Health inspection·June 16, 2023

F 0677 indicated Resident #2's cognition was intact. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #2's care plan, last revised 04/17/23, revealed Resident #2 required ADL assistance with toileting and intervention included 2 people were to assist. Further review revealed a problem of bowel/bladder incontinence, and the interventions use to adult briefs to enhance dignity and use skin barrier after incontinent episodes. Residents Affected - Few An observation and interview on 05/31/23 at 2:43 PM, revealed as the State Surveyor approached Resident #1's room, Resident #1 was screaming from the bathroom, I need help. MA A was observed standing behind the medication cart in front of the room next to Resident # 1's room. Resident #2 was observed lying in bed. Resident #2 stated she had been in the bathroom screaming for help for about 30 minutes. Resident #2 stated the call light was working earlier that morning, but she believed it had stopped working again. Resident #1 was asked, while she was in the bathroom, if she pressed the call light and she stated yes but she believed it was not working again. The State Surveyor went into the hall and advised MA A that Resident #1 was in the bathroom screaming for help. MA A stated she would get a CNA to help. MA A was observed to continue standing at the medication cart. The State Surveyor went on the adjacent halls to look for help but was unable to find anyone to come help. When the State Surveyor returned to Resident #1's hall, MA A was observed standing in the same spot. State Surveyor then asked Resident #2 if anyone was in the bathroom with Resident #1, she stated no, and staff had still not come to help. In an interview on 05/31/23 at 3:16 PM, Resident #1 stated she had bowel movement and needed help wiping herself. She stated she was sometimes incontinent of bowel and had accidents but said made it to the toilet this time. Resident #1 stated she was unable to reach her bottom to clean herself after a bowel movement due to some of her medical conditions. She stated she pressed the call light for help, but she believed it stopped working. She stated the facility had fixed it yesterday (05/30/23) and it worked earlier in the morning but must had stopped. She stated she was screaming for help for about 30-40 minutes. In an interview on 06/01/23 at 2:03 PM, MA A stated even though she was in front of the room next to Resident # 1's room, she could not hear her screaming for help. MA A stated she messed up and should have helped Resident #1. She stated she was not in the middle of an emergency when Resident #1 needed help on 05/31/23 but she was running late for work on 05/31/23 and was trying to focus on what medications needed to be passed. She stated she should have stopped to help Resident #1. MA A stated she had the credentials to help Resident #1 because she was a CNA and MA. MA A stated it was not just the CNA's responsibility to help residents with toileting. MA A stated even if Resident #1 needed something she was not capable of doing, then she should have gone to get a nurse. MA A stated she had been in-serviced about this issue. In a record review and interview on 06/01/23 at 12:24 PM, the DON stated she was made aware of the incident with Resident #1 not receiving help with toileting. She stated her expectations was for all MAs, CNAs, and nurses to help with toileting and incontinence care. The DON stated she also in-serviced staff to continue with doing rounds every 15 minutes due to issues with call lights. She stated incontinence care was not a job only for CNAs. She stated she answered call lights to provide incontinence care and had wiped resident's bottoms, so her expectation was for all other staff to do the same. The DON provided an in-service titled Incontinence Care dated 05/31/23 and stated she started in-servicing yesterday (05/31/23) by going to each direct care staff personally and explaining her expectations regarding incontinence care. She stated she was still meeting individually with staff who did not work yesterday. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676464 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 676464 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2023 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 0677 Level of Harm - Minimal harm or potential for actual harm A record review of the facility's policy titled Activities of Daily Living, Optimal Function, dated 05/02/23, revealed Policy: The facility provides care and services to ensure that a resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that such diminution was unavoidable. The facility provides necessary care to all residents that are unable to carry out activities of daily on their own to ensure they maintain proper nutrition, grooming and hygiene. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676464 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 676464 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2023 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 2 of 5 residents (Residents #1 and Resident #2) reviewed for quality of care. Residents Affected - Few The facility failed to ensure that residents receive treatment and care in accordance with the comprehensive person-centered care plan, and the residents' choices when needing help due to call light malfunction. An Immediate Jeopardy (IJ) was identified on 06/16/23. While the IJ was removed on 06/16/23, the facility remained out of compliance at a severity level of no actual harm with a potential for more than minimal harm and a scope of isolated due to the facility still monitoring the effectiveness of their Plan of Removal. This failure could place the residents at risk of injury and not being able to obtain assistance or care as needed. Findings include: Record review of Resident #1's electronic Face Sheet, dated 05/31/23, revealed a [AGE] year-old male admitted to the facility on [DATE]. Resident #1 had diagnoses which included the following: epilepsy (a disorder of the brain characterized by repeated seizures), transient cerebral ischemic attack (a stroke that lasts only a few minutes), lack of coordination, systemic lupus erythematosus (autoimmune disease in which the immune system attacks its own tissues), muscle weakness, schizophrenia, diabetes mellitus, hemiplegia (a one-sided muscle paralysis or weakness), hypertension (high blood pressure), multiple sclerosis (a potentially disabling disease of the brain and spinal cord), and difficulty walking. Record review of Resident #1's Quarterly MDS, dated [DATE], revealed a BIMS score of 15, which indicated Resident #1's cognition was intact. The MDS revealed Resident #1 had seizure disorder or epilepsy and required one person assistance for the following ADLs: transferring, locomotion on/off unit, dressing, toilet use, and personal hygiene. Further review of the MDS revealed Resident #1 was occasionally incontinent of urine, and frequently incontinent of bowel and needed assistance for toileting hygiene. Record review of Resident #1's care plan, last revised on 04/03/23, revealed Resident #1 was at risk for falling due to weakness, and diagnosis of multiple sclerosis, stroke, and lupus. The interventions included Assist resident with all transfers and encourage resident to call for assistance and not to attempt to transfer self.; Keep call light in reach at all times.; and Provide toileting assistance as needed. The care plan revealed Resident #1 had seizures due to diagnosis of epilepsy. The interventions included Monitor resident for impending seizure symptoms and respond quickly when noted; Changes in consciousness, fixed staring, jerking of arms and legs; Monitor seizure drug level lab boluses as ordered by MD; and Protect resident from injury during a seizure. Use pillows to pad body if in bed, safely lower to the ground to prevent falls if upright, use tongue blade to protect tongue biting. Further review revealed, Resident #1 required ADL assistance with toileting and intervention included one person was to assist. