Health inspection·July 11, 2025

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few 5/26 at 12 p.m. and 5/29/25 at 8 p.m. Wander guard was checked every night from 5/14-5/31/25. Safety checks were also documented every 30 minutes from 5/7-5/31/25. Record review of Resident #2's nursing progress note dated 5/6/25 at 12:01 a.m. by LVN B revealed, Resident observed not in bed during rounds. After searching around the unit and the neighborhood without finding resident. Facility management notified hence elopement protocol activated. Resident Responsible party notified. 911 called with police response. Physician also notified.Record review of statement written by CNA G on 5/6/25 revealed CNA G saw Resident #2 between 11:00 p.m. to 11:30 p.m. when CNA G took a snack to Resident #2, and he was asleep in his bed at that time and was not seen during the rest of CNA G's shift. Record review of statement written by LVN B on 5/6/25 revealed during shift report at 10:00 p.m. on 5/5/25 they were advised the door alarm in the Magnolia room (large sitting room) was going off. LVN B stated that about 12 midnight they made rounds on the unit and Resident #2 was not in his bed. LVN B stated that when they made rounds and Resident #2 was not in the center, they checked the Magnolia door, and it showed a green light (the door was operational) , and the door was secured and locked but could not recall the exact time this occurred. LVN B stated they notified CNA G at 12:15 a.m. to help look for Resident #2 and notified the other units to help search as well. Then 1 a.m. after still not being able to find Resident #2, LVN B drove to the nearby streets and neighborhood to search for him. LVN B returned to the facility at 1:45 a.m. and notified the administrator around 2 a.m. that Resident #2 was missing. LVN B notified the local Police Department and Resident #2's Responsible Party at 3:33 a.m.Record review of written statement, RN C revealed on 5/6/25 when they came on duty at 10 p.m. the alarm in the Magnolia room was going off. RN C stated that LVN B came to them at approximately 2 a.m. and told them that Resident #2 was no longer at the facility and then started a search inside and outside the facility. RN C stated the Administrator called them at 2:33 a.m. and had tried to reach LVN B but they were out looking for Resident #2. Record review of written statement, LVN C revealed there was a buzzing sound to the Magnolia door when they arrived for the 10 p.m. to 6 a.m. shift on 5/5/25. LVN C stated they checked the door at approximately 10:30 p.m. and it was secured. LVN C stated that LVN B notified them around midnight that Resident #2 was not at the facility, and they helped with an internal and external search of the facility but was unable to find Resident #2. Record review of written statement dated 5/12/25, CNA H stated they were notified that Resident #2 was missing about 1:30 a.m. but could not recall who notified them. CNA H stated they had gone to the Magnolia area and the door was unsecured. Per interview on 7/9/25 at 5:09 p.m., the Administrator said CNA H was no longer employed by the facility and was terminated for an unrelated offense and was angry. Record review of skin audit dated 5/6/25 but not timed revealed complete head to toe assessment with no wounds noted and vital signs were within normal limits. Record review of the Provider Investigation Report dated 5/12/25 regarding the elopement incident on 5/6/25 with Resident #2 revealed provider response included staff completed an audit of the elopement book for pictures and care plans to assure that all residents who were at risk had been included. Staff checked proper functioning/positioning of all Code Alert bracelets and all functioned as designed. Door checks to be conducted daily to assure proper function. Elopement drills for all three shifts on 5/6-6/7/25. In-services were immediately implemented for resident safety and Code Alerts during power loss and abuse, neglect, prevention of accidents and supervisions of residents. Ad Hoc QAPI was held with the medical director. Record review of facility's Elopement Binder revealed 1:1 logs for Resident #2 from 5/6-6/6/25 when it was documented per the log that Resident #2 was discharged [DATE]. The 1:1 logs showed documentation who was assigned to Resident #2 while he was under continuous monitoring. There was no documentation on the 1:1 logs from 10 p.m. on 5/10/25 to 6 a.m. on 5/11/25, from 2 p.m. on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455682 If continuation sheet Page 2 of 6 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 455682 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/11/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Afton Oaks Nursing and Rehabilitation Center 7514 Kingsley St Houston, TX 77087 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few 5/23/25 to 6 a.m. on 5/24/25 (duplicate documentation from 2 p.m. to 6 a.m. noted on 5/23/25), from 2:10 p.m. to 5 p.m. on 5/27/25, from 6 a.m. to 8:30 a.m. on 5/28/25, from 10 p.m. on 5/28/25 to 6 a.m. on 5/29/25, from 2 p.m. to 5 p.m. on 5/30/25, from 10 p.m. on 6/4/25 to 8:30 a.m. on 6/5/25 and 6 a.m. to 7 a.m. on 6/6/25. Record review of facility's Elopement Binder revealed facility's audits for proper function and placement for code alert (wander guard) from 5/14 through 6/27/25, door