Health inspection·November 21, 2025

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few was at risk and could have experienced death, been hit by a car, or been picked up by someone. During a telephone interview on 11/17/25 at 3:14 pm. RN B said LVN C came from station 3 and told her CR #1 was on the street. She said she did not know how CR #1 left the facility. She said CR #1 could have had a fall or hit by a car. During an interview on 11/17/25 at 3:33 p.m., the Social Worker said he was the manager on the day of the incident. Staff told SW that CR#1 was out of the facility. SW said he was close to the facility and was going to drive to CR #1 location. SW said the police officer was walking with CR #1. SW said he identified himself, and CR #1 recognized him and said he was ready to go home. SW said CR #1 immediately got into his car. SW said none of the staff knew which door CR #1 went out of. He said CR #1 did not have a wander guard on. He said the risk to CR #1 getting out of the facility was CR #1 could become lost and could have gotten hurt. During an interview on 11/17/25 at 4:31 pm. Regional Corporate Compliance Nurse, said CR#1 had gone out with the church group because there was a church group that morning. He said a staff member should have let the church group out and had a visual of who they were letting out of the facility. He could not give a time of how long CR#1 was out of the facility. He said they should have observed CR#1 was among the church group. He said CR#1 could have been injured, had a fall, been hit by a car, and/ or received other negative outcomes. During an interview on 11/18/25 at 8:56 am. CMA D said she saw CR #1 while she was in an Uber and called CR #1 by name. She said she exited the vehicle and called the facility and spoke with LVN C to inform her that CR #1 was no longer in the facility. She said she got out of the car and repeatedly called CR #1 by name, but CR #1 became aggressive. She stated the risk to CR #1 was significant, as CR #1 could have been hit by a car due to how fast CR #1 was moving. She said CR#1 was not paying attention to his surroundings, and she feared for his safety. She said that if CR #1 had gone one more block, CR #1 would have entered the freeway, but she was able to stop CR #1. During a telephone interview on 11/18/25 at 8:56 am. with LVN C, said she had no idea how CR #1 eloped from the building because she was helping on the floor with other residents. She said CR #1 could have been killed. LVN C said CR #1 has no sense of direction. She said CR #1 was trying to escape by crossing the street while looking backwards instead of at the cars in front of him. Telephone interview on 11/18/2025 at 10:22 am. with the facility's previous administrator stated she did not have time to answer any questions related to the elopement incident. During an interview on 11/18/2025 at 1:43 pm, the Regional Corporate Compliance Nurse said he requested access from IT for the video. Record review of the facility's policy on Elopement Prevention from Nursing Policy and Procedure Manual documented MM TIW WA 03-1.0 read in part. policy statement Every effort will be made to prevent elopement episodes while maintaining the least restrictive environment for residents who are at risk for elopement . 7. If a resident is discovered to be missing, a search shall begin immediately. Environmental Modification 6. Use door alarms or monitoring devices to notify staff when residents try to leave the facility. Physical Plant 1. All facility exits that residents have access to will have a device in place to alert staff of possible elopement attempts. Example of these devices: Wanderguard System (locking or alarming) ? Placement of the residents' device to alarm the system will be verified each shift and documented on a treatment or other flow record. ? Function of the resident's device will be verified at least daily and documented on a treatment of other flow record.? Function of the alarm system will be verified each week and documented in a maintenance log. 3. All exit devices will be verified weekly and a log maintained. Record review of the facility's policy on Elopement Response from Nursing Policy and Procedure Manual documented MM TIW WA 03-1.0 read in part. policy statement Nursing personnel must report and investigate all reports of missing residents. When an elopement has occurred or is suspected, our elopement response plan will be immediately implemented. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455682 If continuation sheet Page 2 of 5 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455682 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/21/2025 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 Policy Interpretation and Implementation 1. It is the responsibility of all personnel to report any resident attempting to leave the premises, or suspected of being missing, to the charge nurse as soon as practical. The Regional Corporate Compliance Nurse was notified of Immediate Jeopardy (IJ) on 11/18/2025 at 4:41 p.m., due to the above failures. The Regional Corporate Compliance Nurse was given a copy of the IJ template, and a Plan of Removal (POR) was requested. The Plan of Removal was submitted by the facility and accepted on 11/19/2025 at 8:11 am.: Facility Immediate Actions: Resident CR#1 transferred to a facility with a secured unit on 10/7/25. Regional Compliance Nurse educated the DON, ADON, and Interim Administrator regarding the Elopement Prevention policy on 11/18/25. Regional Compliance Nurse educated DON, ADON, and Interim Administrator regarding the Elopement Response policy, including referring to the Elopement Risk Binders located at each nurses' station on 11/18/25. Regional Compliance Nurse educated the DON, ADON, and Interim Administrator regarding the operation of exit doors on 11/18/25. Regional Compliance Nurse educated the DON, ADON, and Interim Administrator regarding the process change for residents signing out on 11/18/25. 