Inspection·June 20, 2023

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some with suicidal ideations (often called suicidal thoughts or ideas, is a broad term used to describe a range of contemplations, wishes, and preoccupations with death and suicide). CR #1 was transferred to a local acute care hospital on [DATE]. Record review of CR #1's MDS dated [DATE] revealed he had a BIMS score of 7 (severe cognitive impairment); he felt down, depressed, or hopeless between 7-11 days; he did not experience hallucinations or delusions; he rejected care daily; he wandered daily which placed him at significant risk of getting to potentially dangerous places; he required supervision with no physical assistance for bed mobility, transfers, walking, dressing, and bathing; he required supervision with setup assistance with eating and personal hygiene; he ambulated independently with a walker; he was always continent of bowel and bladder; he experienced coughing or choking during meals or when swallowing medications; and he was prescribed antidepressant medication. Record review of CR #1's care plan updated 05/27/2023 revealed the following: -CR #1 had potential for elopement as evidenced by exit seeking behavior (05/23/2023 exited out the front door). Goals included: Maintain the least restrictive environment while providing safety. Interventions included: Have activities involved with favorite past times. Music. Exercise. Photo in Elopement risk book. All staff to be made aware of CR #1's risk status via staff sign-in book and verbal reports. If possible, have family or volunteers visit on a regular basis. Keep doctor and family informed. SW to make regular visits. Reorient/Redirect as needed. Reassess as needed. SW to obtain detailed prior routine of CR #1. -CR #1 was taking psychotropic medications for Depression (Sertraline). Goals included: CR #1 will not experience adverse side effects. Interventions included: Monitor and record any displayed behavior or mood problems. Encourage appropriate behavior, discourage inappropriate behavior. Monitor effectiveness of psychotropic medications. Monitor for involuntary movements and repetitive behaviors and report to doctor. Review medications every three months for possible dose reduction. Allow CR #1 to express feelings. Protect CR #1 from self-harm or harm to others. Monitor for weight loss. Psych consult as needed. -CR #1 had behavioral symptoms not directed toward others (05/27/2023- CR #1 attempted to harm himself by wrapping a phone cord around his neck- 911 was called- will re-evaluate interventions upon return. Goals included: Incidents of self-harm will be decreased. Interventions included: Gently remind CR #1 that behavior is not appropriate. Provide medication as ordered. Record behaviors on Behavior Tracking form. Monitor pattern of behavior (time of day, precipitating factors, specific staff, or situations). Head to toe assessment completed to check for any injuries (no injuries noted). 1 on 1 monitoring until EMS arrived. -CR #1 exhibited wandering behaviors. Goals included: Current level of mobility will be maintained. Interventions included: Assess potential causes for wandering (need for toilet, water, food, pain relief). Provide diversional activities. Record behaviors on Behavior Tracking form. Redirect CR #1's behavior/activity when wandering is observed. -CR #1 had other behavioral symptoms not directed toward others (refusal of care, threatening to break windows. Goals included: Incident will be decreased. Interventions included: Gently remind CR #1 that behavior is not appropriate. Provide medication as ordered. Record behaviors on Behavior Tracking form. Remove from situation; allow time to calm down. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675495 If continuation sheet Page 2 of 27 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 675495 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laurel Court 3830 Mustang Road Alvin, TX 77511 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some -CR #1 was at risk for falls as evidenced by cognitive impairment, fall history, weakness, unsteady gait, and rhabdomyolysis. Goals included: Dignity will be maintained. CR #1 will not experience falls or injuries from falls. Interventions included: Encourage CR #1 to ask for assistance of staff. Ensure call light is in reach, answer promptly. Therapy to evaluate and treat per orders. Anticipate needs, provide prompt assistance. Assure lighting is adequate and areas are free of clutter. Observation and interview of CR #1 at a psychiatric hospital on [DATE] at 9:00 a.m. revealed he was alert, oriented and ambulated independently with a walker. CR #1 said they went by the rules at the facility. He said he sneaked out the front door and tried to go to Whataburger. He said he did not like living there because there was no place to go, and he was the type of guy who liked to go places. He said they (he did not say who they were) would not let him go sit outside because he had a fall outside. He said he wanted to get some fresh air, but the nurses caught him. CR #1 said he did not