checks from 4/28/25 through 7/4/25and elopement risk binders from 5/12/25 through 6/20/25 . Record review of facility's Elopement Binder revealed in services for Elopement, Response to Power Off on Exit Doors , Abuse and Neglect with objective staff will check wander guard placement every shift dated 5/6/25. The Elopement in-service included the objection to enhance staff monitoring and supervision by establishing protocols for appropriate staff supervision levels based on residents' risk assessments, encouraging regular observations and interactions. The Elopement in-service also included to implement individualized care plans. The Abuse and Neglect in-service included the objective staff will check wander guard placement every shift. All departments were included in the in-services with 130 staff members in-serviced regarding Elopement, 126 staff members in-serviced regarding Response to Power Off on Exit Doors and 136 staff members in-serviced regarding Abuse and Neglect. Record review of list of residents at risk of elopement provided during the investigation on 7/9/25 revealed there were four current residents at risk of elopement: Resident #3, Resident #4, Resident #5 and Resident #6. During interview on 7/9/25 at 11:06 a.m., LVN B said that they last saw Resident #2 between 11:00 p.m. to 12:00 a.m. and he was in bed and was wearing the wander guard. LVN B said Resident #2 was not in bed when they were making rounds around 12 a.m. but could not remember the exact time of the rounds. LVN B said they notified the administrator after searching inside and outside the facility. LVN B stated one of the doors had the alarm going off when they were searching for Resident #2 so that was when they thought he exited the building. LVN B said Resident #2 was not found before their shift ended at 6 a.m. LVN B said she had in-services regarding elopement that included to check the rooms, check the exit doors, and if the resident was missing then notify the administrator immediately. LVN B said Resident #2 had not tried to exit the facility before during their shift. During interview on 7/9/25 at 11:49 a.m., the Administrator said she was notified at 2:18 a.m. on 5/6/25 by LVN B of the elopement of Resident #2. The Administrator said that the Magnolia door was inspected on 5/6/25 after the incident and no issues were found. The Administrator said that Resident #2 was found by the Activities Director and Business Office after they started searching at 8 a.m. on 5/6/25 in addition to other staff members that were already searching for Resident #2. The Administrator said when Resident #2 was returned to the facility they replaced the wander guard and Resident #2 was placed on 1:1 supervision until he was transferred to the behavioral hospital. The Administrator said that staff should notify the Administrator and DON immediately when they realize a resident cannot be accounted for after performing a search of the facility. The Administrator said that Resident #2 had a history of removing the wander guard but was never exit seeking. The Administrator said that Resident #2 would maneuver off the wander guard. The Administrator said Resident #2 had no injuries or signs of distress when he was found. The Administrator said at the time of the incident on 5/6/25 all cameras were outside the facility and located in the Magnolia area which was the second lobby, one area of the dining room and the porch. During interview on 7/9/25 at 12:24 p.m., the Activities Director said they found Resident #2 around 9 a.m. sitting outside a car/mechanical shop at the intersection of two streets which was around a 25 minute walk from the facility per apple maps directions. The Activities Director said Resident #2 was tired and hungry when they found him but had no obvious injuries and was returned to the facility where an assessment by nursing was performed. On (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455682 If continuation sheet Page 3 of 6 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 455682 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/11/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Afton Oaks Nursing and Rehabilitation Center 7514 Kingsley St Houston, TX 77087 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few 7/9/25 at 12:52 p.m. all the exit doors to the facility were checked and sounded an alarm when tested. During interview on 7/9/25 at 1:20 p.m., the Administrator said Code Alert was the name for the wander guard they use. The Administrator said she did counsel LVN B who was the nurse involved in the elopement incident of Resident #2. Observation on 7/9/25 at 1:45 p.m. revealed the Administrator showing a video the Administrator stated was Resident #2 exiting the facility from the Magnolia door. An elderly man dressed in red clothing was seen walking away from the facility. The man was seen walking away from the building in the video at time stamp starting at 2:05:56 a.m. on Tuesday 5/6/25. During interview on 7/9/25 at 4:46 p.m., the Senior Maintenance said he checked the Magnolia door the day after the incident with Resident #2. The Senior Maintenance said he checked the wander guard system, keypad and everything locked down normally and everything was functioning as it should. The Senior Maintenance said that there were no prior problems with the door that he was aware