Health inspection·October 19, 2023

F 0689 10/09/23 at 6:48 AM Level of Harm - Immediate jeopardy to resident health or safety Upon arriving to facility, noted resident walking down street in front of facility. Stopped vehicle and called to resident. Exited vehicle and walked resident to side door facility and escorted her into building. Resident in no signs of distress. No shortness of breath noted, color WNL. DON took resident back to unit. - MDS Nurse Residents Affected - Few 10/09/23 7:36 AM Resident was found out front of the facility. The resident does not have any injuries or falls related to this incident. Appears that the resident was able to get out of the side gate. We returned the resident to the unit, and we did a head count to make sure that all of the residents were accounted for, and they were. - LVN A Review of the facility provider investigation report, not dated, received from the Administrator on 10/13/23, reflected: Resident #1 Information Pertinent Medical Diagnosis: Alzheimer's disease and abnormalities of gait and mobility. Resident #1 resides in our secure memory care unit, but no special supervision is required within the unit. Date/Time you first learned of incident: 7:15am, 10/09/23 Date/Time the incident occurred: approximately 6:30am, 10/09/23 Brief narrative summary of the reportable incident: At about 6:30 AM this morning, 10/09/23, staff member CNA B walked Resident #1 to the dining room in the secure care unit. CNA B then went to the end of the 400 hall to put the trash in the trash bin just outside the door. The secure care unit (400 hall) was all COVID positive, so trash and dirty linens were placed outside the back door to be picked up and disposed of or taken to laundry. In order to open the door at the end of the hall, LVN A pushed the exit button to release the door locks. In doing this the doors at the two ends of the hall released as well as the gate in the courtyard. LVN A was watching down the hall and at the entrance doors to the secure care unit. LVN A assumed that the door from the dining room to the courtyard was locked and secure, as it did not release with the other doors. Apparently, the dining room/courtyard door was not fully shut and thus not locked. While LVN A and CNA B were engaged in taking out the trash, Resident #1 walked outside onto the courtyard patio and then out through the exit gate. She walked to the front of the building, following the sidewalk and then walked down the driveway to the road in front of the facility where the MDS nurse, was arriving for work and walked her back to the building. Staff walked her back to the secure care unit. The date and time of the assessment: 10/9/23, 7:00am Name and title of person who completed assessment: LVN A Results of the assessment including extent of injuries: Resident #1 had no injuries or apparent ill effects. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675185 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 675185 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Longmeadow Healthcare Center 120 Meadowview Dr Justin, TX 76247 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 Provide all steps taken immediately to ensure resident(s) are protected: Level of Harm - Immediate jeopardy to resident health or safety Examined the dining room/courtyard door. Changed out the lock on the door to one that will always automatically lock after entering the code. Maintenance adjusted the door so it was a smoother and dependable full closer, thus ensuring the door would relatch each time it is closed. Ensured the closure mechanism is working correctly. Conducted an in-service with staff on the precise sequence of steps for releasing and relocking the doors. Contacted our Fire System vendor to come out and install a new mag lock at the end of the 400 hall to allow for independent ingress and egress through just that door. Residents Affected - Few In-service on the procedure for releasing and relocking the secure doors and the precautions to ensure it is done safely. The resident was out of the building for approximately 15 minutes on 10/09/23. She was found on the road in front of the building which was next to the driveway of the facility. It was not a busy street. An observation of Resident #1 on 10/13/23 at 1:05 PM reflected she was in the secure care unit. She was standing in the dining room. She was not interviewable but was awake and alert. She wandered around the dining room. The dining room door was locked with a keypad and the door would automatically shut and lock by itself. The back door, front door, and courtyard gate were locked. An interview on 10/13/23 at 5:45 PM with CNA B revealed at around 6:00 AM on 10/09/23 CNA B took Resident #1 to the dining room. She said she did not realize the dining room door was unlocked. She said there was a staff coming to the back door of Hall 400 to drop off papers. She said she was watching two residents who were close to the back door to make sure they did not go outside the door after LVN A unlocked it. She said after the door was relocked CNA B went to get a resident up for breakfast and the DON walked onto the unit with Resident #1. CNA B said when the button at the nurse station was pressed, it unlocked the back door, front door, and the outside gate. CNA B said she received in-services about the doors and following the incident. The dining room door lock was changed and now closed