100% audit of facility residents started and completed on 11/18/25 by DON, ADON, and Regional Compliance Nurse to identify residents at risk for elopement. Findings from that audit revealed four (4) residents with a score of 10 or greater. These residents' face sheet and pictures were added to the Elopement Risk binder that is kept at each nurse's station and at the front desk for all staff to be able to identify the facility residents at risk for elopement. Care plans were reviewed and updated for the four residents identified as at risk for elopement. 100% facility audit completed by Maintenance Director on 11/18/25 of facility entry/exit doors. The Maintenance Director identified ten (10) entry/exit doors. All 10 doors locked and alarmed, and proper function of door was tested and verified on 11/18/25 by the Maintenance Director. Signage was posted at the front door and Station 1 door on 11/18/25 to notify visitors not to open the door or allow anyone else out the door they do not know, including residents. Residents and their responsible parties were notified by Department Managers on 11/18/25 and were educated on resident sign-out procedures, including the location of the sign-out book and elopement prevention. Facility Plan to ensure compliance: 1.Residents identified as having a score of ten (10) or higher on the Elopement Risk Assessment in internal health record, the facility's electronic health record, will be added to the Elopement Risk Binder located at each nurse's station and at the front desk. 2. DON/Designee, including department heads, will in-service facility staff by phone and/or in person regarding the Elopement Response policy starting on 11/18/25. Facility staff, including PRN staff, not in-serviced by 11/19/25 will not work until in-service completed. 3. DON/Designee, including department heads, will in-service facility staff by phone and/or in person regarding the Elopement Prevention policy starting on 11/18/25. Facility staff, including PRN staff, not in-serviced by 11/19/25 are not work until in-service completed. 4. DON/Designee, including department heads, will in-service facility staff by phone and/or in person regarding the operation of exit doors starting on 11/18/25. Facility staff, including PRN staff, not in-serviced by 11/19/25 will not work until in-service completed. 5. DON/Designee, including department heads, will in-service facility staff by phone and/or in person regarding the resident sign-out process starting on 11/18/25. Facility staff, including PRN staff, not in-serviced by 11/19/25 will not work until in-service completed. 6. The Medical Director was notified by the Administrator on 11/18/25 at 4:50pm by the Regional Compliance Nurse regarding the immediate jeopardy citation. 7. An Ad-hoc meeting held on 11/18/25 by the interdisciplinary team to discuss the immediate jeopardies and review the plan for removal. Monitoring Plan of Removal included the following: Record review of the training provided by Regional Corporate Nurse for the ADON, DON, Interim Administrator revealed staff were educated on the elopement policy, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455682 If continuation sheet Page 3 of 5 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455682 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/21/2025 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 elopement binder, operation of the exit doors and how residents are to sign out of the facility. Record review of the facility audits of resident's assessments of elopement revealed 100 percent audit completed. Record review of the facility training provided on 11/18/2025 read in part. Topic: Exit Doors. Staff in-serviced and verified 11/20/2025 all exit doors have a 15 second delay-alarm will sound, and the door will open . Staff must respond to all alarms. Identify if a resident has exited, staff must stay with the residents and call for additional assistance. Record review of the facility training provided on 11/18/2025 read in part . Topic: Elopement Response. Staff in-serviced and verified 11/20/2025 all staff must notify the charge nurse as soon as possible of a resident missing or attempting to leave. If a resident is attempting to leave, try to redirect them. If a resident is suspected of being missing, the charge nurse will attempt to find out if a resident has signed out on a pass; it not on a pass, a search of the building and the premises will be initiated. Charge nurse will notify the Administrator and the DON, primary care provider, and the responsible party. The facility has an elopement risk binder at each nurse's station and at the front desk. This information can be used to assist search teams when looking for a resident. Record review of the facility training provided on 11/18/2025 read in part . Topic: Elopement Prevention. Staff in-serviced and verified 11/20/2025 residents are assessed by nursing to identify the risk for elopement . Wandering can indicate an unmet need. Interventions to redirect wandering include Toileting; Offering Food/Drink; Reduce Physical Discomfort (pain, toileting etc.). Residents can go into courtyards. If additional staff are needed to redirect