Health inspection·May 17, 2024

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure all alleged violations involving abuse and neglect were reported immediately but not later than 24 hours if the events that cause the allegation did not involve abuse and did not result in serious bodily injury to the State Survey Agency for 1 of 1 incident reviewed for reporting. The facility failed to report to the State Survey Agency when Resident #1 was known to have been missing for approximately 1 hour after leaving the hospital where she went for a doctor's appointment. This failure could have affected residents by resulting in a delay of identification of abuse or neglect and lack of timely follow-up on recommended interventions to prevent harm, or impairment. Findings included: Record review of CR #1's face sheet dated 5/16/24 revealed a [AGE] year-old female admitted originally 7/9/20 and most recently 5/25/23. Her diagnoses were: Cerebral infarction (of stroke that occurs when a blood vessel in the brain is blocked, causing damage to brain tissue) (Glaucoma (group of eye conditions that damage the optic nerve and can cause vision loss), Type 2 diabetes mellitus with hyperglycemia (high blood sugar), unspecified disorientation, hallucinations, unsteadiness of feet, history of falling, anemia(condition of low red blood cells or hemoglobin that can cause fatigue), and congestive heart failure. Record review of CR #1's Annual MDS assessment dated [DATE] revealed a BIMS score of 11 which indicated moderate cognitive impairment. Section E- Behaviors revealed CR #1 had hallucinations. Section GG0170 - Mobility Devices revealed CR #1 used a manual wheelchair. CR #1 required substantial/maximal assistance (helper does more than half the effort) with ADLs. Record review of CR #1's care plan last revised 5/10/24 revealed the following in part: Problem: Communication - CR #1 has impaired communication evidence by: Reduced ability to understand other. Impaired daily decision-making ability. Goal: Staff will anticipate and meet all needs the CR #1 is not able to communicate effectively over the next 90 days. Page 1 of 11 676362 676362 05/17/2024 Bridgecrest Rehabilitation Suites 14100 Karissa Court Houston, TX 77049

F 0609 Approach: Reduce or remove all interfering environmental stimuli. Level of Harm - Minimal harm or potential for actual harm Problem: Cognitive Loss/ Dementia - CR #1 appears to have impaired ability to understand others at times and has impaired ability to make daily decisions. Residents Affected - Few Goal: CR #1 will accept helpful reminders, will have needs met by staff as identified or anticipated, will have minimal negative emotional distress related to cognitive issues. Approach: Continue to assess periodically for changes in cognition; adjust approaches to offer more assistance as needed. Record review of CR #1's nursing note dated 5/14/24 at 9:34 a.m. written by LVN A revealed CR#1 was picked up by EMS via wheelchair for a scheduled appointment at 9:00 a.m. Record review of CR #1's nursing note dated 5/14/2024 at 4:57 p.m. written by ADON revealed CR #1 returned vial EMS. The nursing note did not reflect CR #1's elopement from the doctor's office. In an interview on 5/16/24 at 11:21 AM with the Doctor's Office Manager, said CR #1 had an appointment on 5/14/24 and had finished at approximately 11:43 a.m. She said the resident was placed in a waiting room with a T.V. until transportation picked her. She said CR #1 had been dropped off by transportation unaccompanied. The Doctor's Office Manager said she received a call, at 2:29 p.m., from the ADMIN, who inquired if CR #1 was still at the appointment. She said the staff looked for the resident inside the building and CR #1 was found at the sidewalk, stuck in mud next to a major freeway feeder road, in her wheelchair at 3:00 p.m. She said CR #1 was soiled through her pants, sweating, thirsty, and hungry. She said the resident asked for water and peanuts. The Doctor's Office Manager said she notified the ADMIN, transportation picked up the resident approximately 3:55 p.m. In an interview on 5/16/2024 at 11:34 a.m. with the ADMIN, she said CR #1 went to the doctor's appointment, on 5/14/24, without an escort because the staff that set up transportation thought CR #1's family member was supposed to meet her. The ADMIN said she received a call from the transportation company at approximately 2:00 p.m. and they said CR #1 could not be located. The ADMIN said she called the doctor's office to ask if they knew where CR #1 was. The ADMIN said she called the doctor's office staff and asked them to check the building since the resident was missing. She said she did not know how long the doctor's office searched for CR #1, but the doctor's office manager called approximately 3:00 p.m. and said that the resident had been found. The ADMIN said she did not report the incident to the state because the resident was not at the facility. She said if the resident was at the facility, she would have reported the incident. She said she was responsible for reporting facility self-reports. In an interview on 5/16/24 at 3:40 p.m. with CR #1 said she did not remember a doctor appointment. She was asked if she knew her family members names and she said, I don't remember do you. She appeared confused and asked this State Surveyor if she knew she had an appointment. She said she did not remember waiting for transportation at her doctor's visit this week. In an interview on 5/16/24 at 3:51 p.m. with CR #1's family member revealed they were not notified the resident had been missing. She said she was notified of the visit prior to the resident going but she did not confirm she would attend. Record review of the doctor's office timestamped video from 5/14/2024 revealed the following: 676362 Page 2 of 11 676362 05/17/2024 Bridgecrest Rehabilitation Suites 14100 Karissa Court Houston, TX 77049

