Inspection·October 24, 2023

F 0689 Level of Harm - Immediate jeopardy to resident health or safety exterior of the facility, parking lots, bushes, etc. At 5:25am, the search was expanded by car to include the area directly surrounding the facility. [Resident #1] was noted at the gas station about half a block from the facility at approximately 5:30am, with 2 police officers, by [LVN A]. Resident was returned to the facility, and released to the nurse assigned to him, [LVN A] who completed a head to toe assessment and placed the resident on 1:1 staff supervision Residents Affected - Few Review of Resident #1's progress notes dated 09/25/23 completed by LVN B reflected the following: At 5:00 [AM] code silver was initiated. Census was printed and a complete head count was done on all the resident [sic]. At 5:10 we noted that [Resident #1] was missing, CNA's along side with nurses searched the outside grounds. Resident was located at 5:36 am. Resident was returned to the inside of the facility at 5:40 am. A completed head to toe assessment was done, not noted skin abnormalities was seen Resident was placed on a one to one observation for acute monitoring Review of a [NAME] map on 10/24/23 revealed the location where Resident #1 was located on 09/25/23 was 0.3 miles from the facility. Attempts to interview LVN A and LVN B on 10/24/23 were unsuccessful. Interview on 10/24/23 at 11:29 AM with the Receptionist revealed Resident #1 always sat at the front lobby and looked outside and let her know when visitors were coming to the door and greeted all who entered the facility. She stated Resident #1 was confused but had never made any attempts to elope nor expressed wanting to leave to her. Interview on 10/24/23 at 12:29 PM with CNA C revealed Resident #1 had confusion but he was not exit seeking and self-propelled his wheelchair through the facility. Interview on 10/24/23 at 2:42 PM with LVN D revealed Resident #1 was confused and sat in the front lobby greeting all the visitors that entered the facility. Resident #1 was very calm and was never known to be exit seeking. Interview on 10/24/23 at 9:50 AM with the Maintenance Director revealed he was on his way to work the morning Resident #1 eloped from the facility, 09/25/23. When he arrived at the facility, he checked all the exit doors to ensure they were all operating and there were no concerns. The Maintenance Director further stated Resident #1 was confused but he had never known the resident to be exit seeking. Interview on 10/24/23 at 10:56 AM with the ADON revealed Resident #1 used a wheelchair to get around and he was alert and oriented to himself only. She stated the resident did not wander or was exit seeking to her knowledge nor had he ever expressed wanting to leave the facility. Interview on 10/24/23 at 9:00 AM with the Administrator and DON revealed they were immediately made aware of Resident #1's elopement and he was put on 1:1 supervision until he was transferred to a facility with a secure unit to prevent another incident. 2. Review of Resident #2's MDS dated [DATE] revealed the resident was a [AGE] year-old male admitted to the facility on [DATE]. His diagnosis included cerebrovascular accident (stroke) and non-Alzheimer's dementia. The MDS further reflected Resident #2 had a BIMS of 3 (cognition severely impaired). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675153 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 675153 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heritage House at Keller Rehab & Nursing 1150 Whitley Road Keller, TX 76248 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 Review of Resident #2's undated care plan revealed he had impaired cognition and was at risk for a further decline in cognitive and functional decline abilities. Interventions included to monitor/document/report to physician any changes in cognitive function. Review of Resident #2's Elopement assessment dated [DATE] revealed he was low risk. Review of the facility's Provider Investigation Report dated 09/29/23 reflected the following: The resident was noted to be missing from his room at 4:05 PM [on 09/28/23] by his nurse [LVN E]. As she was going to the front to call a code silver, a visitor was informing the receptionist that there was a resident in the parking lot. The resident was returned to the facility at 4:07 PM and a head to toe assessment was completed with no injuries noted. During door alarm checks, it was noted that the 200 hall door lock was malfunctioning. A sentry was placed at the door until the maintenance supervisor repaired the door, then q 4 hour door checks were performed until the alarm company came to inspect all the doors. Door checks continue daily. Interview on 10/24/23 at 3:04 PM with LVN E revealed she arrived to work the day of Resident #2's elopement, 09/28/23 at 2:00 PM, and during her initial rounds, she saw the resident in his room. Around 3:30 PM, she noticed Resident #2 was not in his room or the bathroom and asked nearby staff if they had seen the resident. At that time, they began to look for the resident and they had called a code silver as the same time an employee from a nearby business was in the front lobby saying Resident #2 was at their business and the resident was taken back to the facility. LVN said Resident #2 had not been at the facility long but during that short time, the resident had not been exit-seeking. The LVN further stated the resident was ambulatory without assistance. Resident #2 was put on 1:1 supervision until he was discharged from the facility. Interview on 10/24/23 at 12:29 PM with CNA C revealed the day of Resident #2's elopement, 09/28/23, the resident had been seen at the nurse's station around 3:35 PM, and around 4:00 PM LVN E was looking for the resident and decided to call a code silver. At that same time, they got word that Resident #2 had been found outside next door at a nearby establishment and they had the resident. Facility staff went to the establishment and brought Resident #2 back to the facility. CNA C further stated that during the short time the resident was at the facility, he