Inspection·November 17, 2023

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few appropriate behavior as evidence by a decrease in suspiciousness, aggression, and provocative behavior through the review period. Initiated 07/10/2023 with a revision date 07/24/2023 and target date of 01/20/2024. Interventions: Be matter of fact and respectful when correcting the resident's misperceptions of reality; Demonstrate tolerance of fluctuations in affect and mood. Address inappropriate affect, behavior and/or mood in a calm, yet firm matter. Do not define the resident by the behavior; Maintain routine interactions and activities without increasing the resident's suspiciousness; Orient as needed; Psychological support services as needed and as ordered. Resident #24 had an order for Quetiapine 25mg for Schizophrenia with an order date 11/14/23, a start date of 11/14/2023 and an order status as active. Observation and interview on 11/13/23 at 10:43 am revealed Resident #24 asleep in bed and easily arousable to verbal stimuli. Resident #24 had a slower speech pattern and said that she had no care concerns. She said she received her medications but did not know what medications she had been taking. During an interview with MDS Coordinator on 11/16/23 at 1:13pm, she said Resident #24's PASRR on admission was negative and she was recently diagnosed with schizophrenia on 5/5/23. She said she did not know that all residents with negative level 1 PASRR were supposed to be reassessed after a diagnosis of mental illness . The MDS Coordinator did not say if she had any PASARR training. The MDS Coordinator said she completed the 1012 form on 11/16/23 after surveyors kept asking for the PASARR positive list/ list of the residents with a denial of services letter. She did not say whether or not she had received any training regarding PASARR or form 1012. She said she would wait to see what the recommendations were after the form 1012 was submitted and processed. She did not know why the form had not been completed on 5/5/23 and she said that it would be important for a resident to receive PASARR services if they qualified. The MDS Coordinator said that the potential risk to a resident for not having the corrected forms submitted to identify mental illness, would be that they would not receive the necessary services they qualified for. Record review of Mental Illness/Dementia Resident Review Form 1012 dated 11/16/23 revealed in Section C. Mental Illness (MI) Indication revealed the following: Does this individual have a diagnosis of: 1. Schizophrenia .Yes .Date of Onset: 5/5/2023. Record review of the facility's Form 1012, Mental Illness/Dementia Resident Review dated 11/17/23 at 5:00pm revealed in part . Form 1012 assists nursing facilities in determining whether a resident with a negative Preadmission Screening and Resident Review (PASARR) Level I (PL1) Screening form was submitted into the Long-Term Care (LTC) Portal, needs further evaluation for Mental Illness (MI). When to prepare. The NF completes Form 1012 following: A determination that a resident with a negative PL1 screening form submitted into the LTC portal needs further evaluation for MI. An individual's diagnosis is changed. Record review of the facility's Resident Assessment-Coordination with PASARR Program policy dated implemented 2/2023 and Date Reviewed/Revised: 10/20231 revealed 9. Any resident who exhibits a newly evident or possible serious mental disorder, intellectual disability, or a related condition will be referred promptly to the state mental health or intellectual disability authority for a level II resident review .b. A resident whose intellectual disability or related was not previously identified and evaluated through PASARR. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676442 If continuation sheet Page 2 of 5 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 11/17/2023 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 7 of 10 Residents (Resident #32, Resident #52, Resident #53, Resident #75, Resident #85, Resident #78, Resident #292) reviewed for pharmacy services. The facility failed to ensure controlled drug medications were stored correctly. This failure could place residents who receive medications at risk of not receiving the intended therapeutic benefit of the medications. Findings included: Review of Resident #32's face sheet, dated 11/17/23, revealed the resident was admitted to the facility on [DATE] with diagnoses that included: dementia (the loss of cognitive functioning thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities) and a right femur fracture (a break in the thighbone). Review of Resident #52's face sheet, dated 11/17/23, revealed the resident was admitted to the facility on [DATE] with diagnoses that included: dementia (the loss of cognitive functioning thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities); a right femur fracture (a break in the thighbone); and osteoarthritis (a degenerative joint disease, in which the tissues in the joint break down over time). Review of Resident #53's face sheet, dated 11/17/23, revealed the resident was admitted to the facility on [DATE] with primary diagnosis of Chronic Heart Failure (a long-term condition that happens when your heart can't pump blood well enough to give your body a normal supply). Review of Resident #75's face sheet, dated 11/17/23, revealed the resident was admitted to the facility on [DATE] with primary diagnosis of Alzheimer Disease (a type of dementia that affects memory, thinking and behavior). Review of Resident #78's face sheet, dated 11/17/23, revealed the resident was admitted to the facility on [DATE] with primary diagnosis of Cellulitis of the face (a bacterial infection of the skin spreading to the tissues under your skin). Review of Resident #292's face sheet, dated 11/17/23, revealed the resident was admitted to the facility on [DATE] with primary diagnosis of chronic obstructive pulmonary disease (a condition caused by damage to the airways or other parts of the lung that blocks airflow and makes it hard to breathe). Observation and interview on 11/17/23 at 12:20 PM, the DON revealed that she stored an overflow of controlled substance medications in the DON office in a closet. On observation of the medications stored, there was a total of seven resident's-controlled substance medications stored in the DON's office closet, but not in the designated patient care area medication. The DON stated that the process was implemented on 10/20/2023 and staff was trained and was expected to contact the DON prior to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676442 If continuation sheet Page 3 of 5 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 11/17/2023 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some ordering additional medications from the pharmacy when there is not a supply of the medication in the designated medication cart. At the time of the interview, the DON stated that there was not a process in place to account for the medications that was stored in the DON's office closet. Observation revealed: 1. Resident #32, ACETAMINOPHEN/CODEINE 300MG/30MG TAB were not stored in a permanently affixed compartments for storage of controlled drugs. 