F 0609 11:43 a.m. - 1:00 p.m. Level of Harm - Minimal harm or potential for actual harm 11:43 a.m. - CR #1's doctor's visit was completed. 12:46 p.m. - CR #1 seen waiting at second floor elevator doors. Residents Affected - Few 12:48 p.m. - CR #1 seen exiting the first-floor elevator doors. 12:49 p.m. - CR #1 seen speaking to security guard. 1:00 p.m. - CR #1 seen propelling herself from the parking garage camera towards the major freeway feeder road. Record review of facility Elopement policy dated 11/1/2017 revealed the following in part: Policy: To safely and timely redirect patients/residents to a safe environment. A prompt investigation and search will be conducted if a patient/resident is considered missing . .5. If the search fails to locate the missing patient/resident within (30) thirty minutes from the time the patient/resident is found to be missing, the Administrator and/or designee contact the appropriate community agencies (Police, Local Health Department) and Administration, the patient's/resident's legal representative and attending physician. Staff will provide the Police with all physical identifying information including but not limited to physical appearance, height, weight, age, sex, and clothing, if known . Review of the facility's policy titled Abuse/Neglect (revised 11/1/17 and email revised 10/23/19) reflected the following: .The facility shall report immediately, but not later than 2 hours after the allegation is made if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not result in serious bodily injury to the administrator of the facility and to other officials (including to the State Survey Agency .where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures . Record review of Long-Term Care Regulatory Provider Letter PL 19-17 dated 7/10/19 revealed the following: .A NF must report to HHSC the following types of incidents in accordance with applicable state and federal requirement: . A missing resident Immediately, but not later than 24 hours after the incident occurs or is suspected . 676362 Page 3 of 11 676362 05/17/2024 Bridgecrest Rehabilitation Suites 14100 Karissa Court Houston, TX 77049

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure each resident received adequate supervision to prevent accidents for 1 (CR #1) of 6 residents reviewed for quality of care. Residents Affected - Few The facility failed to ensure CR #1, who was cognitively impaired received adequate supervision when the facility sent her to the doctor's office unsupervised. CR #1 left the doctor's office and was found outside of the building next to a major freeway feeder road by the doctor's office manager. On 5/16/24 at 4:13 p.m. an immediate jeopardy (IJ) was identified. While the IJ was removed on 5/17/24 at 3:31 p.m., the facility remained out of compliance at a severity level of no actual harm with potential for immediate jeopardy and a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. This failure placed facility residents with dementia and impaired cognition at risk of neglect and elopement for lack of supervision during any appointment. Findings included: Record review of CR #1's face sheet dated 5/16/24 revealed a [AGE] year-old female admitted originally 7/9/20 and most recently 5/25/23. Her diagnoses were: Cerebral infarction (of stroke that occurs when a blood vessel in the brain is blocked, causing damage to brain tissue), Glaucoma (group of eye conditions that damage the optic nerve and can cause vision loss), Type 2 diabetes mellitus with hyperglycemia (high blood sugar), unspecified disorientation, hallucinations, unsteadiness of feet, history of falling, anemia (condition of low red blood cells or hemoglobin that can cause fatigue), and congestive heart failure. Record review of CR #1's Annual MDS assessment dated [DATE] revealed a BIMS score of 11 which indicated moderate cognitive impairment. Section E- Behaviors revealed CR #1 had hallucinations. Section GG0170 - Mobility Devices revealed CR #1 used a manual wheelchair. CR #1 required substantial/maximal assistance (helper does more than half the effort) with ADLs. Record review of CR #1's care plan last revised 5/10/24 revealed the following in part: Problem: Communication - CR #1 has impaired communication as evidenced by: Reduced ability to understand others. Impaired daily decision-making ability. Goal: Staff will anticipate and meet all needs. CR #1 is not able to communicate effectively over the next 90 days. Approach: Reduce or remove all interfering environmental stimuli. Problem: Cognitive Loss/ Dementia - CR #1 appeared to have impaired ability to understand others at times and has impaired ability to make daily decisions. 676362 Page 4 of 11 676362 05/17/2024 Bridgecrest Rehabilitation Suites 14100 Karissa Court Houston, TX 77049

