Inspection·October 6, 2023

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few door to the side of the resident's name tag. The surveyor asked how staff communicates fall intervention to be implemented for a resident who is identified as a fall risk. CNA - K stated she believed that the resident assigned nurse would communicate any special needs such as vital checks. The surveyor asked if a patient required an intervention such as a fall mat, how was the information communicated. CNA -K stated that she was not aware, but if a fall mat was required it was placed next to the resident's bed side. The surveyor asked CNA-K if Resident #414 was identified as a fall risk. The CNA - K stated that Resident #414 was identified as a fall risk. CNA - K stated that she did not know if the patient had a recent fall. CNA - K stated that she did not know if the resident required a fall mat at the bedside. The surveyor asked CNA - K how she would find out. The CNA stated that she would check the resident room to see if a fall mat was in place. The surveyor and CNA- K visited the patient's room and CNA - K acknowledged that there was not a fall mat next to the bed nor was there a fall mat in the resident room. The surveyor asked the CNA - K if the CNA staff had the ability to check the resident's care plan to verify fall intervention. CNA-K stated that the CNA staff have access to the resident's care plan, but she did not know if fall interventions were documented in the resident's care plan. The surveyor asked how often should staff check the care plan. CNA-K did not know how often the care plan should be checked. The surveyor asked CNA - K who was responsible for ensuring that fall interventions were implemented and were congruent with the resident's care plan. CNA-K stated that all staff is responsible for ensuring safety interventions are implemented. The surveyor asked what could happen to a resident who is at risk for fall when recommended safety interventions were not implemented. CNA - K stated that the resident could become injured. During an interview and record review on 10/06/2023, at 1:55pm with Resident #414's assigned nurse (LVN - K), the surveyor asked LVN - K if she had received training at the facility related to resident falls and potential interventions. LVN - K stated that she's worked in the facility for a while and had received training related to fall interventions and residents at risk. The surveyor asked LVN - K if she were assigned to a resident requiring the implementation of a fall mat next to the bedside. LVN - K stated that she did not know but stated that she had a few assigned residents who were identified as at risk for fall. The surveyor asked how staff communicates fall intervention to be implemented for a resident who was identified as a fall risk. LVN - K stated that residents who are at risk for fall are identified using a facility implemented system The Falling Star, where a gold star in placed outside the resident's room door to the side of the resident's name tag. LVN - K stated that fall interventions to be implemented were also communicated during the shift handoff report. The surveyor asked LVN - K if she was aware of recommended fall intervention for Resident #414. LVN - K stated that she was not aware of fall accommodation recommended for Resident #414. The surveyor asked LVN - K where would she find the information if information was not communicated during shift handoff. LVN - K stated that she could possibly check to see if there was an order written. The surveyor asked if the information could be found anywhere else. LVN - K stated that she was not aware of any other place where the information would be documented. The surveyor asked if the resident's care plan could a point of reference. LVN - K stated did not know if the fall interventions were documented in the resident's care plan. The surveyor asked LVN - K if they could look at Resident #414's care plan together. LVN - K was able to navigate to the care plan and identified that Resident #414 had recommendations for a fall mat to the bed was added and initiated in the resident's care plan on 08/28/2023. At 2:10, the surveyor and LVN K observed that there was no fall mat next to Resident #414's bedside. The surveyor asked if there was a reason the resident's fall safety intervention was not implemented. LVN - K stated that she was not aware that there was an indication for the fall mat.The surveyor (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676442 If continuation sheet Page 2 of 4 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 676442 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rollingbrook Rehabilitation and Healthcare Center 750 Rollingbrook Dr Baytown, TX 77521 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 asked what could happen to a resident who is at risk for fall when recommended safety accommodates are not implemented. LVN - K stated that the resident could become injured. Phone Interview - on 10/06/2023 at 2:24pm, with Resident #414's Family Member - C. The family member expressed no concerns related to the resident's needs. Family Member - C stated that she was made aware of previous fall occurrence and injury. Family Member - C stated that she was informed that the facility would continue to have a mat next to the bedside to prevent injury, but she was not aware if this accommodation had been implemented after Resident #414's return from hospitalization on 09/23/23. During an interview on 10/06/2023 beginning at 3:00pm, with the Director of Nursing (DON), and the MDS Nurse, the surveyor asked who was responsible for ensuring that fall safety intervention are communicated, documented, and implemented. Per the DON, fall interventions are documented by the DON in the care plan and are communicated with the MDS Nurse and staff when there was a significant change. The DON stated that the nursing staff are responsible for communicating special fall interventions at the start and end of each shift, during the nurse-to -nurse handoff report. The surveyor asked was staff supposed to document that interventions are in place. The DON stated that the information could be documented in a progress note, but it was not a requirement. The surveyor asked who was responsible for ensuring that interventions to accommodate residents' needs are implement. The DON stated that the nursing rounds are completed each shift to ensure that resident's needs are met. The DON stated that staff was trained on how to care for residents at risk for fall upon hire, annually, and additional in-services are provided, as necessary. The DON and the MDS Nurse, confirmed that Resident #414's Care Plan/MDS dated with updates on 09/23/23 was the current resident care plan. The DON confirmed that a fall mat to the resident beside was a current intervention to was initiated on 08/28/2023 and was also a part of the current care plan revised on 09/23/23. The DON stated that she was made aware about 15 minutes prior, by LVN - K that the resident did not have a fall mat next to the resident's beside. She stated that, the staff was working to get a mat placed to the resident's bedside. The DON stated that she was aware that the resident had an actual fall with a right femoral fracture on 09/23/23. She stated that at the time of the fall on 09/23/23, the resident had a fall mat to the beside. The DON did not disclose how she knew that the fall mat was next to the beside at on 09/23/23. The surveyor asked if there was a reason the resident's fall safety intervention was not implemented at this time. The DON stated that she recently started with the facility a couple of weeks ago and realized that there was a system failure and communication gap related to resident's who are at risk for fall. The DON stated that she recently implemented The Falling Star system to identify residents at risk for falls. She stated that moving forward she will educate nursing staff on the importance of reviewing the resident's care plan per shift to ensure that recommended accommodations are implemented. The surveyor asked what could happen to a resident who was at risk for fall when recommended safety accommodates are not implemented. The DON and the MDS Nurse stated that the resident could become injured. During an interview on 10/06/2023 at 4:45pm with the Administrator and Director of Nursing (DON), both agreed that the facility failed to implement safety accommodates for #414. The surveyor requested the facility policy related to accommodation of needs, care planning, and fall safety. Record review of the facility's provided policy, titled Falls and Risk Managing, dated December 2007, indication Policy Statement staff will identify interventions related to the resident specific risks to try to minimize complications from falling. Fall Impact Reduction Methods Mat placed on floor . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676442 If continuation sheet Page 3 of 4 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 676442 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rollingbrook Rehabilitation and Healthcare Center 750 Rollingbrook Dr Baytown, TX 77521 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 Facility failed to provide additional requested policies, related to accommodation of needs and care planning prior to exit on 10/06/2023 at 5:00pm. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676442 If continuation sheet Page 4 of 4