Health inspection·April 5, 2023

F 0689 [Resident #1] requires total assistance with ADL's and an approach of Bed mobility: assist of 2 persons, toileting: assist of 2 persons Level of Harm - Actual harm Residents Affected - Few Review of an incident/accident report for Resident #1, dated 03/15/23, reflected under type of incident/accident fall witnessed was checked, under secondary injury no apparent injury was checked, and under describe exactly what happened was CNA called Nurse that resident was on floor on her buttock. CNA stated she was trying to reposition her and change her resident leg slide and fall. [sic]. The bottom of the report was signed off by RN L. Review of Resident #1's progress notes reflected the following: .around 10:30 [Resident #1's RP] came she said resident need to go to hospital because she saw from camera she have seizure and need to do CT scan. When this nurse check no any sign of seizure she wants to call 911 after few minutes she said we have to wait some hours and after 30 minutes she said she may be she need to go hospital [NAME] transportation. notified [NP Z] and DON called transportation they are not available before 5 pm. notified [Resident #1] she said 5 pm to late call 911. called 911 resident transfer [hospital name] and she left in good condition no sign and symptoms of seizures noted . [sic] completed by RN H on 03/22/23. Around 3:30 pm shift CNA come to nursing station that shift CNA said resident fell when this nurse went resident room found resident on the floor that time resident bed was low position when she fall. Resident was non verbal so this nurse asked CNA about fall she said while she was try to change resident and change resident position and in this between she sliding on the floor. Checked head to toe no any visible injuries noted this time. Continue neuro checked vitals. BP=1o5/75, p=77 r=17, T=97.7, Spo2 =98% without oxygen. Resident was alert with eye opening. Notified Dr, no any further ordered this time. Notified DON, Notified Administrator. Notified [Resident #1's RP] [sic]. Completed by RN L on 03/15/23. Review of Resident #1's hospital records, dated 03/23/23 , reflected the following: HPI: .Per ER documentation patient fell from bed during her bath a few days ago. Patient was not sent to hospital at that time .[Resident #1's RP] brought [Resident #1] to hospital and found to have femur fracture . Further review reflected: CT Abdomen Pelvis w Contrast .2. Fracture deformity through the proximal diaphysis of the right femur with adjacent edema . And Assessment and Plan .Principal Problem: closed displaced subtrochanteric fracture of right femur .Femur fracture, right sustaine a few days ago after a fall atNH . [sic]. Review of Resident #1's Neurological Evaluation Flow Sheet revealed neuro checks were completed from 03/15/23 to 03/17/23 and no change in condition was noted or any sign or symptom of pain was noted. Review of the facility's census dated 04/05/23 revealed Resident #1 was no longer at the facility. In an interview on 04/05/23 at 10:41 AM with CNA C revealed she knew to look in the resident's chart for their assistance level before providing care and to not provide care alone if the resident required two people. CNA C said she cared for Resident #1 after the fall on 03/15/23 and did not notice (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676464 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 676464 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Las Brisas Rehabilitation and Wellness Center 3421 W Story Rd Irving, TX 75038 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 0689 any change in condition in the resident or any signs/symptoms of pain or a fracture. Level of Harm - Actual harm In an interview on 04/05/23 at 11:36 AM with CNA D revealed she knew to look in the resident's chart for their assistance level before providing care and to not provide care alone if the resident required two people. Residents Affected - Few In an interview on 04/05/23 at 11:46 AM with CNA E revealed she knew to look in the resident's chart for their assistance level before providing care and to not provide care alone if the resident required two people. In an interview on 04/05/23 at 11:56 AM with NA F revealed she was not certified yet and was still in training. NA F said she was only allowed to assist in providing care to residents when she was with a CNA or nurse. NA F said she understood she was not allowed to provide care to residents alone. NA F said she knew to look in the resident's chart for their assistance level before providing care and to not provide care alone if the resident required two people. In an interview on 04/05/23 at 12:25 PM with CNA G revealed she knew to look in the resident's chart for their assistance level before providing care and to not provide care alone if the resident required two people . CNA G said she cared for Resident #1 after the fall on 03/15/23 and did not notice any change in condition in the resident or any signs/symptoms of pain or a fracture. In an interview via phone on 04/05/23 at 12:46 PM with LVN A revealed she cared for and continued to monitor Resident #1 after her fall on 03/15/23 for any change in condition or delayed injuries, which Resident #1 had none . LVN A revealed she knew to look in the resident's chart for their assistance level before providing care and to not provide care alone if the resident required two people. In an interview on 04/05/23 at 1:11 PM with CNA J revealed she knew to look in the resident's chart for their assistance level before providing care and to not provide care alone if the resident required two people. In an interview via phone on 04/05/23 at 1:35 PM with RN H revealed she cared for and continued to monitor Resident #1 after her fall on 03/15/23 for any change in condition or delayed injuries, which Resident #1 had none. RN H revealed she knew to look in the resident's chart for their assistance level before providing care and to not provide care alone if the resident required two people. In an interview on 04/05/23 at 2:14 PM with CNA K revealed she knew to look in the resident's chart for their assistance level before providing care and to not provide care alone if the resident required two people. In an interview on 04/05/23 at 2:25 PM with NA B revealed she was not a certified nurse's aide as she was still considered a student in training. NA B said she took care of Resident #1 on 03/15/23 when the CNA for that hallway did not show up and she was asked to care for the residents until someone else came in to relieve her. NA B said she went to complete her rounds on each of the residents and did not check the resident's chart for their assistance level needs. NA B said she was never told or asked about Resident #1's assistance levels but that she needed to be changed . NA B said she knew Resident #1 needed to be changed because she was making her observation rounds NA B said she went in Resident #1's room to provide her incontinent care, and while rolling the resident to the other side to clean her up and she