Health inspection·August 16, 2023

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of Resident #1's Quarterly MDS (a standardized assessment tool that measures health status in nursing home residents) assessment, dated 07/26/23, revealed a BIMS score of 15, which suggested Resident #1 was cognitively intact (being able to follow two simple commands; has sufficient judgment, planning, organization, self-control, and the persistence needed to manage the normal demands of ADL). The Quarterly MDS assessment reflected Resident #1 required set-up help only with ADLs and one-person physical assist with toileting and bathing. Resident #1 had a functional limitation in range of motion on one side of upper and lower extremities. Resident #1 was occasionally incontinent of bladder and frequently incontinent of bowel. The Quarterly MDS did not indicate Resident #1 had any behavioral symptoms or rejection of care during the MDS review period. A review of Resident #1's comprehensive care plan, last reviewed/revised on 08/05/23, indicated that Resident #1 had a dx of MS [Problem start date: 08/09/23]; a dx of seizures [Problem start date: 05/02/23]; incontinence of bowel and bladder [Problem start date: 03/21/23]; risk for falling [Problem start date: 03/21/23] r/t weakness, dx of MS, CVA, and Lupus (Systemic Lupus Erythematosus) (an autoimmune disease that can cause joint pain, fever, skin rashes and organ damage); and required assistance with ADLs [Problem start date: 03/04/23] - including toileting with the assist of one person [Approach start date: 04/03/23] and instruct in proper self-care techniques using self-cleaning device [Approach start date: 05/18/23]. Record review of Resident #1's progress notes, revealed a progress note dated 08/13/23 at 9:42 PM, entered by LVN B. The progress note reflected a statement from [Resident #1's viewpoint]: [Resident #1] was in the bathroom having a BM and turned on the call light for help to get wiped. [Resident #1] asked Resident #2 to call for help . it had been a while and the call light had not been answered. Resident #2 went to the nurses' station and informed CNA C that it had been about an hour since Resident #1 turned on the call light and needed help to get wiped. CNA C told CNA A (the CNA assigned to Resident #1) that Resident #1 said she was in the bathroom for an hour. CNA A lost her temper and said it had not been an hour. CNA A confronted Resident #1 (who was still sitting on the toilet), called Resident #1 a liar, that everyone was tired of her, and CNA A threw a pack of wipes and hit Resident #1's lower abdomen. CNA A raised her middle finger (an obscene gesture made by pointing the middle finger upward while folding the other fingers against the palm) at Resident #1 and said F--- (a four-letter swear word) you, wipe yourself, you are stupid. CNA A walked down the hall and grabbed her backpack. CNA A passed LVN B who was coming out of the last room on Hall 600 . [CNA A] was very upset and yelling but [LVN B] could not understand what CNA A was yelling as she left the unit. [LVN B] returned to the nurses' station and was approached by Resident #2 who asked to report the inappropriate confrontation that happened between [Resident #2] and CNA A. Resident #2 said that CNA C witnessed CNA A raise her middle finger and curse [at Resident #2], but CNA C denied she heard anything. CNA D assisted Resident #1 out of the bathroom. Resident #1 called the DON, then called her [Resident #1's family member] . LVN B overheard Resident #1 on the phone speaking with a 911 dispatcher when she entered the room to assess Resident #1. LVN B measured Resident #1's vitals, performed a HTT assessment and took Resident #1's statement. LVN B accepted a call from the DON when she returned to the nurses' station and acknowledged understanding to complete incident reports. LVN B notified the NP and family member. Record review of CNA A's clock in/out sheet reflected on 08/13/23, a clock in time of 5:53 PM and a clock out time at 7:40 PM = 1 hours, 46 minutes, and 48 seconds. During an observation and interview on 08/15/23 at 11:10 AM, Resident #1 appeared groomed and dressed appropriate to clinical situation. Resident #1 was sitting upright in a manual wheelchair. No (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676464 If continuation sheet Page 2 of 9 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 08/16/2023 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 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few visible injuries or behavior were suggested of physical abuse, neglect, or SQC. Resident #1 was A, A & O to awareness of self, place, time, and situation. Resident #1 indicated on Sunday [08/13/23] after 7:00 PM, she was in the bathroom and turned the call light on to be wiped after she had a BM. Resident #1 stated that no one came, and it had been a little while since she turned the call light on. Resident #1 said that she could not give an amount of time because she did not have her phone and there was not a clock in the