of. The Senior Maintenance said the facility had done the life safety survey recently and all doors locked down with wander guard, released keypad and opened within the 15 second regulations. Observation on 7/10/25 at 9:09 a.m. revealed Resident #4's wander guard was intact on their left ankle. Observation on 7/10/25 at 9:11 a.m. revealed Resident #6's wander guard was intact on their left ankle. Observation on 7/10/25 at 9:16 a.m. revealed Resident #3's wander guard was intact on their left leg. Observation on 7/10/25 at 9:19 a.m. revealed Resident #5's wander guard was intact on their right ankle. During interview on 7/10/25 at 1:11 p.m. , CNA I stated the facility was using Code Orange for elopements. CNA I stated elopement procedures included that someone would print the census and check all the halls to make sure everyone was accounted for including to check all the rooms and doors including bathrooms and closets. CNA I said someone would also go around the premises to search. CNA I said also the Administrator and DON should be notified immediately regarding a resident elopement. During interview on 7/10/25 at 11:17 a.m. the Administrator provided documents with information regarding elopements and if residents remove wander guards. The Administrator said if she and the DON were notified that a resident removed the wander guard, they would implement the documents provided . Record review of the documents provided on 7/10/25 at 11:17 a.m. revealed an Elopement policy if there was a resident that removed their Code Alert (wander guard) the following measures would be implemented: notification by the Charge Nurse to Administrator and DNS, Notification to Family/RP, Notification to Attending Physician and/or NP, Care Plan Conference with resident and/or RP for a secure care consult (consult for a secured/locked unit), Code Alert will be reimplemented until alternative placement, Immediate placement on one-on-one until alternative placement achieved with a secure unit and Notifications to Area Director of Operations and Regional Compliance Nurse. During interview on 7/10/25 at 11:55 a.m., LVN D denied any problems with Resident #5 removing her wander guard and said she had worked with Resident #5 since Resident #5 had arrived at the facility which had been over six months. LVN D said the nurses would monitor residents who removed their wander guard and would start a 1:1 with the resident and notify the administrator. LVN D said they had training regarding this information about two months ago in May. LVN D said how they would monitor a resident who was removing their wander guard was that whoever was on a 1:1 with the resident always had eyes on the resident. LVN D said Resident #5 was the only resident with a wander guard she had at this time. During interview on 7/10/25 at 12:00 p.m., the DON said she started at the facility on 5/27/25 so she was not working at the time of the incident of Resident #2's elopement on 5/6/25. The DON said the nurses would monitor residents if they were removing the wander guard and should notify the DON and Administrator. The DON said that they only have four residents currently with wander guards and none of the four current residents with wander guards have behaviors with removing the wander guard. The DON said (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455682 If continuation sheet Page 4 of 6 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 455682 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/11/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Afton Oaks Nursing and Rehabilitation Center 7514 Kingsley St Houston, TX 77087 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few staff had follow up training regarding wander guards yesterday 7/9/25. During interview on 7/10/25 at 12:00 p.m., the Administrator also agreed none of the four current residents with wander guard have behaviors of removing the wander guard. The Administrator said staff was trained regarding what to do if residents remove wander guards in May.During interview on 7/10/25 at 12:08 p.m., LVN E said he usually works with Resident #3 and Resident #6 and are the only residents at his station with wander guards. LVN E said neither Resident #3 nor Resident #6 tried to remove the wander guard. LVN E said the nurses are who monitor the residents who attempt to remove the wander guards because they are supposed to be checked every shift. LVN E said that the CNAs are supposed to tell the nurses if they see the residents remove the wander guard . LVN E said if the resident was trying to remove the wander guard, then they are to notify the administrator and the DON. LVN E said that they did trainings regarding residents removing the wander guards in May and had an update 7/9/25. LVN E said residents are monitored are through 1:1 observation and this was usually done by a CNA. During interview on 7/10/25 at 12:18 p.m., LVN C said she normally works night shift at the station with Resident #3 and Resident #6. LVN C said that neither Resident #3 nor Resident #6 have problems with trying to remove the wander guards. LVN C said if residents attempted to remove the wander guard, they did 1:1 observation and redirection. LVN C said they checked for placement to make sure the wander guards were functioning correctly and in place. LVN C said that if a resident removes