Health inspection·November 14, 2023

F 0919 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some that interfere with daily function or placed the resident at risk of injury. He used a wheelchair for mobility. He was always incontinent of bowel and bladder. Resident #1 had a fall since reentry prior to assessment. Further review revealed Resident #1 did not have any injury from the fall. Record review of Resident #1's care plan revised on 08/22/2023 revealed: Problem - Resident #1 was at risk for falls d/t impaired cognition, impaired mobility. He had a fall on 06/28/2023 while trying to use the restroom without assistance which resulted in a back fracture. He had a fall on 8/18/2023 trying to use the restroom without assistance, no injury noted. The long-term goal was, Resident #1 will remain free from injury. Approach - place resident in a fall prevention program. Observe frequently and place in supervised area when out of bed. Provide with safety device/appliance if applicable. Provide toileting assistance when needed. Problem - Resident #1 had diagnosis of seizures and at risk for injury. Medication: Levitiracetam. Goal - Resident #1 will not injure self secondary to seizure disorder. Approach included: keep call light within reach. Resident #1 had diagnosis of CVA (brain stroke) with hemiplegia (weakness to one side of the body) and was at risk for decreased cardiac output. Goal - Resident #1 will participate in exercises necessary to maintain muscle strength and tone. Approach included - Place objects (e.g. call bell, tissues) on unaffected side and approach from that side. Problem - Resident #1 required assistance with ADLs and transfers. Goal - Resident #1 will maintain a sense of dignity, being clean, dry, odor free and well groomed. Approach included: toileting - extensive assist with one person assist, transfers - limited/extensive assist with one person assist. Record review of Resident #2's electronic face sheet dated 11/11/2023, revealed a [AGE] year-old male admitted to the facility on [DATE] and initially admitted on [DATE]. His diagnoses included dementia, cellulitis (bacterial infection) of toe, abnormal gait and mobility, Atherosclerosis (narrowing of arteries' walls d/t buildup of plaques), muscle wasting, lack of coordination, assistance with personal hygiene, depression, anxiety, high blood pressure, chronic pain, heart failure, diabetes and end stage renal disease. Record review of Resident #2's quarterly MDS assessment dated [DATE], revealed a BIMS score of 13 out of 15 indicating intact cognition. He used a walker and wheelchair for mobility. Section GG of the MDS revealed he required supervision or touching assistance with toileting hygiene, dressing, personal hygiene, toilet transfers and walking. His primary medical condition was progressive neurological conditions. Record review of Resident #2's care plan revised on 11/06/2023 revealed: Problem included - Resident #2 had a fall 5/26/23 while attempting to get up from toilet. Goal - Resident #2 will remain free from injury and notify staff of any falls. Approach included -give verbal reminders not to ambulate/transfer without assistance when feeling weak/unsteady. Problem - Resident #2 at risk for falling r/t unsteady gait, diabetes and ESRD. Goal - Resident #2 will remain free from injury. Approach included - Resident #2 on the Falling Star program, identified by a yellow name plate. Keep bed in lowest position with brakes locked. Keep call light in reach at all times. Record review of Resident #3's electronic face sheet dated 11/10/2023, revealed a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included dementia, abnormalities of gait and mobility, intermittent explosive disorder, anxiety, cellulitis, UTI, muscle wasting, need for personal care, psychosis, hallucinations, and osteoporosis. Record review of Resident #3's annual MDS assessment dated [DATE], revealed a BIMS score of 11 out of 15 indicating moderate cognitive impairment. She had minimal difficulty with hearing. She (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676362 If continuation sheet Page 2 of 9 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 11/14/2023 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 0919 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some required extensive two person assist for toilet use and personal hygiene. She required extensive one person assist for bed mobility, transfers, and dressing. She used a wheelchair for mobility. She was occasionally incontinent of bowel and bladder. Record review of Resident #3's care plan revised on 07/19/2023 revealed: Problem included - Resident #3 at risk for falls r/t impaired cognition, impaired mobility, incontinence of bowel and bladder and use of psychotic medications. Goal - Resident #3 will remain free from major injury through the next review date. Approach included - Encourage to use environmental devices such as hand grips, handrails, etc. Give verbal reminders not to ambulate/transfer without assistance. Observe frequently and place in supervised area when out of bed. Problem - Resident #3 at risk for pain r/t Osteoporosis, neuropathy, and lumbago (persistent discomfort in lower back). Goal - Resident #3 will not experience unaddressed pain r/t osteoporosis and lumbago through