do anything but sit at the facility because there were no activities he liked. He said two of the nurses stood at the door and would not let him out. He said he was going to get out one way or the other, either they would let him walk out, or kill himself and let the undertaker carry him out. He said the cops picked him up from the facility when he tried to kill himself. CR #1 said he wrapped a telephone cord around his neck. He said he had not been home in a very long time, and he wanted to go home. He said they gave him more medication and he felt better now. He said he did not want to kill himself anymore, he wanted to go home. Record review of CR #1's hospital records dated 05/16/2023 revealed he was admitted to a local acute care hospital via the emergency room on [DATE] after he fell in his home and was on the floor several hours. The document read in part, . Patient states, 'You're wasting your time- I want to die . I don't have any familyThey should have left me on the floor' . Precautions: Falls, Depressed state/ reports, 'I want to die' . Discharge Recommendations: Continue Rehab, Psych Consult. Precautions: Fall, Anxiety/Depression Recommend Psych Consult . Home Medications: . Sertraline (Zoloft) 50 MG tablets daily . Record review of CR #1's hospital records dated 06/02/2023 revealed he was transported to the emergency room by EMS on 05/27/2023. The records read in part, . presenting with EMS after possible strangulation attempt, patient was reported to have been found with a telephone cord around his neck, cyanotic (bluish or grayish color of the skin) appearing face, removed telephone cord and transported to hospital hemodynamically (how your blood flows through your arteries and veins and the forces that affect your blood flow) stable in route. When asked about this, patient reports he was just playing around with cord, had no suicidal intention. Patient would like to leave, does not know why is here, does not want to go back to the facility . patient with history of suicidal ideation . Assessment: Suicidal Attempt . Plan: Admit to floor . Sitter 1:1 . CR #1 was discharged to an inpatient psychiatric hospital on [DATE]. Record review of CR #1's physician's orders for May 2023 revealed he was prescribed Sertraline, 50 mg tablets once daily for depression. Start date: 05/18/2023. Record review of CR #1's MAR for May 2023 revealed he received Sertraline daily as ordered from 05/19/2023 until 05/26/2023. Record review of CR #1's referral for a psychiatry consultation dated 05/21/2023 revealed CR #1's physician gave LVN A verbal orders to refer CR #1 for the consultation on 05/21/2023. The order was electronically signed by LVN A on 05/21/2023 at 8:12 p.m. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675495 If continuation sheet Page 3 of 27 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 675495 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laurel Court 3830 Mustang Road Alvin, TX 77511 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Record review of CR #1's physician progress notes dated 05/22/2023 revealed, . Chief Complaint: New skilled nursing patient seen and examined for admission visit. Patient sitting on side of bed in no apparent distress. Pleasantly confused. States he lives alone. No suicidal ideation today. States he is ready to go home and wants to go home . Physical Exam: . Psychiatric: Judgement/insight: Poor . Summary of Plans: . Consults: Psychiatry to follow . Diagnosis and Assessment: . Dementia - . Has tried to exit seek multiple occasions since admission . Depression - Consult psych. Continue Zoloft 50 mg daily. Per report, suicidal ideation yesterday. None today. Plan: . Urgent consult on psych to evaluate and treat. Recent history of suicidal ideation. None noted today. States he wants to go home and not be in a nursing home . Record review of CR #1's physician progress notes dated 05/24/2023 revealed, Chief Complaint: Skilled nursing patient seen and examined in follow-up . Per staff, patient was found outside of the facility walking along the sidewalk stating that he wanted to go home . Record review of CR #1's progress notes for May 2023 revealed the following: *On 05/21/2023 at 8:05 p.m. (incident occurred at 5:15 p.m.), LVN A wrote, Resident was being evaluated by ST for swallowing issues that were reported. ST was introducing a mechanical soft diet. Resident stated he did not want to change diets. Asked ST 'What for?' He verbalized to ST that he wanted to die instead because he was tired. Will notify MD and refer resident for Psych evaluation. *On 05/22/2023 at 12:24 p.m., LVN B wrote, . Resident wanders throughout facility via walker. He attempted to exit x2 despite redirection . *On 05/23/2023 at 5:52 a.m., LVN C wrote, During rounds resident was noted to be sitting on the bed and asked this writer to come here. Resident thanked this writer for providing care to him and that he will be leaving today. Asked resident was family coming to get him, he stated no, 'I'm walking. I would walk now but it is dark.' Educated resident on the importance of staying at the facility, resident