2. Resident #52, LORAZEPAM 0.5 TAB and TRAMADOL HCL 50MG TAB were not stored in a permanently affixed compartments for storage of controlled drugs. 3. Resident #53, LORAZEPAM 0.5 TAB were not stored in a permanently affixed compartments for storage of controlled drugs. 4. Resident #75, TRAMADOL HCL 50MG TAB were not stored in a permanently affixed compartments for storage of controlled drugs. 5. Resident #85, TRAMADOL HCL 50MG TAB were not stored in a permanently affixed compartments for storage of controlled drugs. 6. Resident #78, HYDROcodone-Acetaminophen10-325MG TAB were not stored in a permanently affixed compartments for storage of controlled drugs. 7. Resident #292, LORAZEPAM 0.5 TAB were not stored in a permanently affixed compartments for storage of controlled drugs. Interview on 11/17/23 at 2:00 PM, the facility's Consultant Pharmacist revealed that he was made aware of the stored overflow of controlled substance medications a couple of months ago but could not recall an actual date. He was not aware of the facility policy and safeguards in place to prevent loss, diversion, or accidental exposure. He revealed that he was not aware of how the medication was being accounted for. According to the Consultant Pharmacist, he does not monitor the facility for drug storage. He stated that he usually complete destruction of medication when notified by the DON. The last destruction took place on 11/14/2023. Interview and observation on 11/17/23 at 4:13 PM with LVN C, assigned to the 100 Hall Nurse Cart revealed that she was not aware of the facility police related the storing the controlled substance. LVN, C stated that no training was provided but the new process was implemented a couple of months ago. She stated that she was made aware that staff should contact the DON prior to ordering from the pharmacy if there is not a supply of controlled substance medication. The surveyor asked, what was the process and how do staff know what medication was available in the overflow supply. LVN C stated that the medication count on the medication cart had Call DON before ordering written on the bottom of the sheet. Observation of the 100 Hall Nurse cart, Resident #52 and Resident#75 Controlled substance record was congruent with the count available in the 410 Hall Nurse Cart but there was no record of the overflow supply that had been removed from the cart and stored in the DON's office. Interview and observation on 11/17/23 at 4:30 PM with LVN T, assigned to the 400 Hall Nurse Cart revealed that she was not aware of the facility policy related the storing the controlled substance. LVN T stated that no training was provided but the new process was implemented approximately a months ago. She stated that she was made aware that staff should contact the DON prior to ordering from (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676442 If continuation sheet Page 4 of 5 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 11/17/2023 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some the pharmacy if there is not a supply of controlled substance medication. The surveyor asked, what was the process and how do staff know what medication was available in the overflow supply. LVN T stated that there is no way of knowing what medications was available in the overflow supply. LVN T stated that the controlled medication was usually secured in a locked cart that is assigned to the primary nurse or medication aide. Observation of the 400 Hall Nurse cart, Resident #85 Controlled substance record was congruent with the count available in the 400 Hall Nurse Cart but there was no record of the overflow supply that had been removed from the cart and stored in the DON's office. Interview with the DON and the Facility Administrator on 11/17/23 at 5:00 PM the Facility Administrator revealed that she was aware of the storage of overflow-controlled substance in the DON's office. Facility Administrator stated that the process was implemented on October 20th, 2023. The administrator stated that the staff is expected to contact the DON prior to order additional controlled medications from the pharmacy. Facility Administrator stated that she did not know how the process was being monitored. The surveyor asked how the overflow supply was accounted for. The DON stated that she had not implemented a process to account for the overflow-controlled substance stored in the DON's office closet as of 11/17/23. The DON stated that she was the only staff that have access to the medication. The DON stated that there was not a controlled drug record and daily visual audit documented on the overflow-controlled substance. The Facility Administrator revealed that she was not aware of how the medication was being accounted for. The DON revealed that there was no policy update since the change was implemented on the October 20th, 2023. Both, the DON, and the Facility aAdministrator revealed that the current implemented process was not congruent with the facility's policy. Review of the training record titled Narcotic Overflow' dated 10/20/23 revealed that all staff was not trained on the new process. The recorded reflected that five leadership staff (non-direct patient care staff) members were trained. Review of the facility's policy titled, Controlled Substance Administration and Accountability, revised February 2023, revealed in part the following The facility will have safeguards in place to prevent loss, diversion, or accidental exposure. The Controlled Drug Record is a permanent medical record document and in conjunction with the MAR is the source for documenting any patient specific narcotic dispensed from the pharmacy. The charge nurse or other designee conducts a daily visual audit of the required documentation of controlled substances. The medication delivered are immediately recorded on the appropriate drug disposition record and store in the controlled drug store are by the nurse accepting delivery. The original Controlled Drug Record form remain in the care area to account for each dose administered. For areas without automated dispensing systems, two licensed nurses account for all controlled substance at the end of each shift. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676442 If continuation sheet Page 5 of 5