Inspection·December 12, 2023

F 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few (the final permanent stage of kidney disease when the kidney can no longer function), left above-the-knee amputation, type 2 diabetes (a disease that occurs when your blood glucose, also called blood sugar, is too high), hemorrhage (bleeding), anemia (A condition in which the blood doesn't have enough healthy red blood cells), and Pancytopenia (low levels of all three blood cell types-red blood cells, white blood cells, and platelets). Review of MDS assessment dated [DATE] revealed CR #1 had a BIMS score of 11. CR #1 required substantial/maximal assistance with bed mobility and was dependent for transfers. MDS section M also revealed CR #1 had pressure ulcer and surgical wound. Review of care plan dated [DATE] revealed CR #1 had a post-surgical wound to the left thigh, the goal was the wound to be free from infection and heal, intervention included monitoring for signs and symptoms of infection, refer to follow up with surgeon as needed. Care plan also revealed CR #1 had arterial wound to the left medial thigh with the goal of pain will be relieved within one hour of intervention and no circulatory concerns will occur, intervention included to provide treatment per order and keep area clean. Care plan also revealed CR #1 had a stage III pressure injury to left lower back with goal that resident will have no complications from wound, and skin will remain clean, dry, and will heal through the next 90 days. Review of SBAR dated [DATE] by Nurse A revealed CR #1 had a change in condition with shortness of breath and in pain with new onset necrosis and fluid filled blisters. Oxygen saturation was 81%. The time of the oxygen saturation assessment was at 4:00pm on [DATE]. Vital signs on the SBAR were from previous days ([DATE] and [DATE]). SBAR also revealed CR #1's family at bedside with resident and suggested resident to go to the hospital. Review of lab dated [DATE] revealed CR #1's abnormal labs - white blood cell count was 13.0 (reference range was 4.0 - 10), RBC 2.68 (range 3.93 - 5.22), Hemoglobin 8.8 (range 11.2 - 15.7), Hematocrit 30.5 Review of CR #1's order for the month of October and [DATE] revealed lab order [DATE], on there was no other follow up lab ordered for the rest of CR #1's stay at the facility. Review of vital sign for [DATE] revealed oxygen saturation of 81% at 4:00pm and 81% at 4:03pm, there were no other vital signs documented for CR #1 on [DATE]. CR #1's vital sign on [DATE] was blood pressure = 100/70 at 11:59am and 106/56 at 6:00pm; pulse=104 bpm, no oxygen saturation assessed. Pain rating was documented as 0 on [DATE], [DATE], and [DATE]. There was no pain rating documented on [DATE] and for the rest of the days that CR #1 was in the facility. Review of private ambulance report dated [DATE] revealed the call was made to the ambulance service at 3:38pm on [DATE]. The ambulance service arrived at the facility to pick up CR #1 at 4:18pm on [DATE]. The report also revealed the resident was complaining of pain, a blister, and tenderness to her right leg. The report revealed CR #1 stated she had an amputation about a month ago and that in the past week the pain, tenderness, and blistering has gotten worse. The assessment showed that CR #1 was hypotensive and tachycardic (rapid fast heartbeat). The ambulance record did not reveal if oxygen was administered to CR #1. The ambulance arrived at the hospital at 4:48pm on [DATE]. CR #1's care transfer from the ambulance service to the ER was made at 5:41pm. Review of the hospital emergency room record dated [DATE] revealed CR #1's time of arrival at the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676442 If continuation sheet Page 2 of 17 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 12/12/2023 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 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few ED was 4:52pm. CR #1 complained of leg pain x week. CR #1's Blood pressure enroute to the hospital was 88/50. CR #1's vital signs at ER at 5:18pm were blood pressure 88/50, heart rate = 117, respiration 17, and oxygen saturation 99%. The record did not indicate if oxygen was administered. The vital signs at 6:10pm were blood pressure = 73/56, heart rate = 119, respiration 20, and SpO2 = 95% on room air. The vital signs at 6:15 were blood pressure = 66/50, heart rate 120, respiration = 22, and SpO2 = 98% on room air. At 6:21pm CR #1 triggered for sepsis (the body's extreme response to an infection, when an infection triggers a chain reaction throughout your body). The vital signs at 7:15pm were blood pressure = 72/52, heart rate 108, respiration = 20, and SpO2 = 96%. The vital signs at 8:00pm were blood pressure = 78/49, heart rate 84, respiration = 21, and SpO2 = 94%. The record revealed at 8:03pm CR #1's heart rate went down to 40, respiration went down to 10, and oxygen saturation was 86%. The hospital emergency room record also revealed CR #1's was having a slowly worsening bradycardia, CR #1 had no palpable pulse, and CPR was initiated. CR #1 was pronounced dead at 8:33pm. Review of the hospital Emergency Department record dated [DATE] revealed CR #1 was at the hospital for leg pain and concern for infection at recent amputation site to lower left extremity . On [DATE] at 3:11pm in an interview with Nurse A who was taking care of CR #1 on [DATE], she stated she did not remember if she checked CR #1's vital signs on [DATE]. The State Surveyor asked how Nurse A completed her SBAR and which vital signs she recorded in the SBAR, Nurse A stated she did not know. Nurse A stated the medication aide was supposed to check CR #1's vital signs because CR #1 was getting blood pressure medication. She was not aware that the vital signs were not checked by the Med Aide, the Med Aide was supposed to check residents' blood pressure during medication administration. Nurse A said vital sign helps to know how residents are doing, and if there was anything going on, it would reflect in the vital sign and prompt intervention would be provided. she stated she did not remember if she administered oxygen to CR #1 when her oxygen saturation dropped to 81%. She said it's been a while and she did not remember. She stated she did not remember the exact time the EMS was called, and she did not remember the time they arrived at the facility. On [DATE] at 3:24pm the Wound Care Nurse said CR #1 was admitted with wounds - post-surgical wound on the amputated left stump, necrotic wound above the stump, and sacrum wound on admission which got worse. She stated she was dressing the wounds everyday and the Wound Care Doctor was seeing CR #1 too, she stated the doctor comes to the facility every week. She stated there was no specific treatment for the right foot with discoloration. The Wound Care Doctor told them to keep monitoring it. She stated she did not notice any signs of infection on the wound, no warmth to touch, no redness, and she said CR #1 did not even complain of pain to the wounds. On [DATE] at 3:37pm, in an interview with the Unit Manager , she stated she did not know if the resident was given oxygen. She said she was busy with another resident and was not present in CR#1's room at the time of the change of condition. She stated, we called 911 right away. The Unit Manager stated they took vital signs of all residents at every shift, especially the residents admitted to the skilled unit. She stated CR #1 was admitted to the skilled unit and her vitals were expected to be checked every shift because vital sign is an important signal that tells if anything was wrong with resident at any time, if they did not check the vital signs they would not know if resident was exhibiting symptoms they could not see. She stated she was not aware that CR #1's vital signs were not checked on [DATE] specially at the time of the change of condition, she stated failure to assess vital sign could prevent resident from receiving prompt intervention. The Unit manager stated that the SBAR was supposed to be completed with the vital signs checked at the time of the change in condition. She stated they would notify the doctor when lab results came back and the doctor would review the lab results to determine if any orders were needed, and failure (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676442 If continuation sheet Page 3 of 17 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 12/12/2023 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 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few to do this could place resident in the risk of having abnormal labs for longer time and could affect residents' health status. On [DATE] in an interview with the DON , she said the practice in the facility and the expectation from all nursing staff were to check and document residents' vital signs every shift. She stated using a previous day vital sign to complete SBAR was not right. the resident had to be assessed at the time of the change of condition, and part of the assessment was to complete vital signs. The DON stated the nurses were expected to administer oxygen to the resident at any time when O2 saturation gets low regardless of whether the resident had order for oxygen or not because O2 sat of 81% is not good as this could place resident in hypoxia (a condition in which oxygen is not available in sufficient amounts at the tissue level to maintain health stability). She stated oxygen should be administered immediately, and the order could be obtained from the doctor later, because prompt intervention must be performed. The DON stated when the doctor ordered labs the expectation was that they would notify the doctor whenever they received the lab results. The DON stated I didn't know about all these because she was not employed at the facility at that time. She started working at the facility on [DATE]. On [DATE] at 4:34pm in a further interview with the Unit Manager we call 911 right away she also said we didn't want her to stay long, if we had called the regular transportation, it would take too long, so 911 is fastest for us and that's what we called she said sometimes it take up to 2 hours for the regular transport to come, so they had to use the 911. Said they do have vital sign on all residents everyday on the floor. Said they had been doing that since the onset of covid, said they always did vital signs on all residents on the halls. On [DATE] at 1:12pm an interview with the Family Member revealed there was no oxygen administered to CR #1 when she had shortness of breath. The Family Member said it took a long time, more than an hour, for the facility to call transport. The Family member stated he requested for 911 to be called. He said it was after a long time, they waited and waited, before the ambulance arrived and it was not a 911, it was a private company ambulance. On [DATE] at 4:11pm during an interview with the Doctor who was caring for CR #1, she stated CR #1's white blood count was coming down. The Doctor said it was 12 when she came back from the hospital on [DATE] and she was hemodynamically stable and clinically stable before she came back to the facility on [DATE]. The Doctor said she suddenly decompensated and became septic, and she decompensated in one day. The Doctor stated, I think it was a very rapid deterioration. It certainly did not happen incrementally over the week, otherwise we would have noticed it. She stated she was trying to remember now because she did not have access to CR #1's record after she had been discharged . She stated she did not remember if she gave any follow-up orders regarding the labs. She stated there was no indication in the record that CR #1 was infected based off her clinical status and her vitals. She stated, I am pretty sure that I ordered labs. She said CR #1 went to the hospital on [DATE] for suicidal ideation and she came back better. Her mental status was better. When she saw CR #1, she stated she wanted to get better, and she wanted to get out of the facility to go home. The Doctor stated the situation on resident's right foot happened in a day. She stated resident recently had an amputation and there was no infection. She said the wound care doctor was managing the wound and the wound care nurse was dressing the wound everyday. She said they would have notified us if there were any changes. The Doctor said CR #1 had a lot of comorbidities and when she got septic it happened really quick. The Doctor said she saw the residents at the facility once or twice per week. She stated the last time she saw the CR #1 was on Thursday [DATE]. She said at that time she was not aware that CR #1 had any issues with the right foot. She was made aware of the necrosis on the right toe and