the wander guard, they notify the Administrator and the DON immediately. LVN C said that all staff would participate in monitoring if a resident were removing the wander guard or trying to elope. LVN C said regarding residents removing wander guards they received training a couple a months ago because they had a resident who was removing the wander guards and then a follow up 7/9/25. LVN C said the training included what to do if they hear an alarm, stand at the doors, full census sweep, 1:1 if the resident was known, make sure the wander guard is in place, safety monitoring and notify the DON/Administrator if the residents was continuing to try and exit. LVN C said the priority is the residents' safety. LVN C said she was working the night of 5/5/25 from 10 p.m. to 6 a.m. LVN C said they heard the alarm going off when she was getting report about 10:15-10:20 p.m. LVN C said she went to the Magnolia door with a couple of CNAs and checked the alarm for proper functioning. LVN C said she pushed the door open and the secondary alarm above the door went off. LVN C said she did a census and told the other nurses to do a census at that time. LVN C said that was when the nurse on Station 4 said she could not find her resident, but LVN C said she could not remember what time that occurred. LVN C said then they completed a search and notified the administrator. LVN C said that on the night of 5/5/25 there was a female resident who was sitting by the door who was wearing a wander guard and LVN C said she thought the female resident had touched the door. LVN C said that the female resident was transferred out to a secured unit and was no longer at the facility. LVN C said that after she checked the door the alarm was no longer going off and did not go off the rest of the night. During interview on 7/10/25 at 12:40 p.m., LVN B said she usually works 10 p.m. to 6 a.m. on the #400 hallway. LVN B said Resident #4 is the only resident on her hallway with a wander guard and Resident #4 has never tried to remove the wander guard. LVN B said that if a resident attempted or removed the wander guard , they initiate a 1:1. LVN B said the nurses or CNA would have to be with the resident all the time if they were attempting to remove the wander guard. LVN B said if a resident was removing the wander guard, they would notify the administrator and DON immediately if a resident was placed on a 1:1. LVN B said that they had elopement training and drill about two months ago and then updated 7/9/25. LVN B said that the training included what they are expected to do if the residents remove the wander guard which included to initiate the 1:1, someone to be with the resident all the time until they can (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455682 If continuation sheet Page 5 of 6 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 455682 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/11/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Afton Oaks Nursing and Rehabilitation Center 7514 Kingsley St Houston, TX 77087 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete find a long term unit to transfer the resident to. LVN B said that she was working the night shift 10 p.m. to 6 a.m. on 5/5/25 when she saw the alarm to the door was going off. LVN B said then they printed the census and checked the residents, and she said she could not remember the exact time but was after 12 midnight. LVN B said the door was alarming about this time around 12 midnight. Observation on 7/10/25 at 1:42 p.m. revealed Resident #5 with wander guard to right ankle. On 7/10/25 at 2:44 p.m., the facility administrator was notified of past noncompliance IJ. An IJ template was provided to the administrator via email at 2:48 p.m. During interview on 7/11/25 at 11:04 a.m., the Administrator stated that potential adverse effects a resident that eloped could have would include physical dangers, health complications and psychological distress. Record review of facility's policy for Elopement dated April 2017 revealed All team members will be alerted to search in the center or grounds as soon as there is an awareness of the resident missing. The policy also stated, If the resident is not quickly located in center or on grounds a point person is designated to make the following notifications: Administrator and Director of Nursing, Designated guardian or resident representative and Police (once the search of center and grounds determines the resident is not here or sooner if there is good indication they will not be located during the search). The policy also stated, Document condition notifications and times of actions deployed. Record review of the facility's undated Elopement policy if there was a resident that removed their Code Alert (wander guard) the following measures would be implemented: notification by the Charge Nurse to Administrator and DNS, Notification to Family/RP, Notification to Attending Physician and/or NP, Care Plan Conference with resident and/or RP for a secure care consult (consult for a secured/locked unit), Code Alert will be reimplemented until alternative placement, Immediate placement on one-on-one until alternative placement achieved with a secure unit and Notifications to Area Director of Operations and Regional Compliance Nurse. Event ID: Facility ID: 455682 If continuation sheet Page 6 of 6