by itself. She said staff no longer pressed the button at the nurse station because the residents were no longer COVID positive. An interview on 10/13/23 at 5:40 PM with LVN A revealed on 10/09/23 the button at the nurse station was pressed to allow someone to come into the secure unit through the back door. LVN A said she did not realize the button also opened the outside gate, and she did not know the dining room door was unlocked. She said it was no longer necessary to press the button to open the back door because the residents on the secure unit no longer had COVID. She said the button was an emergency button and she had received in-services to make sure all of the doors were locked if the button had to be pressed and to do a resident head count. She said the dining room door lock was changed to one that locked automatically after the incident. An interview on 10/13/23 at 4:50 PM with the MDS Nurse revealed on 10/09/23 at around 6:45 AM, she arrived to work and saw Resident #1 walking close to the building. The MDS Nurse said she called the resident's name and walked her back into the building. She said the resident was happy and pleasant and did not have any signs or symptoms of injury. The MDS Nurse said she took the resident to the DON. An interview on 10/13/23 at 2:25 PM with the DON revealed the facility failure related to Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675185 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 675185 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Longmeadow Healthcare Center 120 Meadowview Dr Justin, TX 76247 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 #1's elopement occurred because the facility was following their COVID protocol. She said staff were not allowed to use the front door to enter the unit from the facility. Staff had to enter the unit from the outside by going through the back door. The DON said when staff entered the back door, a button at the nurse station had to be pressed because the back door did not have its own locking mechanism. The DON said when the button was pressed, it unlocked the front door (which had its own separate lock), the back door (which did not have its own separate lock), and the outside gate in the courtyard. The dining room door had its own lock that was a manual lock. She said on 10/09/23, LVN A was watching the front and back doors after she pressed the button to unlock them. The dining room door was not securely locked, and the resident went out the door to the courtyard, and then out the gate. The DON said following the elopement the facility changed the lock on the dining room door so it would automatically lock. She said COVID protocol was no longer in place and the button did not have to be pressed. She said the staff also had a monitoring tool that they had to fill out following the incident anytime the button at the nurse station was pressed. An interview on 10/13/23 at 4:05 PM with the Administrator revealed if the button at the nurse station was pressed, the front door, back door, and outside gate all opened. He said on 10/09/23, no one knew the dining room door was unlocked and so no one was watching that door when the button was pressed. He said the facility failure was that the dining room door was unlocked, but now the dining room door had an automatic lock that did not require staff to secure it. He said the button was no longer being pressed unless there was an emergency, and a monitoring tool was in place and filled out anytime the button was pressed to ensure the doors were all relocked and all residents were accounted for. He said there had not been an elopement before. He also said a 3rd party vendor had been hired to put a separate lock on the back door so that the button would not have to be pressed at all. It was determined these failures placed Resident #1 in an IJ situation from 10/09/23-10/09/23. The facility took the following action to correct the non-compliance on 10/09/23. 1. The facility fixed the dining room door, that Resident #1 eloped through, by installing a new key pad and mechanism that allowed the door to lock automatically. 2. The facility put a monitoring tool in place to ensure the doors were locked after the exit button in the secure unit was pressed and all residents were accounted for. A record review of the facility Monitoring Tool used to check the secure unit doors was reviewed. The staff documented checking the doors on 10/09/23, 10/10/23, 10/11/23, 10/12/23, and 10/13/23. Record review of the facility policy, Elopement Prevention, revised 10/27/10, reflected: 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 . Environmental Modification 1. Allow the resident to wander in a safe and secure setting (e.g., closed courtyard or hallway free from obstacles or stairs) . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675185 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 675185 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Longmeadow Healthcare Center 120 Meadowview Dr Justin, TX 76247 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 5. Use door locks that are out of reach/sight to prevent wanderers from opening doors. Level of Harm - Immediate jeopardy to resident health or safety 6. Use door alarms or monitoring devices to notify staff when residents try to leave the facility . Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675185 If continuation sheet Page 5 of 5