Health inspection·August 15, 2025

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few antibiotics, Noted by RN C Dated 07/18/25 Resident#1's First dose of IV Vancomycin (glycopeptide antibiotic used primarily to treat serious bacterial infections, particularly those caused by Gram-positive bacteria) 1g administered via midline to the right upper arm for treatment of UTI . Noted by RN C Dated 07/19/25 reflected Approximately [1:00 pm] resident with others were taken out to the smoking zone. After the resident finished smoking, he was let inside by the CNA. The resident noted sitting across the nurse station for a few minutes, then wheeled himself on the hallway towards his room. Approximately [1:30 pm] the activity staff notified this nurse that the resident was outside in the front side of the building. This nurse rushed to the front of the building immediately and noted resident sitting on his wheelchair on the driveway with the maintenance Director standing behind him. Maintenance director stated that the resident was across the street. Resident Assisted back into the building. This nurse asked the resident where are you coming from? Resident replied, I don't know, I don't know, I don't know.shaking his head left to right Head to toe assessment completed no injuries noted, Vitals: BP126/60, P68, RR17 T97.7, o2 96% on room air. Resident denies pain at the moment and no s/s of distress noted. Administrator, [FNP] DON and Family notified.[FNP] gave new orders to house the resident in the secure unit. Resident transferred to the secure unit. Report given to the unit nurse . ADM and nurse followed up with resident regarding incident from earlier today. Resident was asked if he went across the street, resident smiled while shaking his head stated I went to the front because I'm a strong man. Resident stated he's fine and asked ADM not to worry .ADM called resident RP again to inform her of resident going outside of facility with no supervision. Resident RP stated, .please don't discharge him, just put him in the locked unit. ADM explained to her the physician has already ordered for him to be in the unit for his safety.Resident received to secure unit due to elopement risk. Resident continuously self-propelling up and down unit and sitting at exit doors waiting for people to enter or exit. Resident voices desire to leave. Redirected through this shift. Noted by Admin. Record review of incident report dated 07/19/25, completed by RN C reflected: Approximately [1:00 pm] resident with others were taken out to the smoking zone. After the resident finished smoking, he was let inside by the CNA. The resident noted sitting across the nurse station for a few minutes, then wheeled himself on the hallway towards his room. Approximately [1:30 pm] the activity staff notified this nurse that the resident was outside in the front side of the building. This nurse rushed to the front of the building immediately and noted resident sitting on his wheelchair on the driveway with the maintenance Director standing behind him. Maintenance director stated that the resident was across the street. Resident Assisted back into the building. This nurse asked the resident where are you coming from? Resident replied, I don't know, I don't know, I don't know.shaking his head left to right Head to toe assessment completed no injuries noted, Vitals: BP126/60, P68, RR17 T97.7, o2 96% on room air. Resident denies pain at the moment and no s/s of distress noted. Administrator, [FNP] DON and Family notified.[FNP] gave new orders to house the resident in the secure unit. Resident transferred to the secure unit. Report given to the unit nurse. ADM and nurse followed up with resident regarding incident from earlier today. Resident was asked if he went across the street, resident smiled while shaking his head stated I went to the front because I'm a strong man. Resident stated he's fine and asked ADM not to worry.ADM called resident RP again to inform her of resident going outside of facility with no supervision. Resident RP stated, .please don't discharge him, just put him in the locked unit. ADM explained to her the physician has already ordered for him to be in the unit for his safety . In an interview on 08/14/25 at 12:25 pm the AAD stated she took Resident#1 outside to smoke on smoke break, and she returned to do activities with the residents. The AAD stated Resident#1 was outside with CNA A on his smoke break. The AAD stated she was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675032 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 675032 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cedar Hill Healthcare Center 230 S Clark Rd Cedar Hill, TX 75104 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 leaving the facility out the front door when the DOM let her know the Resident#1 was across street. The AAD let the nurse know who met the Resident#1 in the parking lot with the DOM. In an interview on 08/14/25 at 12:33 pm the DOM stated the DOM left the facility at approximately 1:30 pm and spotted Resident#1 across the street at the gas station. The DOM brought Resident#1 from across the street, and he refused to go back into the building. The nurse came out and assisted Resident#1 in the building. In an interview and observation on 08/14/25 at 12:45 pm the Admin stated CNA A was coming down 200 hall and heard the front door alarm going off. The admin stated the CNA A stated she looked