blister (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676442 If continuation sheet Page 4 of 17 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 12/12/2023 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 0684 Level of Harm - Immediate jeopardy to resident health or safety on the right leg on [DATE] at the time CR #1 was sent out to the hospital. The Doctor stated at the hospital before CR #1's initial admission, her WBC (White Blood Cell) count was on [DATE] = 25; [DATE] =23; [DATE] = 18.5; [DATE] =16.5; [DATE] =12.9; [DATE] =11.4. The Doctor stated she did not remember if the resident was admitted with antibiotics. She stated the resident was on cefepime until the 25th of October of 2023. The Doctor stated a WBC count was done at the facility on [DATE] and was 13. On [DATE] it was 12.2 at the hospital and on the day the resident died her WBC was up to 19. Residents Affected - Few On [DATE] at 9:59am an attempt was made to interview Medication Aide A who was caring for CR #1 on [DATE], there was no response to the call. On [DATE] at 10:25am in a further interview with Nurse A - the nurse on the floor when CR #1 was having shortness of breath. She stated when you spoke with me the other time, it was just a lot and it had been a while and she did not remember everything, she said she saw a lot of patients everyday and she was not able to remember and needed time to process the information about the resident. She stated she actually did resident's vital sign on that day [DATE], but she did not input it in the PCC, she said I am sorry. She said she also had the patient (CR#1) deep breath and CR #1's oxygen went up to 90s, she said she did not recall if it was 91% or 92%. She said the time the Oxygen saturation was taken was at 4:00pm on [DATE] and she did all the vitals all together including the O2 sat. She stated lack of oxygen could cause a person to be dizzy, weak and could cause someone to pass out and lack of oxygen can cause death. She said the first thing she did when she went in there was to look at resident's skin because of what she was told about the fluid coming out of CR #1's leg. She said she assessed the resident head-to-toe, and then from what the assessment revealed with the low oxygen, and she saw the way the resident was breathing as resident was not breathing well, then she told the resident to deep breath and the oxygen went up to 91% or 92%. She said she sent resident to hospital because of pain - she said when they turned patient during head-to-toe assessment to look at her sacrum wound, the resident stated ouch and she knew that the resident (CR #1) had pain. On [DATE] at 12:14pm in a further interview with the Wound Care Nurse , she said she did not remember because it was a while ago and she had to recall what happened. She stated she was doing wound care on that hallway, and she peeked in to see if CR #1 was in the room and ready for wound care. There was a Therapist in the room with CR #1. She said the Therapist asked her if she saw the foot of CR #1 and she came into the room to look at the right leg. She said the Doctor (who was in charge of resident's care) saw the resident the day prior ([DATE]) and told her (Wound Care Nurse) to keep monitoring and if anything changed, they should send the resident out immediately. The Wound Care Nurse started on the following day ([DATE]), the discoloration progressed from the toes to the resident's ankle and there was a blister on the right leg too. She stated that was the reason why the resident was sent out to the hospital. The Wound Care Nurse stated she was not aware if the vital signs were checked at that time. She said the Therapist checked the resident's pulse ox and felt that the oxygen level was not right. She said she did not remember the specific value, but she remembered the O2 sat started around the 80s and went up to the 90s. She stated when the nurse came into the room the nurse also checked the pulse ox and she did not recall what it was. The wound Care Nurse stated she did not remember if the blood pressure and other vital signs were checked at that time or not. She stated she was trying to calm the patient (CR #1) down because CR #1 was not happy with how her foot looked with the progression of the discoloration. The State Surveyor requested for the Wound Care Doctor's contact from the Wound Care Nurse. On [DATE] at 10:11am in an interview with the Physical Therapy Assistant, she said on [DATE], she could not recall the exact time, she did exercise with the resident's left stump. When she wanted to do the exercise with the right leg, she lifted the leg, there was a [NAME] of fluid from the leg, so (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676442 If continuation sheet Page 5 of 17 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 12/12/2023 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 0684 Level of Harm - Immediate jeopardy to resident health or safety she stopped. She laid the leg on a towel to soak the fluid coming out of it. She checked the resident's O2 sat and it was 80%. She wanted to step out immediately to look for a nurse, but the wound care nurse and the floor nurse came in - the wound care nurse came in first, and she was explaining what she found about the '[NAME]' of fluid from CR #1's leg to the Wound Care Nurse and the Floor nurse (Nurse A) came in after. She said she handed over to the nurses who took over CR #1 from there. She stated she did not know anything that happened after. Residents Affected - Few On [DATE] at 10:15am in an interview with the Occupational Therapist, he stated he went into the room earlier to do exercise with the resident (CR#1) but he noticed CR #1 was not looking good and appeared to be have labored breathing or in severe pain. He stated he did not really know, but the resident was not looking good to him and appeared to be in some sort of distress. He stated he immediately stepped out to get a nurse to check on CR #1. He said it was hard for him to find a nurse. It took him up to 20 minutes to get a hold of a nurse. He said he did not know who the nurse was because they had agency nurses in the building at that time and he did not really know them. He said when he got a nurse and came back to CR #1's room he met the Physical Therapist Assistant and the wound care nurse in the resident's room. He stated he did not do