the next 90 days. Approach included - encourage resident to request pain medication if not getting relief from what she was currently taking. Further review of the care plan revealed no approach to include placement of call light within reach of Resident #3. Record review of Resident #4's electronic face sheet dated 11/11/2023, revealed a [AGE] year-old female admitted to the facility on [DATE] and initially admitted on [DATE]. Her diagnoses included Rhabdomyolysis (rapid muscle breakdown), Glaucoma (eye disease), abnormalities of gait and mobility, need for assistance with personal care, localized edema (fluid retention), high blood pressure, epilepsy (seizures), low blood pressure, pain and osteoarthritis. Record review of Resident #4's quarterly MDS assessment dated [DATE], revealed a BIMS score of 11 out of 15 indicating moderate cognitive impairment. She had impaired vision. She required partial/moderate assistance with the following: rolling left and right from lying on back, moving from sit to lying, lying to sitting, sit to stand, chair/bed-to chair transfer. She required substantial/maximal assistance with toilet transfer. She was occasionally incontinent of bowel and bladder. She had medically complex conditions. Record review of Resident #4's care plan revised on 11/08/2023 revealed: Problem included - Resident #4 at risk of falling r/t unsteady gait at times. Resident #4 had a fall on 11/07/2023, while trying to transfer self. Goal - Resident #4 will be free of falls. Approach included - educate resident on asking for assistance. Further review of the care plan revealed no approach to include placement of call light within reach of Resident #4. Record review of Resident #5's electronic face sheet dated 11/09/2023, revealed an [AGE] year-old female admitted to the facility on [DATE] and initially admitted on [DATE]. Her diagnoses included diabetes, intermittent explosive disorder (behavioral disorder characterized by explosive outbursts of anger/or violence), history of abdominal pain, UTI, insomnia, lack of coordination, legal blindness, high blood pressure, anxiety, abnormalities of gait and mobility. Record review of Resident #5's annual MDS assessment dated [DATE], revealed a BIMS score of 11 out of 15 indicating moderate impaired cognition. She had severely impaired vision. She required total assistance with one-person physical assist for walking. She required extensive assistance with one-person physical assist for bed mobility, transfers, locomotion on or off unit, dressing, eating, toilet use and personal hygiene. She used a wheelchair for mobility. She was always incontinent of bowel and bladder. She had medically complex conditions. Record review of Resident #5's care plan revised on 09/11/2023 revealed: Problem included (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676362 If continuation sheet Page 3 of 9 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 11/14/2023 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 0919 Level of Harm - Immediate jeopardy to resident health or safety Resident #5 experienced a witnessed fall on 09/16/23 and on 09/17/23 with no apparent injuries. Resident #5 had an unwitnessed fall on 10/21/23 with no apparent injuries. Long term goal - Resident #5 will remain injury free. Approach included - fall mats in place, increased frequent rounding on resident. Problem Resident #5 at risk for falling r/t unsteady gait and use of psychotropic medication. Long term goal Resident #5 will remain free from injury. Approach included - keep call light in reach at all times. Observe frequently and place in supervised area when out of bed. Provide toileting assistance when needed. Residents Affected - Some During an observation and interview on 11/09/2023 beginning at 7:45 AM, Resident #6 and Resident #3 were in their room. Resident #3 was sitting in a wheelchair next to the bed and stated the call light was not working. Resident #3 said she was given a bell, but it was not effective as it was not loud enough. She stated the call lights have not been working for about 3 months. She stated when she needed her brief changed, she would holler loudly. She stated that it was aggravating to have to yell and that she had a low tone to her voice and was afraid no one could hear her because of her soft voice. She stated the staff would come after about an hour of her calling out. She stated she was changed recently and was currently dry. Resident #3 pressed the call light. The call light cord was connected to the box mounted to the wall and it did not light up. The lighting fixture above the resident room in the hallway did not light up. There were no bells observed within reach for Resident #3 or Resident #6 anywhere in the room. During an observation and interview on 11/09/2023 beginning at 10:15 AM in room [ROOM NUMBER], Resident #4 stated the call light did not work for a long time. Resident #4 stated she must holler for help or bang on the wall. She stated she and her roommate Resident #5 were not given anything to use like bells. She stated her roommate was blind and if she needed help, Resident #4 would holler for the staff to come. She stated, If we don't have working call lights, I guess they just don't come. Observation of Resident #4 pressing the call light and no