Health inspection·May 30, 2025

F 0583 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few computers were not locked, it was a HIPAA violation. The DON stated the expectation when computers were not being used was to be locked. The DON also stated that PCC should be locked, and the computer was to not display any patient information before walking away. Interview on, 05/30/2025 at 2:52pm, the ADMN stated their expectation of resident's privacy and confidentiality when it came to medical records and PCC logins was to minimize or close out the screen once any task was completed with the resident information. Record review of the facility's Resident Rights policy dated 02/2023 and revised on 01/2025 revealed in part, 7. Privacy and confidentiality. The resident has a right to personal privacy and confidentiality of his or her personal and medical records. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676412 If continuation sheet Page 2 of 7 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 676412 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fall Creek Rehabilitation and Healthcare Center 14949 Mesa Dr Humble, TX 77396 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 residents who needed respiratory care was provided such care, consistent with professional standards of practice for 1 (Resident #26) of 2 residents reviewed for respiratory care. Residents Affected - Few The facility failed to ensure Resident #26's oxygen tubing was changed every seven days as was ordered and per the facility's policy. The failure could place residents at risk of infection. Findings included: Record review of Resident #26's face sheet dated 5/28/2025, revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including Hemiplegia (one sided weakness or paralysis) and Hemiparesis (weakness in one leg, arm, or side of the face) following Nontraumatic Intracerebral Hemorrhage affecting Right Non-dominant side. Record review of Resident #26's quarterly MDS dated [DATE] revealed a BIMS score of 15 that indicated cognition was intact. Record review of Resident #26's Order Summary Report with active orders as of 5/28/25 revealed Oxygen at 3 L/min via NC continuously DX:_SOB_ every night shift every Sun for O2 Change and label water humidification and nasal cannula tubing weekly every Sunday night shift with order date of 5/7/25. Record review of Resident #26's May 2025 MAR and TAR printed 5/28/25 revealed Change and label water humidification and nasal cannula tubing weekly every Sunday night shift. Record review of Resident #26's care plan printed 5/29/25 revealed the resident requires the use of oxygen via nasal cannula. Observation on 5/28/25 at 9:22 a.m. revealed Resident #26 did a thumbs up sign when asked regarding his care from staff. Observation on 5/28/25 at 9:32 a.m. revealed Resident #26 was wearing oxygen at 3 liters via nasal cannula and oxygen tubing was noted to be dated 5/18/25. Observation on 5/29/25 at 8:10 a.m. revealed Resident #26 was wearing oxygen at 3 liters via nasal cannula and oxygen tubing was noted to be dated 5/18/25 and should have been changed on 5/25/25. During interview on 5/29/25 at 8:12 a.m., the DON said night shift was responsible for changing oxygen tubing. The DON asked LVN H to change Resident #26's oxygen tubing. The DON said if oxygen tubing was not changed on time there could be a risk of infection to the resident. During interview on 5/29/25 at 8:13 a.m., LVN H said night shift nursing was responsible for changing resident's oxygen tubing. LVN H said there was not specific day of the week that oxygen tubing was changed and should be changed every seven days from when it was put in. LVN H said if oxygen tubing was not changed on time, then there could be a risk of infection to the resident. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676412 If continuation sheet Page 3 of 7 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 676412 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fall Creek Rehabilitation and Healthcare Center 14949 Mesa Dr Humble, TX 77396 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 - Few During interview on 5/29/25 at 8:36 a.m., the DON said oxygen tubing should be changed weekly on the 10 p.m. to 6 a.m. shift. The DON said she just started in-servicing staff regarding oxygen tubing. During interview on 5/29/25 at 1:34 p.m., the ADON said the night shift nurse was responsible for changing oxygen tubing being changed on Sunday nights and required to be changed every seven days. The ADON said if oxygen tubing was not changed every seven days it could affect the cleanliness of the tubing or possible kinks if the resident was mobile. Observation on 5/29/25 at 3:51 p.m. revealed Resident #26's oxygen tubing was dated 5/29/25. Record review of facility's policy Oxygen Administration revealed to change oxygen tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676412 If continuation sheet Page 4 of 7 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 676412 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fall Creek Rehabilitation and Healthcare Center 14949 Mesa Dr Humble, TX 77396 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 0759 Ensure medication error rates are not 5 percent or greater. 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 the medication error rate was not five percent or greater. The facility had a medication error rate of 12% based on 3 errors out of 25 opportunities which involved 2 of 8 residents (Residents #39 and #30) and 2 of 7 staff (MA G and MA C) reviewed for medication administration. Residents Affected - Few 1.The facility failed to ensure MA G did not administer Chewable Aspirin to Resident #39 instead of delayed release aspirin as ordered by the MD. 2. The facility failed to ensure MA C did not administer Divalproex 250 mg to Resident #30 after it was discontinued by the MD on 5/22/25. 