out the front door and did not see anyone. The admin stated CNA A turned the alarm off and clocked out for lunch. The admin stated she did a one-on-one training with CNA A because she should not have turned the alarm off. The Admin stated the charge nurse should have been notified that the front door alarm went off and a head count should have been completed. The Admin stated she did not believe CNA A looked outside for anyone but since CNA A stated she did look that was way she did an education training with her instead of disciplinary action. The admin showed surveyor from the front door window where the gas station could. be viewed from across the street. Record review of the Admin's statement on 07/19/25 regarding Resident#1's elopement reflected, [Admin] and nurse followed up with resident regarding incident from earlier today. [Resident#1] was asked if he went across the street, Resident smiled while shaking his head, stated. Went to the front because [his] a strong man. Resident stated he's fine and as admin not to worry. Admin call resident RP again to inform her of residents going outside of facility with no supervision .the physician has already ordered for him to be in the unit for his safety. Resident RP was very relieved and thankful to facility.Record Review of the AAD's statement on 07/19/25 reflected, At 1:00 PM, [she] saw [Resident #1] in the front lobby and told him it was time to smoke. [she] then took [residents]to the smoking area around 1:00 PM and then [she] went to go do my activity. Resident was outside and smoking areas singing. Another resident smoking when [she] left him. Record review of CNA B's statement on 07/19/25 reflected. Supervised [ resident] on smoking at around 1:00 PM, smoke break and soon after residents smoke one cigarette. [she] helped residents to come back in because Resident #1 was getting very angry and agitated at the time. [Then took resident#1 to] the nursing stations and then went back out to finish the smoke break for the rest of [residents]. Record review of the DOM's statement on 07/19/25 reflected, leaving the facility about 1:30 PM and notice Resident #1 was across the street at the store. And then went across the street to the store and got out of my car to approach Resident #1.brought resident back to the facility and told nurse that i found resident across the street and I left the resident with the nurse. Record review of RN C's statement on 07/19/25 reflected,The same as the above incident report and his statement to the admin. Record review of CNA A's statement on 07/19/25 reflected, [CNA A] was coming down 200 hall to clock out for lunch upon coming to hall I heard alarm sound. [She] then [looked] out the door and window to see if anyone was leaving and saw no one then [she] reset the alarm. Record review of CNA B time sheet, dated 07/19/25 reflected, she clocked out at 1:19 pm.Record review of DOM time sheet dated 07/19/25 reflected, he clocked out at 1:07 pm.Record review of AAD time sheet dated 07/19/25 reflected, she clocked out at 1:35pm. Attempted to call RN C on 08/14/25 at 1:15pm and was not able to leave voicemail. Attempted to call RN C on 08/15/25 at 8:30 am and was not able to leave voicemail. Attempted to call CNA A on 08/15/25 at 8:35 am was not able to leave a voicemail. Attempted to call CNA B on 08/15/25 at 9:30 am was not able to leave a voicemail. Record review of facility policy, revised 04/24, titled Accidents and Supervision reflected in part: .The resident environment will remain as free of accident hazards as is possible. Each resident will receive adequate supervision and assistive devices to decrease the risk of accidents.5. Supervision is an (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675032 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 675032 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cedar Hill Healthcare Center 230 S Clark Rd Cedar Hill, TX 75104 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 intervention and a means of mitigating accident risk. The facility will provide adequate supervision to prevent accidents. Record review of facility policy, revised 12/07, titled Elopements reflected in part: 4. If an employee discovers that a resident is missing from the facility, he/she shall:Determine if the resident is out on an authorized leave or pass.If the resident was not authorized to leave, initiate a search of the building(s) and premises.If the resident is not located, notify the Administrator and the Director of Nursing Services, the resident's legal representative (sponsor), the attending physician, law enforcement officials, and (as necessary) volunteer agencies (i.e. emergency management, Rescue squad, etc.).Provide search teams with resident identification information; andInitiate an extensive search of the surrounding area.5. When the resident returns to the facility, the Director of Nursing Services or Charge Nurse shall:Examine the resident for injuries.Contact the attending physician and report findings.Notify the resident's legal representative (sponsor)Notify search team that the resident has been located.Complete and file an incident report; andDocument relevant information in the resident's medical record. The non-compliance was identified as past non-compliance (PNC). The IJ began on 07/19/25 and ended on 07/31/25. The facility had corrected the non-compliance before the state's investigation began. The facility took the following