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Goal: CR #1 will accept helpful reminders, will have needs met by staff as identified or anticipated, will have minimal negative emotional distress related to cognitive issues. Approach: Continue to assess periodically for changes in cognition; adjust approaches to offer more assistance as needed. Record review of CR #1's nursing note dated 5/14/24 at 9:34 a.m. written by LVN A revealed CR#1 was picked up by EMS via wheelchair for a scheduled appointment at 9:00 a.m. Record review of CR #1's nursing note dated 5/14/2024 at 4:57 p.m. written by the ADON revealed CR #1 returned vial EMS. The nursing note did not reflect CR #1's elopement from the doctor's office. Attempted interview on 5/17/24 at 9:40 a.m. in CR #1's room. CR #1 was asleep. CR #1's name was called she rolled over and did not wake up. In an interview on 5/16/24 at 11:21 AM with the Doctor's Office Manager, she said CR #1 had an appointment on 5/14/24 and had finished at approximately 11:43 a.m. She said the resident was placed in a waiting room with a T.V. until transportation picked her up. She said CR #1 had been dropped off by transportation unaccompanied. The Doctor's Office Manager said she received a call, at 2:29 p.m., from the ADMIN, who inquired if CR #1 was still at the appointment. She said the staff looked for the resident inside the building and CR #1 was found at the sidewalk, stuck in the mud next to a major freeway feeder road, in her wheelchair at 3:00 p.m. She said CR #1 was soiled through her pants, sweating, thirsty, and hungry. She said the resident asked for water and peanuts. The Doctor's Office Manager said she notified the ADMIN, and transportation picked up the resident approximately 3:55 p.m. In an interview on 5/16/2024 at 11:34 a.m. with the ADMIN, she said CR #1 went to the doctor's appointment, on 5/14/24, without an escort because the staff that set up transportation thought CR #1's family member was supposed to meet her. The ADMIN said she received a call from the transportation company at approximately 2:00 p.m. and they said CR #1 could not be located. The ADMIN said she called the doctor's office and asked if they knew where CR #1 was. The ADMIN said she called the doctor's office staff and asked them to check the building. She said she did not know how long the doctor's office searched for CR #1, but the doctor's office manager called at approximately 3:00 p.m. and said that the resident had been found. The ADMIN said she was told the resident was thirsty and asked for peanuts. She said the resident returned to the facility between 4:00 p.m. - 5:00 p.m. She said the resident's brief and clothing needed to be changed. She said the resident should have either had an escort from the facility or a family member should have been confirmed that they would be in attendance. She said the resident was at risk because her level of cognition would prevent her from making safe decisions. In an interview on 5/16/24 at 12:15 p.m. with the DON, she said when a doctor's appointment was scheduled, the facility nurses set up transportation and should have called the RP to verify if they will be in attendance. She said a resident's cognitive ability to make decisions was what determined if an escort was needed for a doctor's appointment. She said it was rare that a resident would be sent alone to an appointment. The DON said the transportation company will bring the resident into the doctor's office, leave a card, and advise the doctor's office to call when the appointment was completed for the return pickup. The DON said she was notified by the ADMIN and the transportation company that they were not able to locate CR #1 at approximately 2:00 p.m. The DON said the ADMIN called the doctor's office and asked them to look for CR #1. She said the doctor's office manager said that 676362 Page 5 of 11 676362 05/17/2024 Bridgecrest Rehabilitation Suites 14100 Karissa Court Houston, TX 77049