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676464 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 676464 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2023 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 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Record review of Resident #1's electronic clinical record revealed a progress note by LVN B, dated 05/01/23 at 7:08 PM which reflected This nurse was called to resident restroom thinking she might be having a stroke, assessed resident noted facial and mouth drooping to left. Resident A&O (alert & oriented), V/s (vitals) obtain b/p (blood pressure) 113/74, p (pulse)76, r (respiration)19, t (temperature) 97.0. Assisted resident back to bed, and notified [physician], order received to transfer to ER (emergency room). 911 was called to the facility and resident was send to [hospital] for further [NAME] (evaluation);/TX (treatment). RP (representative) notified [RP] unable to reach as this time. LVM (leave voicemail). Record review of Resident #1's hospital records, dated 05/01/23, revealed Per EMS, they state they were called by nursing home staff for a stroke the pt (patient) began experiencing approximately 40 minutes pta (Patient Transport Ambulance). On EMS arrival, they noted the pt was experiencing a questionable, focal seizure localized to the facial region with L-sided (left) gaze deviation. The record revealed labs were conducted and diagnosis revealed Resident #1 was ruled out for a stroke. The record revealed resident was discharged and diagnosis included recurrent seizure. In an interview on 05/31/23 at 12:14 PM, Resident #1 stated the call light in her room was fixed yesterday (05/30/23) but prior to yesterday, the call light was not working for about 2-3 weeks. She stated the facility had provided a bell, but staff were not responding when she pressed the bell, and they would tell her they could not hear it ringing. Resident #1 stated she had to use her cell phone to call to the nurse's station to get help. She stated sometimes they would not answer the phones. Resident #1 stated on 05/01/23 she was in the bathroom and thought she was having a stroke. Resident #1 stated she had a stroke before and she also had epilepsy, so she was accustomed to reoccurring seizures. Resident #1 stated on 05/01/23 it felt more like a stroke because she could not feel the left side of her face and body, which did not normally happen when she had seizures. Resident #1 stated she was in the bathroom yelling for help and no one came until 30-45 minutes. She stated the call light in the bathroom was not working and the facility had not provided accommodations for emergencies in the bathroom. Resident #1 stated once the nurse arrived, they assessed her, and she was sent to the hospital. She stated at the hospital it was determined she did not have a stroke and it was a seizure. She stated she did not have any injuries from the incident. Resident #1 stated she had spoken to the DON about her concerns with the call light not working, especially in the bathroom. She stated the DON advised her that staff were supposed to be doing rounds every 15 minutes, but she stated that was not being done because she had been in the bathroom for almost 45 minutes. Record review of Resident #2's electronic Face Sheet, dated 05/31/23, revealed a [AGE] year-old female admitted to the facility on [DATE]. Resident #2 had diagnoses which included the following: paraplegia (the inability to voluntarily move the lower parts of the body), heart disease, muscle weakness, lack of coordination and muscle wasting atrophy (the decrease in size and wasting of muscle tissue). Record review of Resident #2's Quarterly MDS, dated [DATE], revealed a BIMS score of 15, which indicated Resident #2's cognition was intact. In an interview on 05/31/23 at 12:35 PM, Resident #2 stated she heard Resident #1 in the bathroom screaming. She said it sounded like she was saying help, but her voice did not sound normal. Resident #2 stated she knew something was wrong. She stated the call lights were not working and they gave her a bell, but it was not in reach. Resident #2 stated it did not matter about the bell anyway, because staff never heard them. Resident #2 stated she used her cell phone to call to the nurse's station. She stated when they answered (she does not know who) she told them something was wrong with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676464 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 676464 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2023 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 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Resident #1, and she needed help in the bathroom. Resident #2 stated they told her they would come help. She stated about 30 minutes had passed and no one came to help, so she attempted to call the nurse's station again, but no one answered. Resident #2 stated as time was passing Resident #1's speech was becoming clearer, and she heard her screaming she was having a stroke. Resident #2 stated she was a paraplegic, so she could not get out of bed to find help. Resident #2 stated she called the nurse's station a third time. She stated someone answered the phone (does not know who) and she told them she believed Resident #1 was having a stroke. She said a nurse (does not know name) came about 5 minutes after the third call. Resident #2 stated she believed Resident #1 was in the bathroom for about 45 minutes before the nurse came to the room. In an interview on 05/31/23 at 1:27 PM, the facility's Maintenance Director (MD) stated he started at the facility about 2 weeks ago and there was already an issue with the call light system. He stated there was a bad storm, and the lightning struck the building, which caused the call light system to malfunction. He stated from his understanding a tech company came out and had ordered the equipment to fix the system. He stated he was not sure exactly what date because this was done prior to him working at the facility. He stated the equipment took several weeks to come in and the company returned he believed on 05/19/23 and they replaced the malfunctioned equipment. He stated the system went out again and the company came back out and then realized there was an issue with the call light system at the nurse's station, so they had to order more equipment to fix that. He stated the company returned yesterday (05/30/23) with