exercise with the CR #1. On [DATE] at 12:34pm another attempt was made to interview Medication Aide A who was assigned to CR #1 on [DATE], but there was no response. The State Surveyor left a message on the voicemail. On [DATE] at 5:20pm an attempt was made to contact the Wound Care Doctor, but there was no response. The State Surveyor left a message on the voicemail. On [DATE] at 8:58am in an interview with the Wound Care Doctor, he stated he had a concern regarding CR #1's stump, the left leg that was amputated. He said when he saw CR #1 on [DATE], he personally spoke to the Family Member 1 who was at the bedside, and Family Member 2 over the phone, and told them that the resident (CR#1) needed to follow up with the surgeon who did the amputation as soon as possible. He said he told them that the stump was not looking good, he said the stump appeared necrotic upon admission. He said he did not notice any infection in any of CR #1's wound. He said The amputation wound was compromised, he said she presented from the hospital with gangrene on the amputation stump and upon noticing that on my first visit I spoke to her, I called the family member. The Wound care doctor stated he also noticed during his first assessment on [DATE] that CR #1's right foot had discoloration from poor circulation. He said that he left the information with the Wound Care Nurse who was right there with him when he was assessing CR #1 and was speaking to CR #1's family members. The Wound care doctor stated he did not know if the resident made the appointment to the surgeon. He said I left that with the treatment nurse to follow up particularly for the amputation because the wound was not doing well regarding CR #1's right foot with discoloration, the Wound Care Doctor said he did not recall and had to look at his notes. He said there was not much treatment involved with that except to monitor it and that was my recommendation. He said it was a result of CR #1's poor circulation. On [DATE] at 9:23am an attempt was made to obtain further interview from the Wound Care Nurse regarding the recommendations from the wound care Doctor to schedule an appointment with the Surgeon for CR #1's wound. There was no response to the call. On [DATE] at 10:06am in an interview with Family Member 2, she stated someone spoke with her over the phone at the time CR #1 was just admitted to the facility, but she didn't know who it was. She said Family Member 1 was there at the bedside at the time the person, who she believed to be a doctor, was speaking with her over the phone regarding CR #1's wound. She said the doctor gave the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676442 If continuation sheet Page 6 of 17 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 12/12/2023 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 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few recommendation that they needed to see the surgeon to follow up on the left stump because it was not looking good. She said, I also had a concern about that wound too, but I am not a doctor, I don't know anything. She said she spoke with the receptionist at the surgeons office who said the resident would be due for the two week follow up and the family member should go ahead and schedule the follow up appointment. The receptionist also stated they should take a picture of the stump, send it in to their office, and if there was anything wrong, they could get CR #1 in sooner. She stated she went ahead to schedule the appointment for two weeks, and the receptionist told her they needed to send in a picture for them to see how the wound looked. She said she was not there at the facility but Family Member 1 was there at the facility, and she told him (Family Member 1) to take a picture of the stump. She stated Family Member 1 said he took the picture, and he gave it to a lady who was one of the staff members (he did not know the name of the staff). She said when she came to the facility to visit CR #1 a few days later, she spoke to a lady who was dressing the wound of CR#1. She believed the nurse was the wound care nurse, and the wound care nurse said they had already contacted the surgeon, provided a picture of the stump, they spoke with the surgeon, and everything was fine. She said about a week later when she followed up at the surgeon's office, the receptionist told her that they never received any pictures. She asked Family Member 1 and he (Family Member 1) was upset because he said he took the picture and gave it to one of the staff along with the number of the surgeon's office so they could send the picture in to them. She stated CR #1 did not make it to the surgeon follow-up appointment before she passed. Review of policy titled 'Vital Signs' dated [DATE] revealed, in part, vital signs shall be obtained at least in the following circumstances . at least daily for a resident receiving skilled services .when the residents general condition changes. Review of policy titled 'Oxygen Administration' dated 10/2023 revealed in part, Oxygen is administered to residents who need it, consistent with professional standards of practice .and the resident's goals . Review of policy titled 'Laboratory Services and Reporting' dated [DATE] revealed in part, The facility must provide or obtained laboratory services when ordered by a physician, physician assistant, nurse practitioner, or clinical nurse specialist in accordance with the state law .Promptly notify the ordering physician, physician assistant, nurse practitioner, or clinical nurse specialist of the laboratory results that fall outside the clinical reference range. This was determined to be an Immediate Jeopardy (IJ) on [DATE] The Administrator was notified. The Administrator was provided with the IJ template on [DATE] at 1:45pm. The following Plan of Removal submitted by the facility was accepted on [DATE] at 10:32pm. The plan of removal reflected the following: Plan of Removal Name of facility: Date: [DATE] F- 684 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676442 If continuation sheet Page 7 of 17 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 12/12/2023 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 0684 Problem: Failure to transfer a resident out promptly when there was a change in condition. Level of Harm - Immediate jeopardy to resident health or safety 1. Residents Affected - Few 2. CR#1 no longer resides in the facility. [DATE] The facility DON/Designee conducted an audit of the current residents' v/s to ensure all are free of changes in condition. Any issues identified were immediately addressed. 