bathroom. Resident #1 said that she called out to Resident #2 to locate someone because no one answered the call light. Resident #1 said that CNA A appeared shortly after, enraged and yelling that [Resident #1] had not been waiting for an hour for someone to answer the call light. Resident #1 said that when she tried to tell CNA A that she never said she waited for an hour and just needed to be assisted, CNA A was argumentative, would interrupt when [Resident #1] spoke, said no one wanted [Resident #1] there (at the SNF), always causing confusion, and told Resident #1 to stop lying. Resident #1 said that CNA A raised her middle finger (as an obscene hand gesture) at Resident #1, said F--- (a four-letter swear word) you, threw a pack of wipes at Resident #1's stomach as hard as she could, said you can do it yourself, and left. Resident #1 described the pack of wipes (100-pack) as half full. Resident #1 said that Resident #2 followed behind CNA A telling her that she did not have to talk to [Resident #1] like that. Resident #1 said she turned the call light on again and another CNA (CNA D) answered the call light, wiped, and assisted Resident #1 out of the bathroom. Resident #1 said she feared that she suffered physical harm when CNA A threw the pack of wipes at her stomach. Resident #1 said that her stomach hurt after the pack of wipes hit her stomach and currently felt a dull, intermittent, tightness, cramping, and knots in her stomach where the pack of wipes hit her stomach. Resident #1 stated that she often experienced intermittent stomach discomfort related to stress, anxiety, and when upset. Resident #1 said that she called the DON immediately after coming out the bathroom, around 7:30 PM, to report the incident and then called 911. Resident #1 said that an officer came to take her statement. Resident #1 said on the next day [Monday, 08/14/23] the DON and LBSW came to her room to follow up after the incident and asked how she was doing. Resident #1 stated that she recounted the incident and told them that she felt better. Resident #1 said she did not need to go to the hospital for evaluation or treatment, that she felt safe, and never had a similar past encounter with CNA A. During an interview on 08/15/23 at 11:19 AM, Resident #2 (Resident #1's roommate) stated that she recalled the incident on Sunday (08/13/23). Resident #2 said she heard Resident #1 call out to find someone because no one answered the call light. Resident #2 said she did not know how long Resident #1 was in the bathroom, she just remembered that she took a nap after Resident #1 went to the restroom. Resident #2 said that she left out the room and saw CNA C sitting halfway down the hallway near the nurses' station and told her that Resident #1 needed help, that she been on the toilet for an hour waiting for someone to answer the call light. Resident #2 said that CNA C replied that Resident #1 was a liar, . everyday it's something, always complaining . Resident #2 said CNA C approached CNA A when she came out another resident's room and told her that Resident #1 said she waited an hour, and no one answered the call light. Resident #2 said that CNA A started fussing and headed towards Resident #1's room. Resident #2 described the incident as told by Resident #1. Resident #2 said she followed CNA A out the room and told her that she did not need to talk to Resident #1 like she did when all she needed was help. Resident #2 said that CNA A cursed at her, put up her middle finger, grabbed her personal bag and went down the hall to exit building. Resident #2 said that the way CNA A spoke at her affected emotionally. Resident #2 said that she reported the incident to the nurse. Resident #2 said she felt safe and denied a similar past encounter with CNA A. During an interview on 08/15/23 at 12:04 PM, the LBSW said that she (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676464 If continuation sheet Page 3 of 9 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 08/16/2023 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 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few worked at the SNF for less than one year. The LBSW said that she was familiar with Resident #1. The LBSW described Resident #1 as alert, fully oriented, was self-aware, and did alright for herself. The LBSW said that Resident #1 participated in self-care within functional limits but was fixated that she needed assistance with toileting. The LBSW said that Resident #1 could wipe own self from what she knew. The LBSW said that she and the DON followed up with Resident #1 on Monday (08/14/23) to follow up on an altercation that occurred the night before (Sunday, 08/13/23). The LBSW said that the altercation was reported as alleged physical and verbal abuse. The LBSW said that Resident #1 reported that CNA A verbally and physically abused her (Sunday night). The LBSW denied any mental assessments that were conducted that pertained to the alleged abuse or any interventions taken to assist Resident #1. The LBSW said that Resident #1 said she