light turned on outside the room. Resident #5 was sitting in a wheelchair next to the bed and was holding the call light box. There were no bells anywhere in the room or within reach of either residents. During an observation and interview on 11/09/2023 beginning at 10:30 AM in room [ROOM NUMBER], Resident #1 was sitting in a wheelchair and Resident #2 was reclining in the bed. Resident #1 pressed call light and it did not light up in the hallway. Resident #2 pressed the call light, and it did not light up in the hallway. Resident #2 stated he did not use the call light, that he would get up and go get a nurse if he needed anything. Resident #1 stated he was able to wheel himself to the nurse station if he needed anything. Resident #2 stated he was not given a bell to use. There were no bells observed in the room or within reach of either resident. During an interview on 11/09/2023 at 10:35 AM, CNA C stated she was new and started working at the facility 11/01/2023. CNA C stated she was assigned to 200 hall and was not aware of any rooms with call lights that were not working. During an interview on 11/09/2023 at 10:40 AM, CNA D stated she was floating in 200 Hall and 400 Hall at the time . CNA D stated as far as she knows there were no rooms with call lights that were not working. CNA D stated if she found a call light that did not work, she would put a work order in the computer system so the Maintenance man could work on it and would give the resident bells to use. During an interview on 11/09/2023 at 10:45 AM, LVN E stated he was in charge of 200 Hall. LVN E stated he put bells out yesterday (11/08/2023) but did not remember which rooms and did not have a list of the rooms. LVN E stated he was unaware of call lights not working in rooms 201, 202 and 213. He (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676362 If continuation sheet Page 4 of 9 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 11/14/2023 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 0919 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some stated he did not know why they did not have bells but would make sure residents in 201, 202 and 213 received bells. LVN E stated since the big thunderstorm in September 2023, there had been issues with the call lights. LVN E stated there was no documentation on resident monitoring for residents without working call lights. He stated the documentation logs were more for the exit doors that were not locking after the lightning strike, which had since been repaired. LVN E stated rounds were made on all residents with call lights not working and the CNAs, charge nurses and ADON were all monitoring residents; LVN E did not specify the monitoring schedule. During an interview on 11/09/2203 at 10:58 AM the Maintenance Director stated in September 2023, lighting struck the whole building and knocked out the fire panel system and call light system. He stated currently he did not remember which resident rooms had call lights that were not working and that some may not light up in the hallway but may ring at the nurse station. Maintenance Director stated he was not aware that rooms 201, 202 and 213 call lights were not working but he would check them. During an interview on 11/09/2023 at 11:20 AM, the Maintenance Director stated room [ROOM NUMBER] did light up at the nurse station, 201 and 213 needed new boxes for the wall and that he would be able to replace those. He stated as far as he knew the Service Company told him the call light system was fixed when they replaced the main board in September 2023. He stated he did not have paperwork from the Service Company stating all the call lights were checked. He stated he would not know the call lights were not working unless someone told him. He stated he routinely checks the call light system monthly. He stated he did not check call lights in October 2023. When asked why, he stated, I don't know, I was busy. During an interview on 11/09/2023 at 2:40 PM, LVN E stated residents in rooms 201, 202, 213 had handbells. He stated since the contingency, the bells were put into place, the nursing staff had been checking on residents frequently by walking up and down the halls and checking the rooms. LVN E stated it was the Maintenance Director's responsibility to ensure the call lights were working. During an interview on 11/09/2023 at 2:50 PM, the Administrator stated all the employees were responsible to ensure the call light system was working. The Administrator stated the expectation was that Maintenance Director check the system monthly. The Administrator stated she knew the Maintenance Director did an informal random check of the resident call light system during the first week in October 2023, but that he probably did not have any documentation. The Administrator stated she knew there were issues with the call light system and had several call lights that were not working. The Administrator stated the staff ensure the residents have bells and staff increase monitoring of residents. The Administrator stated the service company technician was supposed to come out to the facility but did not know exactly when so today she contacted the representative and that he was coming out tomorrow (11/10/2023). Surveyor requested email verification of the communication with