F 0689 Level of Harm - Immediate jeopardy to resident health or safety CR #1 had been placed in a TV room while she waited for pick up. She said the doctor's office manager called about an hour later and said CR #1 had been found near a sidewalk. The DON said CR #1 was transported back to the facility by the transportation company. She said CR #1 was cleaned up and provided dinner. The DON said she was not sure if CR #1 was able to navigate safely in the community alone. She said if the resident was not able to make safe decisions and could not navigate her surroundings, she would be at risk for possible injury. Residents Affected - Few In an interview on 5/16/24 at 12:55 p.m. with the ADON, she said the appointment was scheduled by the NP with the doctor's office. The NP would notify the nursing staff of the scheduled appointment and the nursing staff were responsible for the transportation set-up. She said if family was not able to attend the visit, then facility staff would attend. The ADON said she along with LVN A received CR #1 when she returned. The ADON said CR #1 received a brief change, but stated it was not because she was soiled. She said she did a quick head to toe assessment and checked her blood sugar and it was in normal limits. The ADON said CR #1 did not discuss the details of the visit. In an interview on 5/17/2024 at 1:12 p.m. with the NP, she said she scheduled the orthopedic doctor's appointment for CR #1 and notified LVN B who was responsible for transportation. She said the facility staff that set up transportation was responsible for notifying the family member and should have verified if they would be in attendance at the visit. The NP said CR #1's cognition was in and out and becomes confused. The NP said she would be concerned for CR #1's safety if she was alone in the community. In an interview on 5/17/2024 at 2:16 p.m. with LVN B, she said the nurses were responsible for scheduling resident transportation to doctor visits. She said she notified CR #1's family member about the 5/14/24 doctors' appointment. LVN B said the family answered OK to the notification of the visit, but LVN B said she did not verify if the family member was going to attend the doctor's appointment. She said she was not sure if the family member would meet CR #1 at the doctor's office. LVN B said she did not feel CR #1 was confused and communicate to nursing staff if a resident needed an escort. She said she was not present on the day of the appointment for CR #1. LVN B said she did not recall a training on determining if a resident needed an escort or to verify if a family member would be in attendance. In an interview on 5/17/24 at 2:32 p.m. with LVN A, he said he was the nurse on duty when CR #1 left for her doctor's appointment on 5/14/24. He said he was told by LVN B, CR #1's family member would meet her at the doctor's office. He said CR #1's baseline was that she was confused. He said he had not received training on verifying if a resident needed an escort or had a family member that would meet the resident at a doctor's appointment. He said the ADON received CR #1 when she returned from the doctor's appointment at approximately 5:00 p.m. and the ADON made sure she was cleaned up. He said he did assist with the clean up and did not know if the resident was soiled through her clothing. In an interview on 5/16/24 at 3:01 p.m. with the Transportation Manager, he said CR #1 was dropped off at the doctor's office and wheeled inside of the office on 5/14/24 at 8:57 a.m. He said a card was left with the doctor's office staff to call when the resident needed to be picked up. He said dispatch received a return pick up at 11:48 a.m. He said the driver was not able to locate the resident and the driver was unassigned and left the doctor's office at 12:42 p.m. He said a second driver was assigned to pick up the resident at 3:04 p.m. He said the resident was returned back to the nursing facility at 4:56 p.m. 676362 Page 6 of 11 676362 05/17/2024 Bridgecrest Rehabilitation Suites 14100 Karissa Court Houston, TX 77049

F 0689 Level of Harm - Immediate jeopardy to resident health or safety In an interview on 5/16/24 at 3:40 p.m. with CR #1 she said, she did not remember a doctor appointment. She was asked if she knew her family members names and she said, I don't remember do you. She appeared confused and asked this State Surveyor if she knew she had an appointment. She said she did not remember waiting for transportation at her doctor's visit this week. Record review of the doctor's office timestamped video from 5/14/2024 revealed the following: Residents Affected - Few 11:43 a.m. - 1:00 pm 11:43 a.m. - CR #1's doctor's visit was completed. 12:46 p.m. - CR #1 seen waiting at second floor elevator doors. 12:48 p.m. - CR #1 seen exiting the first-floor elevator doors. 12:49 p.m. - CR #1 seen speaking to security guard. 1:00 p.m. - CR #1 seen propelling herself from the parking garage camera towards the major freeway feeder road. In an interview on 5/16/24 at 11:34 a.m. with the ADMIN, a facility policy on transportation and the determination if a resident required an escort to a doctor visit was requested. The ADMIN said the facility did not have policy. Record review of accuweather.com revealed on 5/14/24 the temperature was a high of 88 degrees and a low of 68 degrees. Record review of facility policy on Activities of Daily Living, Optimal Function (revision date 5/5/23) revealed the following in part: The facility provides necessary care to all residents that are unable to carry out activities of daily living on their own. Record review of facility Elopement policy dated 11/1/2017 revealed the following in part: Policy: To safely and timely redirect patients/residents to a safe environment. A prompt investigation and search will be conducted if a patient/resident is considered missing . .5. If the search fails to locate the missing patient/resident within (30) thirty minutes from the time the patient/resident is found to be missing, the Administrator and/or designee contact the appropriate community agencies (Police, Local Health Department) and Administration, the patient's/resident's legal representative and attending physician. Staff will provide the Police with all physical identifying information including but not limited to physical appearance, height, weight, age, sex, and clothing, if known . This was determined to be an Immediate Jeopardy (IJ) On 5/16/24 at 4:13 p.m. The ADMIN and the DON were notified. The Administrator was provided with the IJ template on 5/16/24 at 4:13pm. The following Plan of Removal (POR) was submitted by the facility and accepted on 5/17/24 at 9:26 676362 Page 7 of 11 676362 05/17/2024 Bridgecrest Rehabilitation Suites 14100 Karissa Court Houston, TX 77049