felt better and safe when interviewed on Monday (08/14/23). The LBSW said that an in-service was done, and she conducted resident safe surveys that did not bring forward concerns of CNA A's or other staff behavior. During an interview on 08/15/23 at 1:15 PM, the NFA indicated she first learned of the incident on 08/13/23 at 8:30 PM from the DON and reported to HHSC on 08/14/23 via TULIP (Incidents Submission Portal for Long-Term Care Providers). The NFA said that she was responsible for the initial reporting and overall investigation of the alleged abuse because she was the Abuse Coordinator. The NFA said action was immediately taken to ensure all residents were protected and an investigation was initiated. The NFA indicated staff interviews, safe surveys, and an ANE in-service were conducted as part of the investigation and to prevent reoccurrence. The NFA stated Resident #1 was protected from the alleged perpetrator when CNA A removed herself from the premises. CNA A was not allowed in the facility or on the premises to protect the residents. The NFA said that the DON and LBSW were also involved with the ongoing investigation. The NFA said that she did not currently have a lot of information. The NFA stated she still had interviews to complete and the LBSW needed to complete resident safe surveys. The NFA stated that there were no known previous warnings or similar incidents with CNA A at the facility. The NFA said that she never observed or was reported that CNA A exhibited inappropriate behaviors toward Resident #1 or other residents in the past. The NFA said that there were no known resident/family grievances or problems identified with care delivery provided by CNA A. The NFA indicated that she performed surveillance daily to monitor for potential abuse. The NFA stated a process in place to protect and prevent resident ANE was leadership rounded throughout the facility at different times and across shifts to monitor for potential or actual reported allegations of abuse and the delivery of care and services by direct care staff. The NFA said that it is her expectation of all staff to be polite, respectful, and to meet resident needs. Record review of the facility's self-report dated 08/14/23, submitted by the NFA, indicated the NFA first learned of the incident on 08/13/23 at 8:30 PM. The incident occurred 08/13/23 around 7:45 PM. A brief narrative summary of the reportable incident revealed Resident #1 stated CNA A threw wet wipes at her [Resident #1] stomach and said, fuck you. Resident #2 was a witness to the incident. LVN B immediately assessed Resident #1 and performed a HTT assessment was completed - no injury noted. CNA A removed herself from the premises. LVN B reported the incident to the MD/NP, family member, and DON. Resident #1 called 911. When the officer arrived, Resident #1 gave a statement (account of what happened) to the officer and obtained a report number. Record review of an interview worksheet dated 08/15/23, signed by HR reflected the staff name: CNA A; shift worked: 6P - 6A; reason for interview: Complaint revealed was going about 7 - 7:30 PM CNA C told CNA A that Resident #1 called somebody and told them the call light was on for one hour. CNA A went to Resident #1's room and said that she was just in the room to check everything, and the call light was not on for an hour. CNA A asked Resident #1 when calls were made why not tell them the . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676464 If continuation sheet Page 4 of 9 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 08/16/2023 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 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few (the rest of the sentence was covered up with a correction product) . then Resident #1 (a caret symbol pointed up at the covered section above) cursed her out and called her stupid. CNA A said she got upset because she got called stupid and that she was not doing this tonight and told the nurse she was going home. Record review of an interview worksheet dated 08/15/23, signed by HR reflected the staff name: CNA C; shift worked: 6P - 6A; reason for interview: Complaint revealed Resident #2 came out saying light was on for one hour. CNA C found CNA A. CNA A went to [Resident #1] room. Moments later CNA C heard cursing and arguing. CNA A came out saying she was quitting because Resident #1 called her stupid. Record review of an interview worksheet dated 08/15/23 (over an area covered up with a correction product), signed by HR reflected the staff name: CNA D; shift worked: 08/13/23; reason for interview: Complaint revealed Didn't see anything. DON told [CNA D] to go help CNA A. Heard cursing and fussing at nurses' station by the time she got here. Went to help Resident #1, was on the toilet, and on the phone with her [family member]. [Family member told her to call police. CNA D asked Resident #1 why were wipes everywhere and Resident #1 said that CNA A threw them at her. During an interview on 08/16/23 at 11:08 AM, the DON stated that she worked at