Service Company. Requested verification was not provided by exit date . During an observation on 11/09/2023 at 3:00 PM, Resident #3 was in her room and had a handheld bell within reach. She stated the technicians were working on the call lights. The light fixture outside the room was flashing . Resident #5 in room [ROOM NUMBER] had a handheld bell on the overbed table that was not in reach of the resident who was lying in bed asleep. Resident #4 stated, look where they put the bell on her table, she cannot reach it. There was no bell near Resident #4. Resident #4 stated she was not given a bell. During an interview on 11/10/2023 at 7:15 AM, the Maintenance Director was asked for a copy of work (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676362 If continuation sheet Page 5 of 9 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 11/14/2023 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 0919 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some orders for call lights between the time the Service technicians fixed the call light system on 09/26/2023 and 11/09/2023. The Maintenance Director stated honestly, he did not receive any work orders. He stated if he there were work orders, he would have seen the work orders on his phone and his desk computer. During an observation and interview on 11/10/2023 beginning at 8:20 AM the emergency call light in the bathroom for room [ROOM NUMBER] did not work. Resident #1 stated he used the bathroom himself regularly and had not had to use the call light. He denied falling. Resident #2 stated the call lights have not been working for about 3 weeks now. Resident #2 stated he used the bathroom himself and denied any falls. Resident #2 stated, anything can happen like falls, just like murphy's law: anything that can go wrong will go wrong. During an observation and interview on 11/10/2023 beginning at 8:45 AM in room [ROOM NUMBER], the bathroom call light did not work. Resident #4 stated she liked to use the shower and would prefer the call light work as well. She stated she still had not been given a bell. There was no bell within her reach or anywhere in the room. During an observation and interview on 11/10/2023 at 8:55 AM, Resident #5 was sitting in her wheelchair next to her bed. There was a handheld bell within her reach. She also had the call light box in her hand. Resident #5 stated she was given the bell yesterday (11/09/2023). She stated prior to the bell the call light would never work. She stated she would press the buttons, and no one would come, and she would have to ask Resident #4 to call out for help. During an interview on 11/10/2023 at 9:00 AM, CNA F stated she had a list of rooms with call lights not working. CNA stated she received the list yesterday (11/09/2023) and that usually the nurses would tell her verbally which rooms had call light issues but yesterday was different and she was given a list. During an interview on 11/10/2023 at 9:15 AM, the DON stated the call light system had been a problem since the lighting struck in September 2023. The DON state she was under the impression all the call lights were working d/t it was discussed in one of the morning meetings after the Service Company came out and did their inspection. The DON did not recall the exact dates. The DON stated she learned that some of the call lights were not working last week then the Service Company came and during a meeting, they were told everything was functioning as expected. The DON stated the contingency plan was put in place after the lightning strike and included having bells for the residents. The staff had been in-serviced to do frequent rounds. The DON stated she heard about one call light not working yesterday. She stated the staff were told not to leave residents alone in the restrooms and to give residents bells to use in the restrooms. She stated the residents were educated and reminded to take the bells with them while in the restroom. The DON stated the resident's needs were being met by anticipating their needs and the ones with the call lights out were in the long-term care side. She stated the nursing staff establish a routine with the residents, were able to anticipate their needs and the nurses assessed and made frequent rounds. She stated the managers are out on the floor frequently for extra help. She stated, there are enough staff, and we like to keep the same aides assigned to residents so there is continuation of care. The DON stated the Administrator oversees Maintenance. During a telephone interview and Record Review on 11/10/2023 at 9:30 AM, the Service Company Representative stated the electrical system was red tagged on 9/11/2023 after the lighting strike and the work order was for troubleshooting the damage caused by lightning. The Representative stated the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676362 If continuation sheet Page 6 of 9 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 11/14/2023 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 0919 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some repair was made to the main board to ensure the nursing call system was receiving power supply. The Representative was asked about the note on the invoice dated 09/26/2023, the representative stated it meant that the