F 0689 a.m.: Level of Harm - Immediate jeopardy to resident health or safety PLAN OF REMOVAL F689 Residents Affected - Few Date: 5/16/24 Name of facility: The facility Facility failed to ensure CR#1 had adequate supervision when the facility sent her to the doctor's office unsupervised. Immediate action: CR #1 returned to the facility. Resident was assessed by the Assistant Director of Nursing at 4:57pm on 5/14/24 with no injuries identified. Physician and responsible party notified. Review of upcoming appointments were completed by the Director of Nursing/Designee on 5/16/24 to identify upcoming appointments for cognitively impaired residents with a BIMS score of 12 or less. 4 residents identified with a BIMS score less than 12 scheduled for appointments. Those 4 identified residents have someone scheduled to accompany them. Review of resident's recent BIMS scores completed by the Social Services Director on 5/16/24. The cognitively impaired residents with a BIMS score of less than 12 will have their care plan updated by 5/17/274 to include need for accompaniment for outside appointments. The Social Worker will update the care plan for current residents who have a change in BIMS score and new residents who admit who are cognitively impaired with BIMS score <12 beginning 5/17/24. Reeducation provided to the Director of Nursing and the Administrator by the Clinical Consultant on 5/16/24 on need for family/Responsible Party or facility staff to accompany cognitively impaired residents with a BIMS score of less than 12 to outside appointments. Re-education provided to licensed nurses and certified nursing assistants on need for cognitively impaired residents with BIMS score of less than 12 to have a family member/Responsible Party or facility staff accompany them to outside appointments. This education was completed by 5/16/24 by the Director of Nursing. Any licensed nurse or certified nursing assistant not receiving this education by the target date will receive prior to their next scheduled shift. A review of the days outside appointments will be completed in clinical morning meeting Monday - Friday by the Administrator to validate any cognitively impaired resident with a BIMS score of less than 12 has a family member/Responsible Party or facility staff member scheduled to accompany them. This will begin on 5/17/24 and continue Monday - Friday during the morning meeting process. The Nurse Managers will communicate to the licensed nurse verbally and by writing on the 24-hour report that a resident will have a family member/Responsible party or staff member accompany the resident on an appointment. Licensed Nurses will validate cognitively impaired residents with a BIMS score of less than 12 have 676362 Page 8 of 11 676362 05/17/2024 Bridgecrest Rehabilitation Suites 14100 Karissa Court Houston, TX 77049