slipped off the bed and fell. NA B said she went to get the nurse to assess Resident #1 after the fall. NA B said at the time of the incident she had not been trained by (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676464 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 676464 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Las Brisas Rehabilitation and Wellness Center 3421 W Story Rd Irving, TX 75038 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 0689 Level of Harm - Actual harm Residents Affected - Few the facility on how to provide incontinent care to residents. NA B said at the time of the incident she was not aware that Resident #1 was a fall risk. NA B said after the incident she was suspended and sent home for the day. NA B said she came back to the facility the next day, was written up and in-serviced. NA B said she received in-services regarding repositioning residents, looking at resident's charts for their plan of care, how to determine if a resident requires two persons to assist them or not. NA B said she was also instructed not to provide any care to residents until she was checked off for the skills related to the job. NA B said she had not been checked off for any job related skills yet. NA B said she understood she was not allowed to provide any care to any resident independently. NA B said she also knew to look in the resident's chart for their assistance level before providing care and to not provide care alone if the resident required two people. NA B said the purpose of checking for a resident's assistance level and abiding by that was to keep them safe. In an interview on 04/05/23 at 2:45 PM with RN L revealed NA B came to her at the nurse's station to tell her Resident #1 was on the floor on 03/15/23. RN L said when she went to the room Resident #1 was on the floor, so she completed an assessment and did not find any injuries or change in condition. RN L said NA B told her she had been trying to change Resident #1's brief on her own even though the resident required two people's assistance for care . RN L said Resident #1 did not have any function to her limbs or body which was why she needed two people to provide care for her to keep her safe. RN L said she continued to monitor Resident #1 for any delayed injuries and signs or symptoms of pain and nothing was found . RN L said she received a call from Resident #1's RP on 03/23/23 informing her that the hospital found a femur fracture which occurred after the fall on 03/15/23. RN L said she had completed a skin assessment on Resident #1 on 03/21/23 which did not show any signs there was an underlying fracture. In an interview on 04/05/23 at 3:00 PM with LVN M revealed she cared for and continued to monitor Resident #1 after her fall on 03/15/23 for any change in condition, delayed injuries, or signs and symptoms of pain, which Resident #1 had none. LVN A revealed she knew to look in the resident's chart for their assistance level before providing care and to not provide care alone if the resident required two people. In an interview on 04/05/23 at 3:15 PM with the DON revealed she was not in the building when Resident #1 had a fall on 03/15/23. The DON said she was not sure why NA B provided care in general to Resident #1 or by herself since NA B had not been checked off for any skills as of yet. The DON said she was not sure when the fracture occurred because it could have happened from the fall or any time before or after that. The DON said staff were in-serviced on checking for resident's assistance levels prior to providing care and not providing care to residents who require two people when the staff was alone. The DON said staff were also in-serviced that NA B and NA F were not allowed to provide care to residents alone and always had to be with a certified or licensed staff. The DON specified that NA B and NA F had been specifically instructed not to provide care until they had their skill check off's first . In an interview on 04/05/23 at 4:00 PM with the Administrator revealed she came in the building that day on 03/15/23 and was told that Resident #1 had a fall. The Administrator said she confirmed with staff that an assessment was completed and it was. The Administrator said she interviewed NA B and was told that she was providing peri-care alone and the resident had a fall. The Administrator said she suspended NA B until she could be educated and trained on providing care to residents, including Resident #1. The Administrator said NA B should not have been providing peri-care in general or to Resident #1. The Administrator said Resident #1 was non-verbal and not able to communicate so staff had been assessing her each day for any change in condition or delayed injury from the fall; which (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676464 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 676464 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Las Brisas Rehabilitation and Wellness Center 3421 W Story Rd Irving, TX 75038 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 0689 Level of Harm - Actual harm Residents Affected - Few never occurred. The Administrator said she began in-services with the staff regarding checking resident care levels before providing care, providing care with two or more staff when indicated, falls/fall management, and abuse/neglect. The Administrator said she also instructed NA B and NA F that they could not provide care until they had their skill check off's first by the DON . The Administrator said the nurses and CNA's had been instructed that NA B and NA F were not allowed to provide care alone and had to have a licensed or certified person with them at all times. The Administrator said the purpose of providing care to residents based on their care levels was to keep them safe. Review of an in-service, dated 03/16/23, and titled CNA Class reflected: 1. Do not provide care alone- only with mentor (another certified aide or licensed nurse). 2. Always ask 'how many staff to provide care'. Review of associating sign-in sheet revealed multiple staff signed the sheet, including NA B and NA F. Review of an in-service, dated 03/16/23, and titled Nurse Assistant Program reflected: Nursing assistants are not to provide care for a skill they are not checked off on. Until further notice, the 2 students in the Nurse Aide Program will shadow another CNA and will not provide alone. [sic]. Review of associating sign-in sheet revealed multiple staff signed the sheet. Review of the facility's policy, dated 2022, and titled Fall Management reflected: 3. The facility provides assistive devices and/or therapies based on individual resident needs to facility mobility increase balance awareness, transfers, safe toileting, or other areas to assist the resident with fall prevention. [sic]. The noncompliance was identified as PNC. The noncompliance began on 03/15/23 and ended on 03/16/23. The facility had corrected the noncompliance before the survey began. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676464 If continuation sheet Page 5 of 5