main board power supply was replaced and was receiving power. The Representative stated the technician would not have tested each individual room and that if they did test it would have been included in the notes. The Representative stated it was entirely possible they would not know whether each call light was functioning unless testing was done where the power was not going through and unfortunately, with lighting strikes it was not unusual to find issues later. During an interview on 11/10/2023 at 10:25 AM, CNA G stated that she had a list of which rooms had call lights that did not work and that was why she rounds frequently. CNA G stated the residents have bells to use and the risk of not having call system would be resident falls. During an interview on 11/10/2023 at 10:30 AM, LVN H stated if the call light system did not work the resident had bells and she would do frequent room checks. LVN H was asked what the risks would be to a resident if there was no call system in place, LVN H stated the residents had bells and she would do frequent room checks. During an interview on 11/10/2023 at 10:35 AM, the Administrator stated if the residents did not have a working call system, they would not be able to call the staff and their needs would not be met and that was why after the lightning strike the residents were given hand bells. During an interview on 11/10/2023 at 2:20 PM, the DON stated with some call lights not working she monitored the residents by rounding and conducting resident interviews. The DON stated she was not aware of any accidents related to the call light system malfunctioning. She stated she conducted daily rounds throughout the day and that the managers do the same. The DON stated she will attend meal service to monitor residents in the dining room and all the managers and department heads will rotate monitoring duties during meal service in the dining room as well as meals in the halls. She stated they also have Guardian Angel rounds who monitor residents. During an observation and interview on 11/10/2023 beginning at 3:20 PM in room [ROOM NUMBER], the call light in the room and in the resident bathroom did not work. Resident #7 had a handheld bell and stated she used once, and staff did come. During an observation and interview on 11/10/2023 beginning at 3:30 PM, observation of the door to room [ROOM NUMBER] was closed. CNA J stated the call light should work. In observation CNA J pressed the call light button at Resident #8's bedside and it did not work. The call light in the bathroom did not work. CNA J stated Resident #8 liked to have his door closed d/t residents yelling and this was why she would check on him every 30 minutes to ensure he did not need anything. Resident #8 had a handheld bell within reach, he was lying on his back in bed watching TV. During an observation on 11/10/2023 at 3:35 PM, the Resident in room [ROOM NUMBER] bed A was non-interviewable and the handheld bell was not in reach of the resident. The resident at the window bed was asleep. There were no handbells visible around the resident. Record review of the list of residents who could not use a call system included the resident in room [ROOM NUMBER] bed A. During an interview on 11/10/2023 at 4:10 PM the DON stated she started the list of rooms with call light malfunctioning yesterday 11/09/2023. She stated prior to that the CNAs were given a verbal (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676362 If continuation sheet Page 7 of 9 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 11/14/2023 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 0919 Level of Harm - Immediate jeopardy to resident health or safety report by the nurses on which rooms had call lights that were not working. She stated at that time there were not many rooms with malfunctioning call lights. She did not say which rooms had malfunctioning call lights prior to 11/09/2023. During an observation and interview on 11/10/2023 beginning at 4:15 PM in room [ROOM NUMBER], the call light did not work. Resident #9 had a handheld bell that was not within reach. Residents Affected - Some During an observation and interview on 11/10/2023 beginning at 4:20 PM Resident #3 stated they took her handheld bell away. She pressed the call light, and it was not working. The lighting fixture outside the door was hanging off the wall. The technicians were observed in the building doing their inspection. There was no handbell within reach of the resident. During an observation and interview on 11/10/2023 beginning at 4:25PM, Resident #2 had a handheld bell. Resident #10 did not have the handheld bell within reach. Resident #11 stated the hand bell was useless and was not the answer to the problem. Resident #12 stated she did not know anything about the bell, but she had one at the nightstand. Resident #13 stated that she had to bang the handle of the bell on the overbed table for staff to answer her call. She demonstrated banging the handle on the table hard and loudly. During an observation and interview on 11/10/2023 at 4:30 PM, Resident #5 was asleep in bed and the handheld bell was on the nightstand and not in her reach. Resident #4 stated she could see the bell and would not be able to reach it for Resident #5 and she states she still did not have a