actions to correct the non-compliance prior to the survey: Record review of Resident#1 elopement risk assessment, dated 07/19/25 reflected in part: 1. Mobility - propels self/some assist 2. Mental Stability Wanders aimlessly 4. History of elopement attempts - has had one plus attempts 5. Behavior Modifications - Behavior redirected.7. Diseases (Dementia, any type of mental illness)- one present 8. Summary of the elopement assessment - the resident is at risk for elopement.B-1, Elopement Interventions- Secured unit placement. Record review of Resident#1's order summary report, dated 08/15/25 reflected in part: on 07/21/25 the PA put in a verbal order for Resident#1 to be admitted to the secure unit for wandering/elopement. On 07/22/25 PA put in a verbal order that Resident#1 may be on one-on-one watch. Record review of a training sign in sheet, dated 07/21/25 reflected in part: elopement process, every hour rounding on every exit door, and elopement drill Training sign in sheet dated 07/19/25 - 07/22/25 and 07/31/25 reflected, elopement drill, facility elopement process and missing person. Record review of Resident#1's care plan, revised on 07/21/25 reflected Resident#1 was an elopement risk/[wanderer] as evidenced by disoriented to place and leaving the building. Resident#1's goal reflected safety will be maintained. Resident#1's interventions reflected Attempt to engage in pleasant, meaningful, purposeful enjoyable, activities, during episodes of constant wandering, by playing music or engage him with other activities. Observe for changes in gait/mobility/balance and notify the nurse of any changes. Observe for fatigue and weight loss, report observations to nurse. During an observation and interview on 08/14/25 at 10:30 am revealed, Resident#1 in the secure unit in his wheelchair and transferred himself to the bed. Resident#1 did not want to talk about the elopement. Resident#1 shook his head no and laid down. Observed doors in the secure units worked properly. Observed Resident#1 on Q15 throughout the day. In an interview and observation on 08/14/25 at 10:40 am LVN D stated the elopement happened over the weekend and when he returned to work Resident#1 was in the secure unit. LVN D stated before the elopement Resident#1 was on 200 hall and was on Q15 monitoring. LVN D stated he had not experienced an elopement while working in the facility. LVN D stated he had been trained on the elopement process and procedures. LVN D stated staff should do a head count when the alarm goes off, contact the admin, make an intercom announcement, search for the resident inside and around the facility. In an interview and observation on 08/14/25 at 12:45 pm the Admin stated The Admin added she completed in-services with regular staff on 07/31/25. The admin stated the ADON completed in- services with the PRN staff over the phone in 07/22/25. The Admin stand she completed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675032 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 675032 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cedar Hill Healthcare Center 230 S Clark Rd Cedar Hill, TX 75104 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 elopement drills on 07/31/25, The admin stated they did monthly elopement drills. The Admin stated the facility completed upgrades to the alarm system that included blinking strobe lights and horn that could be heard throughout the facility. In an Interview on 08/14/25 between 1:15pm to 2:30 pm revealed staff were knowledgeable about the policy and procedures for elopement and drills. LVN E, RN F, CNA G, CNA H, CNA I, CNA J, CNA K, RN L, CNA M, CNA N, LVN O, RN Q and CNA P stated they had been doing random drills for elopement. Staff stated when the alarm went off look outside, do head count, and let the charge nurse and admin know the alarm went off. The staff stated search the inside of the building then extend the search to the outside. The staff stated call code white for elopement over the intercom. RN L, RN F, RN Q and LVN O stated when the resident was found a head-to-toe assessment was to be completed and an incident report. During an observation on 08/14/25 at 4:15 pm revealed the Admin set the front door alarm off. The Admin lightly pushed the door and she stated that was the sound the door would make before the upgrade. The surveyor observed the sound was able to be heard in the front of the building but, was too low to be heard throughout the building. The surveyor heard the horn and flashing lights throughout the facility. Observed staff running to the front of the building. Observed exit doors throughout the building and no concerns noted at this time. In an interview on 08/15/25 at 9:35 am the PA stated the facility notified her on Saturday 07/19/25 that Resident#1 had eloped from the facility. The PA stated she gave the order for Resident#1 to be put on the secure unit. The PA stated Resident#1 was combative with staff and exit seeking. The PA stated at this time Resident#1 was appropriate for the secure unit. Record review of Tulip (A web- based system implemented for managing the licensure of long-term care facilities and agencies) reflected a self- report was submitted on 07/18/25. Record review of IC approved quote dated 08/04/25 reflected strobe white wall, amber lens and system sensor wall mini horn, white for installment for upgrades to alarm system. Event ID: Facility ID: 675032 If continuation sheet Page 5 of 5