stated, 'I will think about it .' *On 05/23/2023 at 9:54 a.m., LVN B wrote, . This shift, he eloped out of front door and started to walk down the sidewalk. This nurse and other nurses on duty spoke with resident and attempted to provide redirection. After some time, resident agreed to come back inside. Resident still upset, threatening to break windows. Administrator speaking with RP at this time to make a discharge decision. *On 05/24/2023 at 3:33 a.m., LVN C wrote, . Resident is in bed resting quietly at this time, sitter is sitting outside of door . *On 05/26/2023 at 8:10 p.m., LVN C wrote, Resident is walking around asking staff to help him leave, staff redirects resident. Currently resident is in his room stating that he is leaving as soon as he finds a window to go out of. All staff notified to keep an eye on resident due to him stating he is going to leave. *On 05/27/2023 at 2:31 a.m. (incident occurred 05/26/2023 at 8:50 p.m.), LVN C wrote, This writer seen resident going towards the back door. This writer and another began to stand between resident and the door. Resident asked staff if we could move so he could leave. Asked resident where he was going, he stated, home to his bed because he had things to do. This writer explained to resident that I could not let him leave and I was responsible for his wellbeing. Resident stepped closer to staff and asked resident to please step back, he did. Resident continued to stand at the door. Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675495 If continuation sheet Page 4 of 27 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 675495 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laurel Court 3830 Mustang Road Alvin, TX 77511 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some then stated that he was going to leave one way or another, resident made a cutting sign (gesture) towards his neck. Asked resident what that was, he stated, 'Could you just let me leave?' Call placed to Administrator, advised resident that he would have to go to his room, or I will call 911, orders given from management. Aide offered popcorn, resident stated he guessed he would go brush his teeth and go to bed. Administrator called and asked if I could interview resident to see if he was a danger to himself. When interviewing resident, he could not recall making a cutting sign at his throat, resident also stated that he will never hurt himself, notified Administrator, resident is currently in bed resting quietly . rounds are made every 2 hours. *On 05/27/2023 at 10:12 a.m. (incident occurred at 9:15 a.m.), LVN A wrote, Receptionist was walking towards nursing station when she noted resident sitting in library. When she attempted to approach resident sitting in library, she noted that the resident had the phone cord wrapped around him and attempting to tighten it harder. Receptionist stated that the resident was turning blue when she ran in to intervene and remove the cord from the resident's neck. The Receptionist called for help and LVN E reached out to me on the way to assist resident and Receptionist. *On 05/27/2023 at 10:16 a.m., LVN A wrote, . Assessed resident. Resident stabilized after removing cord from neck and having to sit down. Stated wanted to leave. Asked if he was attempting to kill himself and he stated, 'If that's the only way out then, yes?' Called 911 to have resident transferred to hospital for psych evaluation . RN D spoke with family and advised that resident was being sent out to hospital for Psych evaluation due to suicide attempt. Family stated that it was not the first time the resident has attempted suicide . Record review of CR #1's, Elopement Risk Assessment dated 05/22/2023 revealed LVN F determined CR #1 was a moderate risk for elopements based on his cognitive impairment and wandering behaviors. Action included, Implement Elopement Risk care plan; Implement Frequent Monitoring Form (form was not completed) to determine elopement risk or until Interdisciplinary Team reviews and makes recommendation. Record review of CR #1's, Elopement Risk Assessment dated 05/23/2023 revealed RN G determined CR #1 was an imminent risk for elopements based on his ambulation status, wandering behaviors, and his intentional or unintentional attempts to leave the community. Action included, Implement Elopement Risk care plan; Implement Frequent Monitoring Form (form was not completed) to determine elopement risk or until Interdisciplinary Team reviews and makes recommendation. In an interview with the DON and the Regional Director of Clinical Services on 06/01/2023 at 9:45 a.m., the Regional Director of Clinical Services stated the DON was new to the facility and regional staff was not always in the building. The Regional Director of Clinical Services stated, based on what they knew, CR #1 had no previous suicidal ideations. The Regional Director of Clinical Services said CR #1's wife passed away in the facility many years prior and he had no other family other than a neighbor who helped him out prior to admission. The Regional Director of Clinical Services said CR #1's neighbor stated