the SNF for less than six months. The DON said that her role and responsibility was protective oversight of residents. The DON said that on Sunday (08/13/23) she received two phone calls back-to-back from Resident #1, then a text that said . call me back or I will call 911. The DON said that she replied by text, give me ten minutes. The DON stated that she called Resident #1 back in seven minutes, at 7:39 PM (Sunday 08/13/23). The DON said that Resident #1 stated CNA A not only verbally, but physically abused her. The DON said that what she understood was that there was a disagreement about how long Resident #1 been on toilet . CNA A confronted Resident #1 about how much time elapsed since the call light was turned on, CNA A called Resident #1 a liar, and CNA A threw a pack of wipes at Resident #1 stomach after she [CNA A] became upset. Resident #1 had also reported that Resident #2 spoke up for Resident #1 and CNA A cursed at Resident #2. The DON said that she called the facility and spoke with and interviewed the nurses on shift, enquired if CNA A was present, and was told CNA A left the facility. LVN B identified self as the assigned nurse for Resident #1. The DON asked LVN B to assess Resident #1 and get statements from both Resident #1 and Resident #2. The DON said that she called back to ensure it was completed, that incident reports were completed, MD/NP, and family were notified. The DON said that LVN B informed that Resident #1 had already called police. The DON said that she followed up and interviewed Resident #1 the next day (Monday, 08/24/23) and started an ANE in-service with all staff. The DON said that she never observed or was told that CNA A exhibited inappropriate behaviors toward Resident #1 or other residents. The DON said that she was told that Resident #1 was rude and vulgar to staff and often made staff feel uncomfortable when assisted with wiping Resident #1 after a BM. The DON said that she oversaw that an adaptive device to clean self after a BM was provided and therapy trained Resident #1 to use the appliance; staff were educated and would encourage Resident #1 to use within limits and staff would assist as needed. The DON said she expected staff to be always courteous to residents, even if a resident was rude; staff should always speak to and care for residents with dignity and respect. HR was not available for an interview before Investigator exited on 08/16/23. During a phone interview on 08/16/23 at 1:50 PM, CNA A indicated that she worked at the SNF in the past and was re-hired nine months ago. CNA A stated she worked as a full-time employee until she left on 08/13/23. CNA A said that she received training on ANE during the new hire orientation and participated in ANE in-services. CNA A defined Abuse as afflicting injury or harm to someone - physical (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676464 If continuation sheet Page 5 of 9 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 08/16/2023 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 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few or verbal. CNA A defined Neglect as failure to give care to a resident. CNA A indicated before the incident, there was an appropriate staff/resident interaction with Resident #1. CNA A said that she worked with Resident #1 on Saturday, 08/12/23 and Sunday, 08/13/23. CNA A said that she was scheduled 6P to 6A on Sunday, 08/13/23. CNA A said that as she entered another resident's room to provide care (four rooms down from Resident #1's room), another CNA told her that Resident #1 waited for an hour for someone to answer call light. CNA A said that she vented out loud that there were no call lights on and went to Resident #1's room. CNA A said she stood in the doorway of the bathroom and told Resident #1 that the call light was not on for an hour. CNA A said that Resident #1 started cursing and CNA A told her to tell the truth and stop trying to get people in trouble . say exactly the way it is. CNA A said that she tried to be calm when Resident #1 called her stupid. CNA A said that she told Resident #1 . cannot take care of you and be stupid . I'm not doing this today . not in the mood for this today . CNA A said she was holding a pack of wipes to assist Resident #1 and threw them on the box next to the toilet and left out the room. CNA A said that she felt like she was not in the right frame of mind after the altercation. CNA A did not confirm or deny that she raised her middle finger (as an obscene hand gesture) at Resident #1 and Resident #2 or said F--- (a four-letter swear word) you to Resident #1. CNA A said she told CNA C as she walked down the hallway and the nurse at the nurses' station that she was going home and left the facility. CNA A said when she got home, she texted the Scheduler I quit. CNA A said that she was upset and felt that she did not deserve for Resident #1 to call her stupid and speak to her in that manner. During an interview with sampled residents on 08/16/23 between 3:00 PM and 4:00 PM resided on the same