equipment for the nurse's station and everything was working. He stated later yesterday evening, they found out that some of the call lights were still not working. The MD stated the tech company was currently in the building and they were conducting an audit on which rooms were not working. He stated its difficult to account for which rooms are working because one minute they are working and the next they are not. In an interview on 05/31/23 at 2:15 PM, the Administrator stated the call light system first went out on 04/06/23. She stated the MD at that time was trying to fix the system and realized he was unable to, so they called a tech company to come help. She stated the tech company came on 04/11/23 and discovered equipment was burned due to the lightening and they had to order new equipment. The Administrator stated equipment did not come in until 05/16/23. She stated they provided bells to the residents and staff were doing round every 15 minutes. She stated there were no bells provided for the bathroom and that is why staff were doing rounds every 15 minutes. She stated the tech company replaced the equipment and call lights were working. She stated on 05/24/23 it was discovered the call light were no longer working and they called the tech company back out. The Administrator stated the facility went back to using bells and doing rounds every 15 minutes. She stated the tech company explained the equipment at the nurse's station was burned out and had to be replaced. She stated they ordered more parts, and they returned yesterday (05/30/23) to install the new equipment. The Administrator stated yesterday the call lights were working after the tech left, and then later in the evening they learned they were out again in some rooms. She stated the tech was currently in the building working on the call lights. She stated she was aware of the incident with Resident #1 on 05/01/23. The Administrator stated staff were expected to complete rounds every 15 minutes, so staff were in-serviced on making sure they are doing rounds every 15 minutes, after this incident occurred. In an interview on 06/01/23 at 9:30 AM, LVN B stated on 05/01/23 she was at the nurse's station charting and Resident #2 called and stated Resident #1 was in the bathroom, and she believed she was having a stroke. LVN B stated she immediately went to the room. She stated she assessed the resident for injuries and took her vitals. She stated there were no injuries and her vitals were stable, but Resident #1's face was droopy she believed on the left side. She stated she notified the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676464 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 676464 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2023 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 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few DON, family, and doctor. LVN B stated she received orders from the doctor to send Resident #1 to hospital, so she called 911. LVN B stated she only spoke to Resident #2 twice and she immediately went to the resident's room. She stated the call lights system were not working and residents were provided bells to notify for help. LVN B stated CNAs were doing rounds every 15 minutes. She stated she did not know how long Resident #1 was in the bathroom nor the last time a CNA had checked on her. An observation and interview on 05/31/23 at 2:43 PM revealed as the Investigator approached Resident #1's room, Resident #1 was screaming from the bathroom I need help. MA A was observed standing behind the medication cart in front of the room next to Resident # 1's room. Resident #2 was observed lying in bed. Resident #2 stated she had been in the bathroom screaming for help for about 30 minutes. Resident #2 stated the call light was working earlier this morning, but she believed it had gone out again. Resident #1 was asked, while she was in the bathroom, if she pressed the call light and she stated yes but she believed it was not working again. The Investigator went into the hall and advised MA A that Resident #1 was in the bathroom screaming for help. MA A stated she would get a CNA to help. MA A was observed to continue to stand at the medication cart. The investigator went on the adjacent halls to look for help but was unable to find anyone to come help. When the Investigator returned to Resident #1's hall, MA A was observed to be standing in the same spot. When the Investigator asked Resident #2 was anyone in the bathroom with Resident #1, she stated no, and staff had still not come to help. In an interview on 05/31/23 at 3:16 PM, Resident #1 stated she made a bowel movement and needed help wiping herself. She stated she was sometimes incontinent with her bowels and had accidents, but she made it to the toilet this time. Resident #1 stated she was unable to reach her bottom to clean herself after a bowel movement due to some of her medical conditions. She stated she pressed the call light for help, but she believed it stopped working. She stated the facility had fixed it yesterday (05/30/23) and it worked earlier in the morning but must have stopped. She stated she was screaming for help for about 30-40 minutes. In a record review and interview on 06/01/23 at 12:24, the DON, she stated was aware of the incident on 05/01/23 with Resident #1. She stated since the call lights were out, the residents were given bells to call for help and the staff were doing rounds every 15 minutes. She stated Resident #1 and Resident #2 did tell her that Resident #1 was in the bathroom for about 30 minutes and staff had not come in to help. The DON stated she did speak to the nurse, who answered the first phone call made by Resident #2, but she couldn't recall which nurse it was, but the nurse told her she was in the middle of working with another resident and was checking their chart, when Resident #2 called. The DON stated the nurse advised her that when Resident #2 called she said Resident #1 needed help in the bathroom. She stated the nurse said she did not tell her it was emergency and she assumed she needed help with toileting. The DON stated nurse told her there was no one in the halls to ask them to check on Resident #1, so she went to finish up with her current situation and then was going to check on Resident #1. She stated when Resident #2 called the second time and spoke to LVN B and said Resident #1 was having a stroke in the bathroom, LVN B went to the room right away. The DON stated if staff would have been completing rounds every 15 minutes on 05/01/23 this would not have happened. She stated she in-serviced all direct care staff that had to do 15-minute rounds the following day. The DON stated she was made aware of the incident with Resident #1 not receiving help with toileting. She stated her expectations was for all CMAs, CNAs, and nurses to help with toileting and incontinence care. The DON stated she also in-serviced staff to continue with doing rounds every 15 minutes due to issues with call lights. She stated incontinence care was not a job only for CNAs. She stated she answered call lights to provide incontinence care and had wiped resident's bottoms, so her expectation was for all other staff to do the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676464 