had never been exit seeking nor had he ever made the comment about wanting to leave. Interview on 10/24/23 at 9:50 AM with the Maintenance Director revealed when he was made aware of Resident #2's elopement, he was called to check the exit doors and he found the exit door on 200 hall was not working. It appeared the exit door had come out of adjustment but once he fixed it, it began to work again. The Maintenance Director stated all the exit doors were checked weekly and all the doors had just been checked a few day prior, when Resident #1 eloped on 09/25/23 and they had all been in good and operating correctly. After Resident #2's incident, the mag lock on the 200 hall door was replaced and all facility exit doors were being checked and the codes were being changed every morning as well. Interview on 10/24/23 at 10:56 AM with the ADON revealed on the day of Resident #2's elopement, 09/28/23, she was in her office on the 500 hall when she heard LVN E asked if anyone had seen Resident #2. At that time, they activated a code silver when they saw an employee of a nearby business in the front lobby saying they had one of their residents. Resident #2 was brought back to the facility and the nurse did a head-to-toe assessment and there were no injuries noted. After the resident was brought back to the facility, he was asked why he had left and the resident stated because this is a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675153 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 675153 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heritage House at Keller Rehab & Nursing 1150 Whitley Road Keller, TX 76248 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 free country. Resident #2 was put on 1:1 supervision until he was discharged from the facility with family. The ADON further stated the resident had only been at the facility for a short time and he had never shown exit seeking behaviors. Observation from the 200 exit door of the facility on 10/24/23 at 2:23 PM revealed the establishment where Resident #2 was found was about 100 yards from the facility premises. The establishment and facility shared a paved parking lot with some landscaped grass. Interview on 10/24/23 at 5:27 PM with the Regional Nurse Consultant revealed Residents #1 and #2 were discharged from the facility to a secure unit. All staff were re-educated on code silver and live drills were done every shift for a week and a half, then daily, then transitioned weekly and now are being done monthly so all staff knew what to do in case a resident went missing. Exit door checks were being done daily by the Maintenance Director and the mag lock was changed on the hall 200 exit door. She further stated there was an elopement assessment done on all the residents after the incidents and there were two additional residents identified and measures were put in place to prevent any further incidents. Observation on 10/24/23 from 9:34 AM to 9:50 AM revealed all 13 facility exit doors were checked with the Maintenance Director and all of the doors were functioning properly. Each door was equipped with a 15 second egress release followed by an alarm after it was opened. There were 3 dining room doors and there was an additional louder alarm added so they could be heard throughout the facility. Review of the facility's policy titled Missing Resident Policy revised on 08/15/23 reflected the following: This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk This was determined to be a Past Non-Compliance Immediate Jeopardy on 10/24/23 at 5:15 PM. The Administrator, DON, and Regional Nurse Consultant were notified. The Administrator was provided with the IJ template on 10/24/23 at 5:26 PM. The facility took the following actions to correct the non-compliance prior to the investigation: Record review of the following in-services, dated 09/25/23 and 09/28/23, reflected the in-services were conducted and signed by all facility staff on all three shifts, 6:00 AM to 2:00 PM, 2:00 PM to 10:00 PM and 10:00 PM to 6:00 AM: - Missing resident guidelines; - Missing resident protocol-Elopement binder; - Code Silver; - Exit seeking behavior; and - Head count procedural guidelines. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675153 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 675153 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heritage House at Keller Rehab & Nursing 1150 Whitley Road Keller, TX 76248 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 Interviews on 10/24/23 from 9:34 AM to 3:59 PM with the Receptionist, HR Director, Restorative Aide, Maintenance Director, ADON, LVN A, LVN B, CNA C, LVN D, and LVN E who worked all three shifts revealed they were able to conduct a code silver drill for a missing resident, perform a head count check, what to do when they heard a door alarm and monitor any changes in condition that could indicate a resident was a high elopement risk. Record review of the facility's Code Silver drills revealed they were conducted daily on each shift beginning on 09/25/23 and they were currently being done monthly with no end date. Record review of exit door checks on 09/25/23, after Resident #1 eloped, revealed all exit doors were functioning properly. Record review dated 09/28/23 revealed staff were doing 15 minute checks on the 200 hall door from 4:20 PM until the Maintenance Director arrived and it was fixed at 6:47 PM. Record review of the fire and security invoice revealed that on 09/30/23 a delayed egress lock was replaced on the 200 hall. Record review of the door alarm checks dated 09/29/23 to 10/23/23 revealed they were being checked daily by the Maintenance Director. Record review revealed an elopement assessment was completed on all the residents on 09/29/23 to identify any additional high risk residents. Two additional residents were identified as being at high risk for elopement. One of the resident was transferred out to a more secure facility and the other resident was monitored until he was deemed safe to remain at the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675153 If continuation sheet Page 5 of 5