residents, stay with the residents, stay with the resident, and call for help (charge nurse, Adon, Don, Administrator). Record review of the facility training provided on 11/19/2025 read in part. Topic: Resident sign out. Staff in-serviced and verified on 11/20/2025; the sign-out book will be located at the reception desk if present. When the receptionist leaves for the day, the sign-out book will be moved to Station 1 . All residents leaving the building are required to sign out. Record review of the facility training provided on 11/19/2025 read in part. Topic: Exit Doors. Staff in-serviced and verified on 11/20/2025 all exit doors have a 15 second delay-alarm will sound, and the door will open . Staff must respond to all alarms. Identify if a resident has exited, staff must stay with the residents and call for additional assistance. Record review of the facility training provided on 11/19/2025 read in part . Topic: Elopement Response. Staff in-serviced and verified 11/20/2025 all staff must notify the charge nurse as soon as possible of a resident missing or attempting to leave. If a resident is attempting to leave, try to redirect them. If a resident is suspected of being missing, the charge nurse will attempt to find out if a resident has signed out on a pass; it not on a pass, a search of the building and the premises will be initiated. The charge nurse will notify the Administrator, the DON, the primary care provider, and the responsible party. The facility has an elopement risk binder at each nurse's station and at the front desk. This information can be used to assist search teams when looking for a resident. Record review of the facility training provided on 11/19/2025 read in part . Topic: Elopement Prevention. Staff in-serviced and verified 11/20/2025 residents are assessed by nursing to identify the risk for elopement . Wandering can indicate an unmet need. Interventions to redirect wandering include Toileting; Offering Food/Drink; Reduce Physical Discomfort (pain, toileting etc.). Residents can go into courtyards. If additional staff are needed to redirect residents, stay with the residents, stay with the resident, and call for help (Charge Nurse, ADON, DON, Administrator). Record review of Monitoring Plan of Removal revealed signatures of meeting, which included Interim Administrator, DON, ADON, Medical Director, Social Services, Dietary, Activity Director, Regional Corporate Compliance Nurse, an unknown other: An Ad-hoc meeting held on 11/18/25 by the interdisciplinary team to discuss the immediate jeopardies (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455682 If continuation sheet Page 4 of 5 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455682 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/21/2025 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 and review the plan for removal. During an interview on 11/19/2025 with Interim ADM, DON, Traveling Corporate DON, ADON, SW, Maintenance Supervisor revealed staff in-person and or by telephone were in-serviced. Regional Corporate Compliance Nurse said if the employee or prn was not in serviced that staff employee cannot work their shift until all in-services were completed. During an interview on 11/19/2025 between 12:50 pm and 4:00pm with ADON, RN's ,B, E; Certified Occupational Therapy Assistant, 4-CMA's, D,F,G,H; 18-CNA's, I,J,K,L,M,N,O,P,Q,R,S,T,U,V,W,X,Y,Z; 2-Dietary Staff's, A, AA; 2-Facility Marketing Admission's, BB, CC; 1-Facility Director of Nursing, Laundry staff, LVN Charge Nurse's, DD, EE, FF, GG, HH, Social Worker indicated that employees had received training on elopement prevention and the steps to follow when a resident attempts to leave the building. Staff consistently reported that all exterior doors are equipped with a 15-second delayed-egress system that triggers an alarm when engaged. Staff stated they are expected to investigate all alarms immediately. Staff described their responsibilities when a resident approaches or exits through a monitored door. They stated they are to remain with the resident, attempt redirection when appropriate, and contact the charge nurse for assistance. Staff explained that if a resident cannot be located, nursing leadership initiates a search and determines whether the resident had signed out or otherwise been approved to leave the facility. Staff reported that the administrative staff, the DON/ADON, the residents' provider, and the responsible party are notified according to facility protocol. Staff also noted the presence of an Elopement Risk Binder at each nurse's station and the front desk. They stated this resource contains relevant information to support staff during search efforts. The staff in-services revealed interventions such as toileting, offering fluids or snacks, and addressing comfort to redirect residents. Staff stated if additional help is needed, they contact the nurse charge or nursing administration. The information provided was consistent with staff and aligned with the facility's in-service training conducted November 18, 2025, and November 19, 2025. The Regional Corporate Compliance Nurse, DON, Interim Administrator, Traveling DON, ADON were informed the immediate jeopardy was removed. While the IJ was removed on 11/19/25 at 4:33 pm. The facility remained out of compliance with a severity of no actual harm with potential for more than minimal harm that was not an immediate jeopardy and a scope of isolated, due to the facility's need to evaluate the effectiveness of the corrective system. Event ID: Facility ID: 455682 If continuation sheet Page 5 of 5