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 676464 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2023 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 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few same. The DON provided an in-service titled Incontinence Care dated 05/31/23 and stated she started in-servicing yesterday (05/31/23) by going to each direct care staff personally and explaining her expectations regarding incontinence care. She stated she was still meeting individually with staff who did not work yesterday. In an interview on 06/16/23 at 12:28 PM, CNA C stated she was covering Resident #1's hall the day she was sent out to the hospital. She stated did not know exactly what happened to Resident #1, but what she recalled was her coming out of another resident's room and saw the paramedics taking Resident #1 out on a stretcher. CNA C stated she was giving showers to the residents during the time of the incident. She stated the call light system was not working so residents were given bells and they were doing 15-minute rounds. CNA C stated showers took longer than 15 minutes, so she let the nurse know when she was giving showers, so they could do the rounds. She stated even though showers take longer than 15 minutes, she would still complete rounds. CNA C stated once she is done with a resident's shower, she would do a round and then get started on the next shower. In an interview on 06/16/23 at 11:18 PM, the DON stated Resident #1 was alert and oriented, so she advised her to take her phone with her to the bathroom and provided her personal cell phone number to call if she needed help and was unable to get anyone. She stated the 15-minute rounds meant the CNAs were going up and down the hall listening for bells or anyone calling for help. She stated it did not mean they were going to each resident rooms because they were not able to complete that. She stated staff who were assigned to the hall could have been helping a resident, which could take over 15 minutes. The DON stated the expectation was once staff were finished with the resident if it took over 15 minutes, they should do rounds before moving on to the next task. The DON stated their corporate approved 1 additional staff per shift to help with the rounds. She stated the corporate would not approve any additional people, due to budget constraints. The DON stated staff were documenting the rounds and she was responsible for monitoring. She stated she checked the sheets three times per week. A record review of the facility document titled Q 15- Minute Checks- 600 (hall) PM Shift, dated 05/01/23, revealed from the timeframes of 6:00 PM to 4:45 AM, 15-minute checks were completed and checked off. The document did not have a staff signature on it, just a check mark. A record review of the facility's policy titled Statement of Resident Rights, undated, revealed You, the resident, do not give up any rights when you enter a nursing facility. The Facility must encourage and assist you to fully exercise your rights . You have a right to: 1. All care necessary for you to have the highest possible level of health; 2. Safe, decent, and clean conditions; 4. Be treated with courtesy, consideration, and respect . A record review of the facility policy titled Emergency Disaster and Life Safety Policies and Procedures, dated 02/01/20, revealed 4. Nursing personnel: D. Will establish and maintain a medical communication system to all areas not equipped with patent/resident call lights. This may include but is not limited to: 1. Use of bells or other devices 2. Runners to convey information 3. Periodic or routine rounds . This failure resulted in an identification of an Immediate Jeopardy on 06/16/2023 at 4:45 PM. The Administrator was informed and provided the IJ template on 06/16/2023 at 4:49 PM and a Plan of Removal (POR) was requested. The Plan of Removal reflected: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676464 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 676464 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2023 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 0684

F558 - Reasonable accommodations of needs/preferences Level of Harm - Immediate jeopardy to resident health or safety Resident identified with no negative outcomes Residents Affected - Few Diversify notified immediately for request a quote for repair of the call light system Call light system failure identified on 4/6/23. Repair quote for call light system repair from Diversify received on 4/11/23 Diversify returned on 5/24/23 after receiving the needed part for repair of the call light system. Once there, Diversify identified a more complex issue and were required to involve additional technicians and additional electrical repair 6/2/23 Diversify returned to continue repairs 6/9/23 Diversify returned and were able to partially repair the call light system 6/12/23 Diversify returned and completely repaired the call light system Residents who reside in the facility have the potential to be affected by this alleged deficient practice. In the event of call light system failure 15-minute checks will be initiated to monitor residents for needs and will continue until the call light system has been repaired. A monitoring tool will be used to document the 15-minute checks and will be used until call light system is repaired In the event the call light system fails affected residents will be provided bells. In the event of call light system failure, a resident council meeting will be held to inform residents of plan for alerting staff for assistance and the plan for the repair of the call light system In the event of call light system failure, the administrator will contact companies to obtain quotes for repairs of the call light system Facility employees will be educated on the plan that was initiated: Immediate notification to administrator of call light failure residents will have handheld call bells to alert the nursing staff for assistance in the event of call light failure An assignment will be made by the administrator and/or Director of Nursing for 15-minute checks on residents to monitor for residents needs in the event of call light failure Any employee not receiving this education by 6/16/23 will receive before their next scheduled shift. This will include any agency personnel and new hire orientation. Maintenance Director will perform weekly preventive maintenance to validate the call light system (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676464 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 676464 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2023 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 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few is functioning properly for 4 weeks, then monthly. Regional Maintenance Director will validate monthly preventive maintenance completed. Director of Nursing and Administrator will make rounds throughout the day to validate that the call light system is functioning properly, and resident needs are being met. In the event of call light system failure, Clinical Consultant will validate 15-minute checks completed weekly. Any concerns will be addressed at time of discovery. The