3. [DATE] The Licensed nurse assigned to the resident during the residents change in condition was placed on suspension pending investigation. The following in-services were initiated by the DON on [DATE]: Any nurse, or medication aide not present or in-serviced on [DATE], will not be allowed to resume their duties until in-serviced. Ongoing in-service will be completed by the DON, the Unit Managers, the WC nurse or the RN Supervisor, until all Licensed staff, medication aides, weekend, PRN, and agency staff have completed the in-service. In-service completion projected for [DATE]. 4. [DATE] The DON/Designee immediately initiated an in-service with the licensed nurses, including medication aides regarding what is a change in condition, resident assessment, nursing interventions, and prompt transfers. Licensed nurses will not be allowed to work until after completion of the in-service. Completed [DATE]. 5. [DATE] The DON conducted an in-service with the nursing staff including floor nurses and managers to overview the interventions a nurse must initiate in case of an emergency pending MD/NP call back/approval such as with hypoxia/hypotension episodes based on the facility Medical Director Protocol. Nursing staff will not be allowed to work until after completion of the in-service. Completed [DATE]. 6. [DATE] The DON conducted an in-service with the nurse management team on the facility expectations to assist floor nurses during emergencies including assessment, intervention, and prompt transfers. Nursing managers will not be allowed to work until after the completion of the in-service. Completed [DATE]. 7. [DATE] Re-in-service licensed staff, including medication aides on Immediately reporting sentinel events to the DON and/or the Administrator including but not limited to the residents' changes in condition, transfers, any allegations regardless of time or day. Licensed nurses will not be allowed to work until after completion of in-service. Completed [DATE]. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676442 If continuation sheet Page 8 of 17 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 12/12/2023 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 0684 8. Level of Harm - Immediate jeopardy to resident health or safety [DATE] The DON/designee began a questionnaire to validate effectiveness of the training. The questionnaire is conducted with Licensed staff. Immediate re-education will be completed by the DNS/designee if any staff is unable to answer appropriately to the questions on the questionnaire. Staff will not be allowed to work until after completion on the questionnaire. Completed [DATE]. Residents Affected - Few Monitoring as of [DATE]: 9. [DATE] The DON or administrator is notified of all resident changes in condition, emergencies, and resident transfers to provide guidance and ensure proper assessment, interventions, and transfers are done appropriately. Issues identified will be immediately addressed through further education, disciplinary action, and or termination of employment. 10. [DATE] The DON/IDT reviews the SBARS and transfers out of the facility from the prior day at least 5x per week to ensure the process was appropriately followed. Any issues identified will be addressed immediately. 11. An impromptu QAPI meeting was conducted with the facility Medical Director, on [DATE] to notify of the potential for noncompliance and the action plan implemented for approval. Plan approved on [DATE]. 12. [DATE] The Administrator, DNS/Designee will report the findings to the QI process and QA committee monthly until deemed no longer necessary. Any concerns or recommendations will be addressed immediately. The State Surveyor confirmed the Plan of Removal for the IJ by monitoring from [DATE] through [DATE] as follows: On [DATE] at 2:12pm in an interview with Nurse B (the weekend supervisor), she stated she got a training this morning when she first got to the floor. She said the Administrator trained her on an in-service today [DATE], and the training was about vital signs. They must ensure to always check their residents vital signs every shift. They must check resident's blood pressure for blood pressure medications and document when blood pressure was taken. If the blood pressure was outside the parameters prescribed by the prescriber, the medication would be held (not given to the patient), and the reason for not giving it would be documented as well as the value of the blood pressure. She said she was also in-serviced to always see what happened when any of the nurses have issues with any of their residents and to go in there in person to see what was going on. On [DATE] at 2:20pm in an interview with Nurse C, she said she had training today ([DATE]). The training was about vital sign monitoring every shift and as needed. She said she had a training, about (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676442 If continuation sheet Page 9 of 17 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 12/12/2023 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 0684 when to call a manager, or a supervisor in charge of the shift or in charge of the hall. She said the supervisor should be called when a resident had a change of condition, when Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676442 If continuation sheet Page 10 of 17 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 12/12/2023 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 - Few 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 1 of 3 residents (CR#1) reviewed for drug administration. 1. The facility failed to obtain vital signs for CR #1 on [DATE] . 2. The facility failed ensure CR #1's Midodrine medication (medication prescribed to increase blood pressure for residents with persistent low blood pressure) was not withheld. CR #1 continued to deteriorate and expired at the hospital on [DATE]. 