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few a family member/responsible party or facility staff accompaniment with them prior to the resident leaving for any outside appointment. Should a cognitively impaired resident with a BIMS score less than 12 have an outside appointment on the weekend, the licensed nurse will validate the resident has as escort to the appointment. Licensed Nurses will validate prior to the end of their shift any resident who has left for an appointment without an accompaniment has returned. If the resident has not returned, the licensed nurse will follow up with the office staff at the appointment for an update on the resident and this will be communicated to the next shift. Elopement Policy was reviewed on 5/16/24 by the Administrator and the Director of Nursing and no changes were indicated. Ad Hoc QAPI was held on 5/16/24 to review the contents of this plan. The Medical Director was notified on 5/16/24 of the Immediate Jeopardy and the contents of this plan. MONITORING Record review of the facility list of 4 residents with upcoming doctor visits via transportation service revealed the following: Interview on 5/17/2024 at 12:38 p.m. with CNA A said she had been trained on 5/16/24 on when a resident should be escorted to a doctor's visit. She said she had to be present with the resident the entire time of the visit. She said she was informed she would escort a resident of (Resident #2) on 5/22/24 to an appointment. She said she was trained to inform family members who took residents to doctor's appointments that they must remain with the resident throughout the entire visit. In an interview on 5/17/24 at 11:57 a.m. with RP of Resident #3 said she was currently at visit with the resident. The RP said the DON had informed her that a family member must remain with a resident throughout a doctor's visit until they return to the facility or are with transportation. In an interview on 5/17/24 at 12:05 p.m. with RP of Resident #4 said she was aware and always stayed with the resident throughout the visit and returned her back to the facility. She was aware to never leave the resident alone. She was aware of the next 4 visits (5/22/24, 5/28/24, 6/5/24, 6/13/24) and would be present. Interview on 5/17/24 at 12:33 p.m. with RP of Resident #5 said she was aware and informed by the facility that she would meet the resident for her doctor's visit and be with her until transportation picked her up. Interviews with the following Nurses and CNA's revealed the following: Nurses and CNA's confirmed they had been educated on the need for cognitively impaired residents with a BIMS score of less than 12 to have a family member/Responsible Party or facility staff accompany them to outside appointments. The Nurses said they would communicate to the licensed nurses verbally and by writing on the 24-hour report that a resident will have a family member/Responsible party or staff member accompany the resident on an appointment. Nurses confirmed they would validate 676362 Page 9 of 11 676362 05/17/2024 Bridgecrest Rehabilitation Suites 14100 Karissa Court Houston, TX 77049

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few cognitively impaired residents with a BIMS score of less than 12 have a family member/responsible party or facility staff accompaniment with them prior to the resident leaving for any outside appointment. Nurses and CNAs confirmed the same process would be required for weekend appointments. LVN C (day shift) - Interviewed on 5/17/24 at 12:58 p.m. RN A (day shift)- Interviewed on 5/17/24 at 1:10 p.m. LPN A (day shift) - Interviewed on 5/17/24 at 1:22 p.m. LVN D (night shift) - Interviewed on 5/17/24 at 1:37 p.m. CNA D (day shift) - Interviewed on 5/17/24 at 1:48 p.m. LVN E (night shift) - Interviewed on 5/17/24 at 2:08 p.m. PRN CNA B (night shift) - Interviewed on 5/17/24 at 2:42 p.m. LVN F (night shift) - Interviewed on 5/17/24 at 2:55 p.m. CNA C (night shift) - Interviewed on 5/17/24 at 3:01 p.m. In an interview on 5/17/2024 at 2:00 pm with the nurses that were ending their shifts revealed they had verified the residents who had gone out for appointments today had returned by making physical observations. In an interview on 5/17/2024 at 2:26 pm with the SW, she said she had updated all residents with BIMS score of less than 12 to have staff or family member accompany the resident to appointments throughout the visit. Record review of facility audit of resident's recent BIMS scores completed by the Social Services Director on 5/16/24. Cognitively impaired residents with a BIMS score of less than 12 will have their care plan updated by 5/17/274 to include need for accompaniment for outside appointments. Record review of 10 sampled residents revealed their care plans had been updated to reflect the following This resident will need to be accompanied by responsible party or staff for all appointments due to BIMS score less than 12). In an interview on 5/17/2024 at 11:36 AM with ADMIN and DON, the DON said she was reeducated by the Clinical Consultant on 5/16/2024 on the need for family/Responsible Party or facility staff to accompany cognitively impaired residents with a BIMS score of less than 12 to outside appointments. The ADMIN said she was aware that residents with a BIMS score less than 12 had to be escorted to appointments with family members or facility staff. The ADMIN said she would review on the day of the outside appointments in the clinical morning meeting Monday - Friday to validate any cognitively impaired resident with a BIMS score of less than 12 has a family member/Responsible Party or facility staff member scheduled to accompany them. Record review of Ad Hoc QAPI held on 5/16/2024 was completed with the following participants: Medical Director, the DON, the ADMIN, the ADON. 676362 Page 10 of 11 676362 05/17/2024 Bridgecrest Rehabilitation Suites 14100 Karissa Court Houston, TX 77049

F 0689 Level of Harm - Immediate jeopardy to resident health or safety The ADMIN was informed the IJ was removed on 5/17/24 at 3:31 p.m. While the IJ was removed on 5/17/24 at 3:31 p.m., the facility remained out of compliance at a severity level of no actual harm with potential for immediate jeopardy and a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. Residents Affected - Few 676362 Page 11 of 11