bell of her own. During an interview on 11/10/2023 at 4:35 PM, the Administrator stated the Service Company would be giving her a quote to repair the call system but could not fix it today. The Administrator stated the Fire Marshall and Service Company were at the facility on 11/06/2023 and that the Fire Marshall notified her that the system was working. During an interview on 11/10/2023 at 6:15 PM the Administrator stated all residents should have handheld bells and did not know why some did not have them. The Administrator stated there were no monitoring logs for this necessarily and there were no logs regarding which staff members handed out the bells and to which residents. The Administrator stated the bells should be in reach so the residents can notify staff when they need assistance. She stated she expected the call lights to be checked every month by Maintenance and did not know the reason why the checks were not completed in October 2023. During an interview on 11/13/2023 at 10:00 AM, LVN E stated to his knowledge the contingency plan was in effect until further notice. He stated without a functioning call system a lot of things could happen to the residents. He stated their care would not be rendered if they need assistance. He stated it would depend on the level of care, for example if they needed peri care and they did not get the assistance d/t the call lights not functioning then they may develop a rash. During an interview and record review on11/13/2023 beginning at 1:15 PM the Maintenance Director was asked about the workorder report generated 11/10/203 for closed dates of 09/26/2023 to 11/08/2023. He stated the workorder #1382 opened 10/03/2023 at 7:37 PM and for call light broken in 200 Hall, was not specific and he left by the closed date and time of 10/12/2023 at 6:49PM. He stated there was no specific room listed for workorder #1396 for call light blinking red in 100 Hall opened on 10/09/2023 at 6:19 PM and closed on 10/25/2023 at 1:05PM. He did not say anything when asked if he (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676362 If continuation sheet Page 8 of 9 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 11/14/2023 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 0919 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some followed up on the two workorders. Further review revealed no room numbers were associated with each call light malfunction. During an interview on 11/14/2023 at 11:45 AM, the Administrator confirmed that lightning struck the building on Saturday 09/09/2023 and the Service Company came to the facility on the same day. Record review of the facility reported incident reported on 09/09/2023 revealed the facility was struck by lightning in the early morning hours of 09/09/2023 which attributed to the alarm system and call light system malfunctioning. The Maintenance Director attempted to reset the system with the aid of the Service Company. This was unsuccessful and therefore the fire marshal was contacted. On 09/09/2023 the staff were in-serviced on elopement of high-risk residents, in-serviced for answering call light frequently, frequent checks of the residents, staff to provide residents with physical bells and staff to answer ringing of bells immediately. Record review of the Service Company invoice for nurse call repair dated 09/11/2023 indicated a quote to replace the main control board/power supply and that the damage to the field device was not determined until the main was replaced. Record review of the Service Company invoice for the fire alarm dated 09/14/2023 indicated a quote for the fire alarm and that damage to other devices was not determined until the mainboard could be replaced. Record review of the Service Company invoice dated 9/26/2023 read in part: .Notes: Replaced main board of power supply. Tested and working. Cleared red tag . Record review of the facility Monthly Nurse Call Checks log sheets revealed on 06/14/2023 100 Hall rooms were marked as checked and passed. On 07/20/2023 200 Hall rooms were marked as checked and passed. On 08/15/2023 300 Hall rooms were marked and checked as passed. Further review of the Monthly Nurse Call Checks log sheets revealed there were no Monthly Nurse Call Checks completed for September 2023 and October 2023. Record review of the Service Company invoice dated 11/10/2023 read in part: .service completed: Check nurse call issues .Notes: Service call to check nurse call system. We did a complete audit of the system. We found multiple issues on each hall with devices after facility took a lightning strike. Rooms with issues were 111, 113, 115, 117, 119, 123, 125, 118, 114, 112, 110, 106, 104, 102, 201, 203, 205, 207, 209, 211, 213, 215, 217, 219, 218, 210, 208, 206, 202, 303, 309, 311, 313, 315, 317, 319, and 314. Most bed stations in these rooms will need to be replaced. 2 techs were on site for work. Record review of the facility nursing policy and procedure for call lights, responding to, revised on May 5, 2023, read in part: Policy: the staff will respond to call lights or other requests for assistance to meet patient's/resident's needs. Procedures: 1. Respond to call lights and requests for assista[TRUNCATED] FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676362 If continuation sheet Page 9 of 9