3. The facility failed to ensure CR #1 received pain medication when she was in pain on [DATE]. CR #1 continued to deteriorate and expired at the hospital on [DATE]. An Immediate Jeopardy (IJ) situation was identified on [DATE]. While the IJ was removed on [DATE] at 9:52 AM, the facility remained out of compliance at a scope of isolated with actual harm that was not immediate, due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk of low quality of care, worsening of condition, hospitalization and death. Findings include: Record review of CR #1's face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE]. CR #1 had diagnoses which included peripheral vascular disease (A circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), atrial fibrillation (An irregular, rapid heart rate that commonly causes poor blood flow), presence of cardiac pacemaker (A device used to control the heartbeat which stimulates the heart as needed to keep it beating regularly), essential primary hypertension (hypertension occurs when you have abnormally high blood pressure that's not the result of a medical condition) and atherosclerotic heart disease (disease caused by the buildup of plaque causing coronary arteries to narrow and limiting blood circulation). Record review of CR #1's physician order, dated [DATE], reflected: Midodrine HCL oral tablet 5 mg. Give 3 tablets by mouth three times a day for hypotension. Hold if SBP is >120 mm Hg. Record review of CR #1's vital sign reflected Pain rating was documented as 0 on [DATE], [DATE], and [DATE], there was no pain rating assessed and documented for the rest of the days CR #1 was in the facility. Record review of CR #1's order, dated [DATE], reflected CR #1 had as needed pain medication Oxycodone HCI oral tablet 5 mg, give 1 tablet by mouth every 8 hours as needed for pain, max daily amount 15 mg Record review of CR #1's Medication Administration Record for the month of [DATE] reflected there was no documentation of pain medication administered to CR #1 on [DATE]. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676442 If continuation sheet Page 11 of 17 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 12/12/2023 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 Record review of CR #1's Medication Administration Record for the month of [DATE] reflected there was no documentation of midodrine medication administered to CR #1 on [DATE]. The MAR reflected the medication was withheld due to vital sign out of parameter. The MAR also reflected no vital signs documented. Residents Affected - Few Record review of CR #1's vital sign reflected there was no vital sign documented for CR #1 on [DATE]. Record review of hospital emergency room record dated [DATE], reflected CR #1's time of arrival at the ED was 4:52 PM. CR #1's Blood pressure enroute to the hospital was 88/50. CR #1's vital signs at the ER at 5:18 pm were blood pressure 88/50, heart rate = 117, respiration 17, and oxygen saturation 99. Vital sign at 6:10 PM were blood pressure = 73/56, heart rate = 119, respiration 20, SpO2 = 95% on room air. Vital sign at 6:15pm were blood pressure = 66/50, heart rate 120, respiration = 22, SpO2 = 98% on room air. Vital sign at 7:15 PM were blood pressure = 72/52, heart rate 108, respiration = 20, SpO2 = 96%. Vital sign at 8:00 PM were blood pressure = 78/49, heart rate 84, respiration = 21, SpO2 = 94%. The record reflected at 8:03 PM CR #1's heart rate went down to 40, respiration went down to 10, and oxygen saturation was 86%. CR #1 was having a slowly worsening bradycardia (slow heart rate), CR #1 had no palpable pulse at 8:07 PM and CPR initiated. CR was pronounced dead at 8:33 PM. Interview on [DATE] at 3:11 PM with Nurse A who was taking care of CR #1 on [DATE], she stated she did not remember if she checked CR #1's vital signs on [DATE]. The State Surveyor asked how Nurse A completed her SBAR and which vital signs she recorded in the SBAR, Nurse A stated she did not know . Nurse A stated the medication Aide was supposed to check CR #1's vital signs because CR #1 was getting blood pressure medication midodrine. She stated she was not aware the vital signs were not checked by the Med Aide and she was not aware the blood pressure medication was not given. She stated the Medication Aide was supposed to notify her (Nurse A) when holding medication due to vital signs out of parameter. Interview on [DATE] at 3:37 PM with the Unit Manager, she stated she was busy with another resident and was not present in the CR#1's room at the time of the change of condition and she did not know CR #1's medication (Midodrine) was not given. The Unit Manager stated they took vital signs of all residents at every shift, especially the residents admitted to the skilled unit. She stated CR #1 was admitted to the skilled unit and her vitals were expected to be checked every shift by the nurse, and the medication aides were supposed to check residents' vital sign before giving them (or withholding) blood pressure medications. She stated she was not aware CR #1 was not given midodrine on [DATE] and she was not aware of CR #1's vital sign value, and the vital signs were not documented. The Unit manager stated Medication Aide who withheld Midodrine on [DATE] no longer worked at the facility . She stated the Medication Aide was supposed to document the vital signs and notify the nurse on the floor about the decision to hold the medication. Interview on [DATE] with the DON, she said the practice in the facility and the expectation from all nursing staff was all residents on blood pressure medication must have their blood pressure checked before administering medication. She stated if the vitals fell outside the parameter, the medication would not be given. She said the vital signs would be documented along with the reason for not administering the medication, and the nurse in care of the resident would be notified as well. The DON stated I didn't know about all these, she stated she did not know about everything that happened to Cr #1 because she was not employed at the facility at that time, because she started working at the facility on [DATE]. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676442 If continuation sheet Page 12 of 17 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 12/12/2023 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 - Few Interview on [DATE] at 4:11 PM with the Doctor who was caring for CR #1, she stated the expectation was for the facility to follow orders, which included medication orders, prescribed for all residents, and if any resident had a change in condition, they would notify her (the Doctor). Attempted interview on [DATE] at 9:59am with the Medication Aide A working on the floor on [DATE] there was no response to the call. On [DATE] at 12:34 PM another attempt was made to interview the Medication Aide who was assigned to CR #1 on [DATE] but there was no response, the Surveyor left message on the voicemail. Interview on [DATE] at 10:02 AM with Medication Aide B, she said she had administered midodrine to residents in the past and she currently had a resident getting midodrine. Medication Aide B said there was usually a parameter given by the prescriber for all blood pressure medications. She said if the blood pressure was too high, she would not give midodrine, and would tell the nurse, and would come back to recheck the blood pressure again. She said she would document the vital signs and put code #4 which meant the blood pressure was outside the parameters, she would document the blood pressure value in the resident's medication administration record. She stated the vital sign was part of resident's record and must be documented because it was the evidence why the medication was withheld. On [DATE] at 10:25am in a further interview with Nurse A - the nurse on the floor when CR #1 was having shortness of breath. She stated when you spoke with me the other time, it was just a lot and it had been a while and she did not remember everything, she said she saw a lot of patients everyday and she was not able to remember and she needed time to process the information about the CR #1 in her mind. She stated she did not administer pain medication to CR #1 on [DATE] and she did not remember the reason why she did not administer pain medication to CR #1. Nurse A stated pain could cause residents to become uncomfortable and to be intolerance to care interventions. Record review of the facility's policy titled Medication Administration, dated 12/2020, reflected, in part, obtain and record vital signs when applicable or per physician orders . When applicable hold medication for those vital signs outside the physicians prescribed parameters .For those medications requiring vital signs, record the vital signs onto the MAR. Record review of the facility's policy titled Vital Signs, dated [DATE], reflected, in part, vital signs shall be obtained at least in the following circumstances . at least daily for a resident receiving skilled services .when the residents general condition changes. This was determined to be an Immediate Jeopardy (IJ) on [DATE]. The Administrator was notified. The Administrator was provided with the IJ template on [DATE] at 1:45pm. While the IJ was removed on [DATE] at 9:52am the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. The following Plan of removal submitted by the facility was accepted on [DATE] at 10:32 PM: Plan of Removal Problem: Failure to obtain v/s and withheld anti-hypotensive medication. 1. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676442 If continuation sheet Page 13 of 17 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 12/12/2023 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 CR# 1 no longer resides in the facility. Level of Harm - Minimal harm or potential for actual harm 2. Residents Affected - Few [DATE] The facility DON/Designee conducted an audit of current residents with order for midodrine to ensure blood pressure parameters are obtained and followed. Any issues identified were immediately addressed. 3. The Medication Aide who did not document the blood pressure is no longer employed by the facility since [DATE] . The following in-services were initiated by the DON [DATE]: Any nurse or medication aide not present or in-serviced on [DATE], will not be allowed to assume their duties until in-serviced. Ongoing In-services will be completed by DON, Unit Managers, WC nurse or RN Supervisor, until all licensed staff, weekend, prn, and agency staff in completed. In-services completion projected for [DATE]. 4. [DATE] The DON/designee conducted an in-service with the facility licensed staff, including medication aides regarding midodrine management to include following parameter, notifying the licensed nurse when the BP is low and medication held, and EMAR documentation of V/S. Licensed staff will not be allowed to work until they are in-serviced. Completed [DATE]. 5. [DATE] the DON/Designee immediately initiated an in-service with the licensed nurses, including medication aides regarding what is a change in condition including resident assessment, nursing interventions, and prompt transfers. Licensed staff will not be allowed to work until after completion of in-service. Completed [DATE]. 6. [DATE] The DON conducted an in-service with the nursing staff including floor nurses and managers to overview interventions a nurse must initiate in case of emergency pending MD/NP called back/approval such as with hypoxia/hypotension episodes based on the facility Medical Director Protocol. Licensed staff will not be allowed to work until after completion of in-service. Completed [DATE]. 7. [DATE] The DON conducted an in-service with the nurse management team on the facility expectations to assist floor nurses during emergencies including assessment, intervention, and prompt transfers. Nurse managers will not be allowed to work their shift until completion of in-service. Completed [DATE]. 8. [DATE] Re-in-services licensed staff, including medication aides on Immediately reporting sentinel (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676442 If continuation sheet Page 14 of 17 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 12/12/2023 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 events to the DON and or Administrator including by not limited to residents' changes in condition, transfers, any allegations regardless of time or day. Staff will not be allowed to work until after completion of in-service. Completed [DATE] . 9. Residents Affected - Few [DATE] The DON conducted and in-service with the unit managers, wc nurse and RN supervisor on how to review the weights and vitals dashboard and the Not administered Med Passes in last 24-Hours reports in PCC to monitor abnormal v/s and ensure medications are provided as indicated. Unit managers will not be allowed to work until after completion of in-service. Completed [DATE]. 