hall as Resident #1 denied staff had negative behaviors, any threatening interactions with administration or personnel, or voiced concerns about QOC/QOL. During an interview, the sample residents confirmed that they felt safe, were treated with dignity, and their rights respected. Interview with residents indicated no concerns with staff responsiveness to their care needs. During a phone interview on 08/17/2023 at 3:14 PM, LVN B stated that she worked as an agency nurse on 08/13/23. LVN B said that she was coming out of a room on the 600 Hall when CNA A passed by her, shouting, and appeared very upset. LVN B said that she did not know what was going on and could not understand what CNA A was yelling. LVN B said that when she returned to the nurses' station, Resident #2 approached and stated she wanted to report the behavior of CNA A toward her [Resident #2] and Resident #1. LVN B said that Resident #2 reported that CNA A yelled and cursed at Resident #1 and Resident #2. LVN B said that Resident #2 stated that CNA A threw a pack of wipes at Resident #1, raised her middle finger, and told Resident #1 F--- you. LVN B said that she immediately went to check on Resident #1, performed an assessment, visually inspected the area Resident #1 said she was hit with the wipes - did not observe any discoloration or any sign of injury, and Resident #1 denied pain at the area. LVN B said that she received a call from the DON who instructed to complete an incident report. LVN B said the police came later and took a statement from Resident #1. CNA C was not available for interview before Investigator exit on 08/16/23. CNA C signature was not noted on the ANE in-service sign in sheet when reviewed by Investigator on 08/16/23. Record review of the facility's Abuse, Neglect, Exploitation, or Mistreatment policy revised 10/01/2020, reflected in part, the following: POLICY: 1. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676464 If continuation sheet Page 6 of 9 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 08/16/2023 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 0600 The facility's leadership prohibits neglect, mental, physical and/or verbal abuse . Level of Harm - Minimal harm or potential for actual harm 2. Residents Affected - Few The facility ensures that alleged violations involving abuse, neglect, exploitation or mistreatment . are reported immediately DEFINITIONS by CMS section 483.5 1. Abuse is the willful infliction of injury . 5. Mistreatment means inappropriate treatment of a resident 6. Neglect is the failure of the facility . to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. PROCEDURES: Facility Leadership General Procedures: 1. Report immediately . not later than 24 hours if the events that cause the allegation do not result in bodily injury . 2. Conduct a prompt investigation of any allegation of suspected abuse, neglect or exploitation or mistreatment and implement immediate action to safeguard resident. Component I: Screening 1. Pre-employment background screening is mandated for all facility employees Component II: Training 1. All employees and volunteers receive ongoing abuse prohibition education . III: Prevention (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676464 If continuation sheet Page 7 of 9 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 08/16/2023 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 0600 1. Level of Harm - Minimal harm or potential for actual harm Abuse Prohibition Handout 2. Residents Affected - Few Abuse Prohibition poster 3. The In-Touch with Compliance Hot Line 4. Adequate supervision of staff is maintained to identify and prevent inappropriate behaviors, such as: A. The use of derogatory/harassing language B. Rough handling C. Ignoring the patients/resident's needs requests 5. Ongoing assessment, care planning, and monitoring of those patients/residents with special needs that may lead to neglect . Component IV: Identification 1. Assess suspected or alleged reports of abuse or neglect . Component V: Reporting/Response 1. Immediately and verbally report all alleged violations concerning abuse, neglect, or misappropriation of property to the Facility Abuse Coordinator . Component VI: Investigation (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676464 If continuation sheet Page 8 of 9 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 08/16/2023 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 0600 Component VII: Protection Level of Harm - Minimal harm or potential for actual harm During the investigation, the facility protects the patient/resident, as appropriate . Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Record review of CNA A's employee records indicated hire date 11/10/22. A background check was completed 11/04/22. An EMR/NAR was last checked on 04/05/23. Review of CNA A's personnel file did not identify any other allegations nor concerns. CNA A did not have any related disciplinary actions or warnings in their file. Event ID: Facility ID: 676464 If continuation sheet Page 9 of 9