medical director was informed of the Immediate Jeopardy and the contents of this plan on 6/16/23. An ad hoc Quality Assurance Performance Improvement meeting will be held on 6/16/23. The Plan of Removal was accepted on 06/16/23 at 6:12 PM. Monitoring of the plan of removal included: Observations and interviews were conducted on 06/16/23 from 1:45 PM to 3:05 PM on various rooms and revealed Rooms 401, 405, 406, 408, 413, 418, 419, 503, 506, 510, 511, 517, 518, 521, 522, 603, 604, and 608 call lights were working. Interviews with the residents of these rooms revealed the call lights had been working for approximately one week and staff were responding. Interviews with the 2 RNs, 1 LVN, 2 CMAs, 5 CNAs, who worked multiple shifts, revealed the call lights had been working for approximately one week and they knew the protocols should the call lights go out, which included residents would be provided bells and they were required to complete 15-minutes rounds. A record review on 06/16/23 of a memo from the tech company who fixed the call light system, dated 06/16/23, reflected the following To Whom It May Concern: As of June 12, 2023, our technicians have completed work to make sure that all devices on 400, 500, and 600 halls are operating for nurse call emergency calls for the rooms. By Friday, June 9 we were able to have most of the rooms up with the exceptions of a few devices needed to be ordered. In an observation and interview on 06/16/23 at 6:17 PM, the DON was observed providing in-services on expectations (report to DON/Administrator, bells, 15-minute checks) should call light system go out to 3 nurses and 4 CNAs. The DON stated she would continue to in-service the night and weekend staff. She stated all staff would be required to complete in-service, prior to starting their shift. The DON stated she would be responsible for doing rounds to ensure the call light system was working and were being answered. The Administrator were informed the Immediate Jeopardy was removed on 06/16/23 at 6:20 PM. The facility remained out of compliance at a severity level of no actual harm with a potential for more than minimal harm and a scope of isolated, due to the facility's need to evaluate the effectiveness of the corrective systems. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676464 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 676464 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2023 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 0919 Make sure that a working call system is available in each resident's bathroom and bathing area. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to be adequately equipped to allow resident to call for assistance for 2 of 5 residents (Residents #1 and Resident #2) reviewed for accommodation of needs. Residents Affected - Few The facility failed to be adequately equipped to allow residents to call for staff assistance when needing help due to call light malfunction. An Immediate Jeopardy (IJ) was identified on 06/16/23. While the IJ was removed on 06/16/23, the facility remained out of compliance at a severity level of no actual harm with a potential for more than minimal harm and a scope of isolated due to the facility still monitoring the effectiveness of their Plan of Removal. This failure could place the residents at risk of injury and not being able to obtain assistance or care as needed. Findings include: Record review of Resident #1's electronic Face Sheet, dated 05/31/23, revealed a [AGE] year-old male admitted to the facility on [DATE]. Resident #1 had diagnoses which included the following: epilepsy (a disorder of the brain characterized by repeated seizures), transient cerebral ischemic attack (a stroke that lasts only a few minutes), lack of coordination, systemic lupus erythematosus (autoimmune disease in which the immune system attacks its own tissues), muscle weakness, schizophrenia, diabetes mellitus, hemiplegia (a one-sided muscle paralysis or weakness), hypertension (high blood pressure), multiple sclerosis (a potentially disabling disease of the brain and spinal cord), and difficulty walking. Record review of Resident #1's Quarterly MDS, dated [DATE], revealed a BIMS score of 15, which indicated Resident #1's cognition was intact. The MDS revealed Resident #1 had seizure disorder or epilepsy and required one person assistance for the following ADLs: transferring, locomotion on/off unit, dressing, toilet use, and personal hygiene. Further review of the MDS revealed Resident #1 was occasionally incontinent of urine, and frequently incontinent of bowel and needed assistance for toileting hygiene. Record review of Resident #1's care plan, last revised on 04/03/23, revealed Resident #1 was at risk for falling due to weakness, and diagnosis of multiple sclerosis, stroke, and lupus. The interventions included Assist resident with all transfers and encourage resident to call for assistance and not to attempt to transfer self.; Keep call light in reach at all times.; and Provide toileting assistance as needed. The care plan revealed Resident #1 had seizures due to diagnosis of epilepsy. The interventions included Monitor resident for impending seizure symptoms and respond quickly when noted; Changes in consciousness, fixed staring, jerking of arms and legs; Monitor seizure drug level lab boluses as ordered by MD; and Protect resident from injury during a seizure. Use pillows to pad body if in bed, safely lower to the ground to prevent falls if upright, use tongue blade to protect tongue biting. Further review revealed, Resident #1 required ADL assistance with toileting and intervention included one person was to assist. Record review of Resident #1's electronic clinical record revealed a progress note by LVN B, dated 05/01/23 at 7:08 PM which reflected This nurse was called to resident restroom thinking she might be (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676464 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 676464 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2023 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 0919 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few having a stroke, assessed resident noted facial and mouth drooping to left. Resident A&O (alert & oriented), V/s (vitals) obtain b/p (blood pressure) 113/74, p (pulse)76, r (respiration)19, t (temperature) 97.0. Assisted resident back to bed, and notified [physician], order received to transfer to ER (emergency room). 