse at night changed out the tubing and nebulizer setups every week on Sunday. She stated the risk could be infections. During an interview on 02/01/2023 at 8:38 AM, the DON stated the nurses on the night shift were responsible for changing out the oxygen tubing and nebulizer setups each Sunday night or as needed. She stated the ADON was responsible for hall checks and ensuring tasks were completed. She stated the risk could be infection and improper distribution of oxygen. She stated she had put new processes in place and in-serviced all staff on the facility policy and expected the policy to be followed. During an interview on 02/01/2023 at 10:45 AM, the Interim Administrator stated the DON and ADON were responsible for oversight in the nursing department. He stated he would assist with overseeing the DON and ADON were retraining nursing staff on policy and procedures and his expectation was that the policy was followed. Record review of the facility policy and procedure titled Respiratory equipment change schedule, dated 04/01/2022, indicated .nasal cannula to change per state regulation and bubbler changed with circuit. Record review of the facility policy and procedure titled Respiratory Equipment change schedule, dated 04/01/2022, indicated .aerosol tubing to be changed weekly or per state regulations. Nebulizer setup to be placed in a clean, dry plastic bag labeled with patient/resident name. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676362 If continuation sheet Page 15 of 19 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 676362 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bridgecrest Rehabilitation Suites 14100 Karissa Court Houston, TX 77049 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview and record review the facility failed to ensure drugs and biological's used in the facility were labeled in accordance with currently accepted professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 of 3 medication carts (nurse cart 200 hall) reviewed for labeling and storage. The facility failed to remove expired medication and expired glucose control solution from the nurse medication cart on hall 200. This deficient practice could place residents at risk for receiving outdated medications and improper glucose monitoring and could result in residents not receiving the intended therapeutic effects of their medications causing a health decline. Findings include: During observation of the medication cart on 200 hall on 01/31/23 at 9:50 AM revealed Resident #31 had Basaglar 100 units/milliliter insulin pen with an open date of 01/01/2023. The Label on the pen indicated to discard after 28 days of the open date. The glucose control solution on 200 hall medication cart was dated as opened on 4/25/2022 and the package insert indicated to discard 90 days after opening. During an interview on 01/31/23 at 9:55 AM, LVN A stated she had been employed at the facility for 5 months. She stated it was the nurses responsibility to check medication expiration dates before administering. She stated she did not administer Resident #31's Basaglar insulin and it was given in the evening. She stated the night nurses were responsible for checking glucometer controls and was not aware how long control solution was good for. She stated the risk could be ineffective medication and inaccurate blood sugar readings. During an interview on 01/30/2023 at 11:48 AM, LVN D stated every nurse was responsible for checking medication expiration dates before administering them and a resident could have an adverse effect if they took expired medications. LVN D stated glucose controls were checked on the night shift but at times other shifts may have to check controls. She stated control solution did expire and she would look at the package insert to know how long it was good for. She stated blood glucose levels could be inaccurate if glucometer controls were checked with expired solution. She stated she thought the pharmacist checked the carts monthly for expired medications. During an interview on 01/31/23 at 10:06 AM, the DON stated the nurses were responsible for checking every medication's expiration dates before administering them and the risk of not doing so could be an adverse reaction. The DON stated the night nurses were responsible for ensuring the glucometers were checked and control solution was within date. The DON stated there had not been a system in place for monitoring medication carts but the plan was to schedule routine cart audits and provide retraining to the staff. During an interview on 02/01/2023 at 10:45 AM, the Interim Administrator stated the DON and ADON were responsible for oversight in the nursing department. He stated he would assist with overseeing the DON and ADON retrained nursing staff on policy and procedures and those policies were followed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676362 If continuation sheet Page 16 of 19 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 676362 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bridgecrest Rehabilitation Suites 14100 Karissa Court Houston, TX 77049 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Record Review of the facility policy and procedure titled Medication Administration - Insulin Pen, dated 07/01/2016 indicated, .Inspect expiration date on pen. Inspect date opened to ensure pen use within established parameters. (max 28 days or less depending on product. Record review of the facility policy and procedure titled Bedside Blood Glucose Monitoring Quality Control, dated 07/01/2016, indicated, .5. Once open, glucose control solutions are stable for the number of months designated by the manufacturer or until the expiration date, whichever comes first. Event ID: Facility ID: 676362 If continuation sheet