3. The facility failed to ensure MA C did not administer one Vitamin D 1000 IU tablet to Resident #30 instead of two as ordered by the MD. These failures could place residents at risk of incomplete therapeutic outcomes, increased negative side effects and decline in health. Findings include: 1. Record review of Resident #39's face sheet, dated 5/29/25, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included cerebral infarction (stroke), chronic kidney disease (a condition characterized by a gradual loss of kidney function), and hypertensive heart disease (a long-term condition that develops over many years in people who have high blood pressure). Record review of Resident #39's quarterly MDS assessment, dated 5/3/25, revealed a BIMS score of 10 out of 15, which indicated moderate cognitive impairment. He required assistance from staff with ADL care. Record review of Resident #39's care plan dated 3/3/25 revealed he received aspirin/antiplatelet therapy and was at risk for increased bleeding, bruising. Interventions were to give medications per order. Record review of Resident #39's Physician's orders for May 2025 revealed and order for: Aspirin 81 oral tablet delayed release by mouth one time a day for anticoagulant, order date 4/10/24. In an observation on 5/29/25 at 7:50 a.m. revealed MA G prepared Resident #39's medication for administration. She prepared 8 medications which included Chewable Aspirin 81 mg (instead of delayed release Aspirin as ordered by the MD). She administered the medications to Resident #39. In an interview on 5/29/25 at 8:12 am MA G said she used chewable Aspirin for the delayed release order because the other Aspirin bottle said enteric coated. In an interview on 5/29/25 at 3:59 p.m. the DON said delayed release Aspirin was not chewable. She (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676412 If continuation sheet Page 5 of 7 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 676412 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fall Creek Rehabilitation and Healthcare Center 14949 Mesa Dr Humble, TX 77396 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 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few said the enteric coated Aspirin was normally used for the delayed released order. She said chewable Aspirin was fast acting and delayed release worked over a period of time. 2. Record review of Resident #30's face sheet, dated 5/29/25, revealed an [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included cerebral infarction (stroke), schizophrenia (a serious mental health condition that affects how people think, feel and behave), delusional disorders (an unshakable belief in something that's untrue), type 2 diabetes, and hemiplegia (a symptom that involves one-sided paralysis) and hemiparesis (one-sided muscle weakness). Record review of Resident #30's annual MDS assessment, dated 3/15/25, revealed a BIMS score of 13 out of 15, which indicated no cognitive impairment. She required assistance from staff with ADL's. Record review of Resident #39's Physician's orders for May 2025 revealed orders for Cholecalciferol tablet 1000 Units give 2 tablets by mouth one time a day for Vitamin D deficiency, order date 5/1/25, Divalproex Sodium Delayed Release 125 mg give 1 tablet by mouth two times a day for mood disorder, order date 5/22/25. There was no order for Divalproex 250 mg. Record review of Resident #39's Order Audit Report dated 5/29/25 revealed Divalproex 250 mg (Depakote) was discontinued on 5/22/25. In an observation on 5/29/25 at 8:26 a.m. revealed MA C prepared 10 pills for Resident #30 which included Divalproex 250 mg - 1 tablet, Vitamin D 1000 IU - 1 tablet, Divalproex 125 mg - 1 tablet, Gabapentin 300 mg - 1 tablet, Metoprolol 25 mg - 1 tablet, Nuedexta - 1 tablet, Sertraline 100 mg - (2) 50 mg tablets, Sertraline 50 mg - 1 tablet, Zetia 10 mg - 1 tablet, and eye drops. She entered the room and administered the medications to Resident #30. MA C returned to the medication cart and completed documentation of the administration. After documentation was complete, observation of the eMAR for Resident #30 revealed Divalproex 250 mg was not listed and the order for Vitamin D 1000 IU indicated two tablets. In an interview on 5/29/25 at 8:49 a.m. MA C said she administered 1 Vitamin D 1000 IU tablet to Resident #30 instead of 2 because she did not read the directions and it was an oversight. She said she administered both Depakote tablets (250 mg and 125 mg) and did not see the 250 mg on the MAR. She said the medication package would not normally be on the cart if it was discontinued. She said when preparing medication, she normally went through each pill and reviewed the date, time, and medication but this time she just handed the Surveyor the medication (to observe). She said Resident #30 was on Depakote for mood disorder. In an interview on 5/29/25 at 1:00 p.m. the MD said Resident #30 had a dose change for Depakote due to a gradual dose reduction and was informed by the facility that she received both doses. She said a one-time extra dose should not have any adverse effect, but the facility would check her Depakote level. She said Depakote could cause increased sedation. She said the facility would educate staff to match the MAR to the medication. In an interview on 5/29/25 at 3:51 p.m. the DON said she expected nursing staff to always follow the six rights (medication, patient, dose, time, diagnosis, and route) of medication administration and compare the MAR to the medication being given. She said the facility completed a medication error, and a CBC (a blood test that measures amounts and sizes of your red blood cells, hemoglobin, white blood cells and platelets) and Depakote level would be obtained on Resident #30. She said the resident had a history of schizophrenia and Depakote toxicity could cause elevated blood pressure, dry (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676412 If continuation sheet Page 6 of 7 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 676412 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fall Creek Rehabilitation and Healthcare Center 14949 Mesa Dr Humble, TX 77396 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 0759 Level of Harm - Minimal harm or potential for actual harm mouth, and elevated heart rate. She said Resident #30 did not have any adverse reactions. She said nursing staff do medication skills checks annually, random, and as needed. In an interview on 5/30/25 at 4:21 p.m. the Administrator said she expected nursing staff to compare the medication packet to the MAR to ensure it matches the MAR. Residents Affected - Few Record review of www.bayeraspirin.com accessed on 6/9/25 revealed in part, What does safety coating or enteric coating mean? Enteric coating is a delayed-release safety coating that provides added stomach protection. It is designed to allow the aspirin tablet or caplet to pass through the stomach to the small intestine (duodenum) before dissolving. This delayed release coating means that it will take longer for the aspirin to be absorbed. For this reason, products with enteric coating are not recommended for quick pain relief or use during a suspected heart attack. Enteric coated aspirin is most often used by patients who are on an aspirin regimen under their doctor's supervision or recommendation . Record review of the facility's undated Administering Medications policy read in part, .Medications shall be administered in a safe and timely manner, and as prescribed . 3. Medications must be administered in accordance with the orders . 7. The individual administering the medication shall follow the three rights of medication administration: right resident; right dose; right time . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676412 If continuation sheet Page 7 of 7