911 was called to the facility and resident was send to [hospital] for further [NAME] (evaluation);/TX (treatment). RP (representative) notified [RP] unable to reach as this time. LVM (leave voicemail). Record review of Resident #1's hospital records, dated 05/01/23, revealed Per EMS, they state they were called by nursing home staff for a stroke the pt (patient) began experiencing approximately 40 minutes pta (Patient Transport Ambulance). On EMS arrival, they noted the pt was experiencing a questionable, focal seizure localized to the facial region with L-sided (left) gaze deviation. The record revealed labs were conducted and diagnosis revealed Resident #1 was ruled out for a stroke. The record revealed resident was discharged and diagnosis included recurrent seizure. In an interview on 05/31/23 at 12:14 PM, Resident #1 stated the call light in her room was fixed yesterday (05/30/23) but prior to yesterday, the call light was not working for about 2-3 weeks. She stated the facility had provided a bell, but staff were not responding when she pressed the bell, and they would tell her they could not hear it ringing. Resident #1 stated she had to use her cell phone to call to the nurse's station to get help. She stated sometimes they would not answer the phones. Resident #1 stated on 05/01/23 she was in the bathroom and thought she was having a stroke. Resident #1 stated she had a stroke before and she also had epilepsy, so she was accustomed to reoccurring seizures. Resident #1 stated on 05/01/23 it felt more like a stroke because she could not feel the left side of her face and body, which did not normally happen when she had seizures. Resident #1 stated she was in the bathroom yelling for help and no one came until 30-45 minutes. She stated the call light in the bathroom was not working and the facility had not provided accommodations for emergencies in the bathroom. Resident #1 stated once the nurse arrived, they assessed her, and she was sent to the hospital. She stated at the hospital it was determined she did not have a stroke and it was a seizure. She stated she did not have any injuries from the incident. Resident #1 stated she had spoken to the DON about her concerns with the call light not working, especially in the bathroom. She stated the DON advised her that staff were supposed to be doing rounds every 15 minutes, but she stated that was not being done because she had been in the bathroom for almost 45 minutes. Record review of Resident #2's electronic Face Sheet, dated 05/31/23, revealed a [AGE] year-old female admitted to the facility on [DATE]. Resident #2 had diagnoses which included the following: paraplegia (the inability to voluntarily move the lower parts of the body), heart disease, muscle weakness, lack of coordination and muscle wasting atrophy (the decrease in size and wasting of muscle tissue). Record review of Resident #2's Quarterly MDS, dated [DATE], revealed a BIMS score of 15, which indicated Resident #2's cognition was intact. In an interview on 05/31/23 at 12:35 PM, Resident #2 stated she heard Resident #1 in the bathroom screaming. She said it sounded like she was saying help, but her voice did not sound normal. Resident #2 stated she knew something was wrong. She stated the call lights were not working and they gave her a bell, but it was not in reach. Resident #2 stated it did not matter about the bell anyway, because staff never heard them. Resident #2 stated she used her cell phone to call to the nurse's station. She stated when they answered (she does not know who) she told them something was wrong with Resident #1, and she needed help in the bathroom. Resident #2 stated they told her they would come help. She stated about 30 minutes had passed and no one came to help, so she attempted to call the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676464 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 676464 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2023 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 0919 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few nurse's station again, but no one answered. Resident #2 stated as time was passing Resident #1's speech was becoming clearer, and she heard her screaming she was having a stroke. Resident #2 stated she was a paraplegic, so she could not get out of bed to find help. Resident #2 stated she called the nurse's station a third time. She stated someone answered the phone (does not know who) and she told them she believed Resident #1 was having a stroke. She said a nurse (does not know name) came about 5 minutes after the third call. Resident #2 stated she believed Resident #1 was in the bathroom for about 45 minutes before the nurse came to the room. In an interview on 05/31/23 at 1:27 PM, the facility's Maintenance Director (MD) stated he started at the facility about 2 weeks ago and there was already an issue with the call light system. He stated there was a bad storm, and the lightning struck the building, which caused the call light system to malfunction. He stated from his understanding a tech company came out and had ordered the equipment to fix the system. He stated he was not sure exactly what date because this was done prior to him working at the facility. He stated the equipment took several weeks to come in and the company returned he believed on 05/19/23 and they replaced the malfunctioned equipment. He stated the system went out again and the company came back out and then realized there was an issue with the call light system at the nurse's station, so they had to order more equipment to fix that. He stated the company returned yesterday (05/30/23) with equipment for the nurse's station and everything was working. He stated later yesterday evening, they found out that some of the call lights were still not working. The MD stated the tech company was currently in the building and they were conducting an audit on which rooms were not working. He stated its difficult to account for which rooms are working because one minute they are working and the next they are not. In an interview on 05/31/23 at 2:15 PM, the Administrator stated the call light system first went out on 04/06/23. She stated the MD at that time was trying to fix the system and realized he was unable to, so they called a tech company to come help. She stated the tech company came on 04/11/23 and discovered equipment was burned due to the lightening and they had to order new equipment. The Administrator stated equipment did not come in until 05/16/23. She stated they provided bells to the residents and staff were doing round every 15 minutes. She stated there were no bells provided for the bathroom and that is why staff were doing rounds every 15 minutes. She stated the tech company replaced the equipment and call lights were working. She stated on 05/24/23 it was discovered the call light were no longer working and they called the tech company back out. The Administrator stated the facility went back to using bells and doing rounds every 15 minutes. She stated the tech company explained the equipment at the nurse's station was burned out and had to be replaced. She stated they ordered more parts, and they returned yesterday (05/30/23) to install the new equipment. The Administrator stated yesterday the call lights were working after the tech left, and then later in the evening they learned they were out again in some rooms. She stated the tech was currently in the building working on the call lights. She stated she was aware of the incident with Resident #1 on 05/01/23. The Administrator stated staff were expected to complete rounds every 15 minutes, so staff were in-serviced on making sure they are doing rounds every 15 minutes, after this incident occurred. In an interview on 06/01/23 at 9:30 AM, LVN B stated on 05/01/23 she was at the nurse's station charting and Resident #2 called and stated Resident #1 was in the bathroom, and she believed she was having a stroke. LVN B stated she immediately went to the room. She stated she assessed the resident