Page 17 of 19 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 676362 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bridgecrest Rehabilitation Suites 14100 Karissa Court Houston, TX 77049 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 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to maintain an effective pest control program so that the facility was free of pests and rodents for 1 of 4 hallways (hall 100) reviewed for environment and pests. Residents Affected - Few The facility failed to ensure ants were kept out of the room of Resident #4. This failure could place residents at risk for ant bites and injury due to an ineffective pest control program at the facility. Findings include: Record review of Resident #4's face sheet, dated 01/30/2023, indicated a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included abscess of the buttock, muscle wasting, lack of coordination (difficulty maintain balance) and nausea. Record review of A Significant Change MDS Assessment for Resident #4, dated 9/12/2022, indicated she had moderate impairment in thinking with a BIMS score of 9. Resident #4 required extensive assistance with bed mobility, transfers, dressing, toilet use and personal hygiene. During an observation and interview on 01/30/23 at 11:00 AM, a dirt mound with red ants were actively moving about in Resident #4's bathroom, crawling on the floor and along the wall. A white powdery substance was along the wall in the bedroom and bathroom. Red ants were at the base of the bathroom door with red dirt piled up at the right-side door facing. Resident #4 was sitting up in bed in her room alert to person, place, and time. She said she had been a resident at the facility for a long time. She said there were ants in her bathroom. She said the nursing staff told the maintenance man and he put poison out along the walls in her bedroom and bathroom on Friday, but the ants were still alive in her bathroom. Resident #4 said had not been bitten but she was scared they might come in her bed and bite her. She said no one had offered to move her from her room and to her knowledge no one had come and sprayed Saturday or Sunday. During an interview on 01/30/23 at 3:30 AM, the Maintenance Director (MD) said the nursing staff told him about the ants on Friday. He said housekeeping swept and mopped, then he put down ant/roach killer powder and the MD then contacted pest control. He did not follow up to see if pest control came to treat the room because he was off on Saturday and Sunday. He said no staff member at the facility called him to let him know the ants were still active. The MD said he had not been back to look at the area since Friday. He said he was not aware the ants were not dead. The MD said not ensuring the ants were dead and not removing the residents from the room could result in bites and pain. The MD said he would call pest control again today since the ant were still alive and active and request treatment of the area. During an interview on 1/30/23 at 3:41 AM, ADON B was not aware ants were in Resident #4's room but would see that ants were treated by Pest Control. The ADON said she would check to see what needed to be done. She said the nurses should have called the MD and reported the ants were not dead. She said the resident should have been moved. She said the risk could be ant bites and pain. Record Review of pest control receipts dated 1/25/23, 12/28/22 and 11/23/22 included treatment for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676362 If continuation sheet Page 18 of 19 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 676362 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bridgecrest Rehabilitation Suites 14100 Karissa Court Houston, TX 77049 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 0925 ants. Level of Harm - Minimal harm or potential for actual harm Record review of progress notes written by the SW for Resident #4, dated 01/31/2023 at 11:19 a.m., revealed SW received call back from this neighbor's daughter on yesterday evening. SW informed her of this temporary room change and provided her with the room number currently in 106. Residents Affected - Few Record review of Nurses Notes for Resident #4 dated 01/30/2023 at 04:52 p.m. revealed SW visited 1:1 with this neighbor regarding her changing from room [ROOM NUMBER] to 106 temporarily. She verbalized understanding. SW informed her that a message was left on her daughter's voice mail requesting a return call to this SW, will inform the daughter of this room change related to ants in her former room. Resident was able to sign the room change form. SW will continue to assist accordingly. 01/30/2023 04:27 PM Resident has been moved to another room temporarily related to ants in room. Social services have reached out to family. Resident skin check performed with no noted bites, redness to skin. Medical Doctor notified of temporary room change, ADON. Record review of the facility policy titled Pest Control, revised 7/1/2016, indicated, . Facility staff will: A Note and report any evidence of pest activity. All documentation/ reports shall be as detailed as possible. B. Report sighting of live pests immediately to the Integrated Pest Management Coordinator to request emergency service to provide additional, unscheduled treatment as necessary. C. Make note of the exact location of where the pest sighting has occurred and inform the integrated Pest Management Coordinator immediately. maintain an effective pest control program to prevent or eliminate infestation of pests and rodents. 1. This facility maintains an ongoing pest control program to ensure that the building is kept free from insects and rodents FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676362 If continuation sheet Page 19 of 19