10. [DATE] The DON/designee began a questionnaire to validate effectiveness of the training. The questionnaire is conducted with Licensed staff. Immediate re-education will be completed by the DNS/designee if any staff is unable to answer appropriately to the questions on the questionnaire. Staff will not be allowed to work until after completion on the questionnaire Completed [DATE]. Monitoring as of [DATE]: 11. [DATE] The DON or administrator is notified of all resident changes in condition, emergencies, and resident transfers to provide guidance and ensure proper assessment, interventions and transfers are done appropriately. Issues identified will be immediately addressed through further education, disciplinary action and or termination of employment. 12. [DATE] The DON, ADON and unit managers review the weights and vitals dashboard and the Not administered Med Passes in last 24-Hours reports in PCC during the clinical morning meeting at least daily to identify abnormal v/s and missed medication on the MARS to ensure proper follow up. Any resident with abnormal blood pressure is reassessed by their nurse. 13. An impromptu QAPI meeting was conducted with the facility Medical Director, on [DATE] to notify of the potential for noncompliance and the action plan implemented for approval. Plan approved on [DATE]. 14. [DATE] The Administrator/Designee will report the findings to the QI process and QA committee monthly until deemed no longer necessary. Any concerns or recommendations will be addressed immediately. The State Surveyor confirmed the Plan of Removal for the IJ by monitoring from [DATE] through [DATE] as follows : Interview on [DATE] at 2:12 PM with Nurse B , the weekend supervisor, she stated she did a training (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676442 If continuation sheet Page 15 of 17 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 12/12/2023 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 - Few this morning when she first got to the floor. She said the Administrator trained her today [DATE], and the training was about vital signs that they must ensure to always check their residents vital signs every shift, and to check the resident's blood pressure for blood pressure medications, to document whenever the blood pressure was taken, and if the blood pressure was outside the parameter prescribed by the prescriber, the medication would be held and not given to the patient, and the reason for not giving it would be documented and the value of the blood pressure would be documented as well. Interview on [DATE] at 2:20 PM with Nurse C, she said she had training today ([DATE]). The training was about vital sign monitoring every shift and as needed. She said before giving blood pressure medication, she had to check vital signs and hold medication if vitals were outside parameters and document the vital signs. Interview on [DATE] at 2:36 PM with Nurse D, she said she had a training today. She said the training was about vital signs and parameters. She said they had to check vital signs of all residents every shift and before blood pressure medications, and during change of condition. Interview on [DATE] at 2:39 PM with Nurse E, she said she had to train today and yesterday. She said she was in-serviced on checking residents' blood pressure before giving blood pressure medications. She stated she was also trained to hold blood pressure medication if the vitals were not within the specified range by the doctor and she must document it in the resident's chart. Interview on [DATE] at 12:59 PM with CMA C, she said she had in-service this morning about blood pressure. She stated she was trained to check the resident's blood pressure before administration of the blood pressure medications, and if the blood pressure was outside the parameter on the doctor order she said she would let the nurse know. She said she usually would check twice to confirm. She said if after she checked twice and the vital signs were still outside the parameter of what the doctor ordered, she would hold the medication, she would notify the nurse, and she will document in the PCC. Interview on [DATE] at 6:04 AM with Nurse G, she said she entered the facility to resume her shift and she did the in-service this morning. She said the training was about checking resident vital signs every shift. She said they should always monitor residents with blood pressure medication to make sure the CNA checked the resident's blood pressure during administration of the blood pressure medication. She said if the blood pressure was outside the ordered parameter, it should be documented on the MAR and the medication would be withheld. Interview on [DATE] at 6:17 AM with Medication Aide B, she said she was in serviced about checking resident's blood pressure accurately during administration of blood pressure medications. She said if a resident's blood pressure was outside the prescribed parameter, she would hold the medication and would check the blood pressure again and would inform the nurse in charge of the resident. She said she would also document the blood pressure in the medication administration record and state the reason why the medication was not given. Interview on [DATE] at the 6:22am with Medication Aide C, she stated she was trained today when she came in and she was also trained over the phone by the unit manager and the DON. She said she must be sure to check resident's vital signs before administering blood pressure medication and if the blood pressure was not within the parameter the doctor ordered, she would hold the medication and notify the nurse so the nurse could notify the doctor. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676442 If continuation sheet Page 16 of 17 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 12/12/2023 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 She said she would also recheck the blood pressure again and she would document everything in the MAR. Level of Harm - Minimal harm or potential for actual harm Record review reflected: Residents Affected - Few Impromptu QAPI meeting of the Administrator with the medical Director; In-service training documentations were reviewed. Questionnaire for nursing staffs were also reviewed. The Administrator was informed the Immediate Jeopardy was removed on [DATE] at 9:52am. The facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676442 If continuation sheet Page 17 of 17