for injuries and took her vitals. She stated there were no injuries and her vitals were stable, but Resident #1's face was droopy she believed on the left side. She stated she notified the DON, family, and doctor. LVN B stated she received orders from the doctor to send Resident #1 to hospital, so she called 911. LVN B stated she only spoke to Resident #2 twice and she immediately went (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676464 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 676464 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2023 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 0919 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few to the resident's room. She stated the call lights system were not working and residents were provided bells to notify for help. LVN B stated CNAs were doing rounds every 15 minutes. She stated she did not know how long Resident #1 was in the bathroom nor the last time a CNA had checked on her. An observation and interview on 05/31/23 at 2:43 PM revealed as the Investigator approached Resident #1's room, Resident #1 was screaming from the bathroom I need help. MA A was observed standing behind the medication cart in front of the room next to Resident # 1's room. Resident #2 was observed lying in bed. Resident #2 stated she had been in the bathroom screaming for help for about 30 minutes. Resident #2 stated the call light was working earlier this morning, but she believed it had gone out again. Resident #1 was asked, while she was in the bathroom, if she pressed the call light and she stated yes but she believed it was not working again. The Investigator went into the hall and advised MA A that Resident #1 was in the bathroom screaming for help. MA A stated she would get a CNA to help. MA A was observed to continue to stand at the medication cart. The investigator went on the adjacent halls to look for help but was unable to find anyone to come help. When the Investigator returned to Resident #1's hall, MA A was observed to be standing in the same spot. When the Investigator asked Resident #2 was anyone in the bathroom with Resident #1, she stated no, and staff had still not come to help. In an interview on 05/31/23 at 3:16 PM, Resident #1 stated she made a bowel movement and needed help wiping herself. She stated she was sometimes incontinent with her bowels and had accidents, but she made it to the toilet this time. Resident #1 stated she was unable to reach her bottom to clean herself after a bowel movement due to some of her medical conditions. She stated she pressed the call light for help, but she believed it stopped working. She stated the facility had fixed it yesterday (05/30/23) and it worked earlier in the morning but must have stopped. She stated she was screaming for help for about 30-40 minutes. In a record review and interview on 06/01/23 at 12:24, the DON, she stated was aware of the incident on 05/01/23 with Resident #1. She stated since the call lights were out, the residents were given bells to call for help and the staff were doing rounds every 15 minutes. She stated Resident #1 and Resident #2 did tell her that Resident #1 was in the bathroom for about 30 minutes and staff had not come in to help. The DON stated she did speak to the nurse, who answered the first phone call made by Resident #2, but she couldn't recall which nurse it was, but the nurse told her she was in the middle of working with another resident and was checking their chart, when Resident #2 called. The DON stated the nurse advised her that when Resident #2 called she said Resident #1 needed help in the bathroom. She stated the nurse said she did not tell her it was emergency and she assumed she needed help with toileting. The DON stated nurse told her there was no one in the halls to ask them to check on Resident #1, so she went to finish up with her current situation and then was going to check on Resident #1. She stated when Resident #2 called the second time and spoke to LVN B and said Resident #1 was having a stroke in the bathroom, LVN B went to the room right away. The DON stated if staff would have been completing rounds every 15 minutes on 05/01/23 this would not have happened. She stated she in-serviced all direct care staff that had to do 15-minute rounds the following day. The DON stated she was made aware of the incident with Resident #1 not receiving help with toileting. She stated her expectations was for all CMAs, CNAs, and nurses to help with toileting and incontinence care. The DON stated she also in-serviced staff to continue with doing rounds every 15 minutes due to issues with call lights. She stated incontinence care was not a job only for CNAs. She stated she answered call lights to provide incontinence care and had wiped resident's bottoms, so her expectation was for all other staff to do the same. The DON provided an in-service titled Incontinence Care dated 05/31/23 and stated she started in-servicing yesterday (05/31/23) by going to each direct care staff personally and explaining her (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676464 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 676464 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2023 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 0919 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few expectations regarding incontinence care. She stated she was still meeting individually with staff who did not work yesterday. In an interview on 06/16/23 at 12:28 PM, CNA C stated she was covering Resident #1's hall the day she was sent out to the hospital. She stated did not know exactly what happened to Resident #1, but what she recalled was her coming out of another resident's room and saw the paramedics taking Resident #1 out on a stretcher. CNA C stated she was giving showers to the residents during the time of the incident. She stated the call light system was not working so residents were given bells and they were doing 15-minute rounds. CNA C stated showers took longer than 15 minutes, so she let the nurse know when she was giving showers, so they could do the rounds. She stated even though showers take longer than 15 minutes, she would still complete rounds. CNA C stated once she is done with a resident's shower, she would do a round and then get started on the next shower. In an interview on 06/16/23 at 11:18 PM, the DON stated Resident #1 was alert and oriented, so she advised her to take her phone with her to the bathroom and provided her personal cell phone number to call if she needed help and was unable to get anyone. She stated the 15-minute rounds meant the CNAs were going up and down the hall listening for bells or anyone calling for help. She stated it did not mean they were going to each resident rooms because they were not able to complete that. She stated staff who were assigned to the hall could have been helping a resident, which could take over 15 minutes. The DON stated the expectation was once staff were finished with the resident if it took over 15 minutes, they should do rounds before moving on to the next task. The DON stated their corporate approved 1 additional staff per shift to help with the rounds. She stated the corporate would not approve any additional people, due to budget constraints. The DON stated staff were documenting the rounds and she was responsible for monitoring. She stated she checked the sheets three times per week. A record review of the facility document titled Q 15- Minute Checks- 600 (hall) PM Shift, dated 05/01/23, revealed from the timeframes of 6:00 PM to 4:45 AM, 15-minute checks were completed and checked off. The document did not have a staff signature on it, just a check mark. A record review of the facility's policy titled Statement of Resident Rights, undated, revealed You, the resident, do not give up any rights when you enter a nursing facility. The Facility must encourage and assist you to fully exercise your rights . You have a right to: 1. All care necessary for you to have the highest possible level of health; 2. Safe, decent, and clean conditions; 4. Be treated with courtesy, consideration, and respect . A record review of the facility policy titled Emergency Disaster and Life Safety Policies and Procedures, dated 02/01/20, revealed 4. Nursing personnel: D. Will establish and maintain a medical communication system to all areas not equipped with patent/resident call lights. This may include but is not limited to: 1. Use of bells or other devices 2. Runners to convey information 3. Periodic or routine rounds . This failure resulted in an identification of an Immediate Jeopardy on 06/16/2023 at 4:45 PM. The Administrator was informed and provided the IJ template on 06/16/2023 at 4:49 PM and a Plan of Removal (POR) was requested. The Plan of Removal reflected:

F558 - Reasonable accommodations of needs/preferences (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676464 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 676464 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2023 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 0919 Resident identified with no negative outcomes Level of Harm - Immediate jeopardy to resident health or safety Call light system failure identified on 4/6/23. Residents Affected - Few Repair quote for call light system repair from Diversify received on 4/11/23 Diversify notified immediately for request a quote for repair of the call light system Diversify returned on 5/24/23 after receiving the needed part for repair of the call light system. Once there, Diversify identified a more complex issue and were required to involve additional technicians and additional electrical repair 6/2/23 Diversify returned to continue repairs 6/9/23 Diversify returned and were able to partially repair the call light system 6/12/23 Diversify returned and completely repaired the call light system Residents who reside in the facility have the potential to be affected by this alleged deficient practice. In the event of call light system failure 15-minute checks will be initiated to monitor residents for needs and will continue until the call light system has been repaired. A monitoring tool will be used to document the 15-minute checks and will be used until call light system is repaired In the event the call light system fails affected residents will be provided bells. In the event of call light system failure, a resident council meeting will be held to inform residents of plan for alerting staff for assistance and the plan for the repair of the call light system In the event of call light system failure, the administrator will contact companies to obtain quotes for repairs of the call light system Facility employees will be educated on the plan that was initiated: Immediate notification to administrator of call light failure residents will have handheld call bells to alert the nursing staff for assistance in the event of call light failure An assignment will be made by the administrator and/or Director of Nursing for 15-minute checks on residents to monitor for residents needs in the event of call light failure Any employee not receiving this education by 6/16/23 will receive before their next scheduled shift. This will include any agency personnel and new hire orientation. Maintenance Director will perform weekly preventive maintenance to validate the call light system is functioning properly for 4 weeks, then monthly. Regional Maintenance Director will validate monthly preventive maintenance completed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676464 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 676464 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2023 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 0919 Director of Nursing and Administrator will make rounds throughout the day to validate that the call light system is functioning properly, and resident needs are being met. Level of Harm - Immediate jeopardy to resident health or safety In the event of call light system failure, Clinical Consultant will validate 15-minute checks completed weekly. Any concerns will be addressed at time of discovery. Residents Affected - Few The medical director was informed of the Immediate Jeopardy and the contents of this plan on 6/16/23. An ad hoc Quality Assurance Performance Improvement meeting will be held on 6/16/23. The Plan of Removal was accepted on 06/16/23 at 6:12 PM. Monitoring of the plan of removal included: Observations and interviews were conducted on 06/16/23 from 1:45 PM to 3:05 PM on various rooms and revealed Rooms 401, 405, 406, 408, 413, 418, 419, 503, 506, 510, 511, 517, 518, 521, 522, 603, 604, and 608 call lights were working. Interviews with the residents of these rooms revealed the call lights had been working for approximately one week and staff were responding. Interviews with the 2 RNs, 1 LVN, 2 CMAs, 5 CNAs, who worked multiple shifts, revealed the call lights had been working for approximately one week and they knew the protocols should the call lights go out, which included residents would be provided bells and they were required to complete 15-minutes rounds. A record review on 06/16/23 of a memo from the tech company who fixed the call light system, dated 06/16/23, reflected the following To Whom It May Concern: As of June 12, 2023, our technicians have completed work to make sure that all devices on 400, 500, and 600 halls are operating for nurse call emergency calls for the rooms. By Friday, June 9 we were able to have most of the rooms up with the exceptions of a few devices needed to be ordered. In an observation and interview on 06/16/23 at 6:17 PM, the DON was observed providing in-services on expectations (report to DON/Administrator, bells, 15-minute checks) should call light system go out to 3 nurses and 4 CNAs. The DON stated she would continue to in-service the night and weekend staff. She stated all staff would be required to complete in-service, prior to starting their shift. The DON stated she would be responsible for doing rounds to ensure the call light system was working and were being answered. The Administrator were informed the Immediate Jeopardy was removed on 06/16/23 at 6:20 PM. The facility remained out of compliance at a severity level of no actual harm with a potential for more than minimal harm and a scope of isolated, due to the facility's need to evaluate the effectiveness of the corrective systems. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676464 If continuation sheet Page 17 of 17