he (CR #1) previously talked about wanting to die. The DON stated to their (administration) knowledge, CR #1 spoke with the ST and referenced dying. The DON said CR #1's physician was notified and ordered an urgent referral for psychiatric services, but psych services was not able to see CR #1 before the suicide attempt. The Regional Director of Clinical Services stated CR #1's physician spoke with LVN A and that is where it ended. The Regional Director of Clinical Services stated LVN A was educated because something like that (suicidal ideations) should be escalated to the top (DON and Administrator). The Regional Director of Clinical Services said LVN A did not let anybody else know about the conversation between CR #1 and the ST. The Regional Director of Clinical (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675495 If continuation sheet Page 5 of 27 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 675495 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laurel Court 3830 Mustang Road Alvin, TX 77511 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Services said CR #1's physician documented his suicidal ideations and that she wanted an urgent psych consult. The Regional Director of Clinical Services said the incident was not communicated to the top (administration), so they did not have an opportunity to follow-up on the referral. The facility's elopement policy was requested, but the wandering policy was provided. In an interview with the VP of Clinical Operations on 06/01/2023 at 11:00 a.m., she stated the facility did an emergency QAPI on 05/27/2023, after CR #1 attempted suicide. She said all staff involved were counseled and in-serviced. She said nursing staff talked to each resident who could speak and used a special psychiatric tool given to them by a psych provider to interview about depression and suicide. She said the residents who could not talk were assessed head to toe to insure nothing was out of the ordinary for them. She said the Administrator was suspended because their investigation found he may have known about CR #1's prior history of depression. In a telephone interview with the Administrator on 06/01/2023 at 11:45 a.m., he stated he knew CR #1 kept saying he wanted to go home because he wanted to shampoo his carpet at home. He said it was not out of the ordinary for residents to express desires to go home. The Administrator said CR #1 had previously been admitted to the facility for rehab and he (CR #1) wanted attention, that was it. The Administrator said CR #1 was not depressed and he just wanted to go home and do chores. The Administrator said CR #1's depression, suicidal ideations, or behaviors were never brought to his attention prior to admission, and he never spoke to CR #1's family before or after his admission. The Administrator said the night before the suicide attempt (05/26/2023), LVN C called him around 10:00 p.m. He said he thought LVN C texted him, or he missed her call and then she texted saying CR #1 was trying to leave the building and that he wanted to kill himself. The Administrator said he sent LVN C a text to call 911, but she sent a text or called him, saying CR #1 was doing fine after they gave him popcorn. The Administrator said he called the LVN C back and she said CR #1 was fine and brushing his teeth. The Administrator said he told LVN C he needed to know what CR #1's state of mind was. He said LVN C said CR #1 could not even recall what he said earlier. He said he told LVN C to put CR #1 on monitoring (no monitoring was documented) and notify him if anything changed. He said he did not receive any more calls that night until incident on Saturday, 05/27/2023 when LVN A called and said CR #1 tried to hurt himself. In a telephone interview with LVN A on 06/01/2023 at 11:59 a.m., he stated he was a charge nurse and he only worked weekends. He said on 05/21/2023, the ST approached him and said CR #1 had difficulty swallowing and she wanted to down grade his diet (to a mechanical soft diet). He said the ST told him CR #1 refused the food she used to assess him and said he (CR #1) was tired and wanted to die. LVN A said he went to follow-up with CR #1 in his room and asked about his diet. LVN A said he wanted CR #1 to say in his own words how he felt, but he did not express a desire to die to him. LVN A said he did not ask CR #1 about what he said to the ST. LVN A said he called CR #1's doctor and got an order for a psych consultation and he documented the situation. LVN A said the order was not an urgent order. He said orders for psychiatric services were usually turned in to the SW. LVN A said he slipped the referral under the SW's door on Sunday, 05/21/2023, and he did not hear anything else about CR #1's referral after that. He said he did not relay this information to the DON, the Administrator, or anybody else. He said he did not know the SW was on vacation, but had he known, he would have taken the referral order to someone else. He said no special monitoring or intervention was initiated for CR #1. LVN A said that next weekend, 05/27/2023, CR #1 said he wanted to go home, but that was nothing out of ordinary from his usual agitation. He said on 05/27/2023, he heard another nurse call his name and he ran to the library room and saw CR #1 there with the Receptionist. He said by the time he got to the library, other staff had removed the phone cord from CR #1's neck and he (CR #1) was just shaking. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675495 If continuation sheet Page 6 of 27 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 675495 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laurel Court 3830 Mustang Road Alvin, TX 77511 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some He said he got someone to stay with CR #1 while he called his doctor for an order to send him out and he called CR #1's family and the Administrator. LVN A said the police arrived while he was assessing CR #1 and CR #1 told the officer, Oh, I tried to kill myself, but it was nothing big. LVN A said the officer asked CR #1 again if he wanted to kill himself and CR #1 said yes. LVN A said he did not assign CR #1 a sitter the previous weekend when he initially expressing suicidal ideations. He said RN D called CR #1's family (after the suicide attempt) who said CR #1 had a history of suicidal ideations and had done this (attempted suicide) before. He said CR #1's family never mentioned prior to him having the cord around his neck that he had a history of suicide attempts. LVN A said after he was in-serviced (after CR #1's suicide attempt), he realized he should have expedited the information about the suicidal ideations and referral to the DON or management to let them know what was stated. In a telephone interview with CR #1's NP on 06/01/2023 at 12:33 p.m., she stated she visited CR #1 on 05/22/2023, after he was admitted on [DATE]. She said she was notified about CR #1's suicidal ideations on 05/21/2023 and when she saw him on 05/22/2023, she asked him about the day before. She said she asked him if he still wanted to harm himself and he said no, he just wanted to go home and did not want to be in the facility. The NP said she documented in her notes that she put in an urgent request for psych services. The NP said the order was urgent based on CR #1's history of depression. She said she was familiar with the facility's referral process and the request had to be submitted to the SW then sent thru the referral portal. She said the process took a little while, so it was urgent to be done timely. She said she knew the psych provider saw patients at the facility on Mondays, so she knew CR #1 probably would not have been seen Monday, 05/22/2023. She said she was not aware CR #1's discharging facility recommended he be evaluated by psych services. She said had CR #1 exhibited behaviors, the facility staff could have notified psych for medication if needed. The NP said she had no prior knowledge of CR #1's history of suicidal ideations. She said she saw CR #1 again on 05/24/2023 and staff notified her CR #1 had eloped. She said she was not notified of any other incident of suicidal ideations. She said had staff notified her or the on-call doctor that CR #1 made a throat cutting motion (on the morning of 05/27/2023), she would have sent him out to the hospital at that time. In an interview with the SW on 06/01/2023 at 1:00 p.m., she stated, usually, the NP or doctor would write an order and the nurse would print the order and give it to her. She said she sent an email to the psychiatric provider and made the referral. The SW said the process usually only took one day and the provider came on Mondays. She said she never received a referral or request for CR #1 to receive psych services. She said she was on vacation 05/14/2023 - 05/24/2023. She said when she returned from vacation, she did not see any request for CR #1 under her door. The SW said nobody ever asked her about any referral for CR #1. She said the facility's nurses could do the referrals if she was not here. The SW said if the psych provider was in the building and the nurses let them know someone needed to be seen, psych would have evaluated CR #1 even without the referral. She said if the referral was already in their computer system, they could have given it to him (psych) and he could have sent the referral to his (psych) office. The SW provided a copy of CR #1's order for psych services from the computer system and said the order did not say anything about urgency. She said she never saw a psych referral mention urgency. She said that (06/01/2023) was the first time she saw CR #1's referral for psych services. Observation of the facility on 06/01/2023 at 1:30 p.m. revealed the library was located in a room (not open to the rest of the building) between the reception desk (front entrance) and the nurse's station. Further observation revealed someone would have to pass the entrance to the library to see if anyone was inside the library. There was a telephone with a cord on a small table next to a chair. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675495 If continuation sheet Page 7 of 27 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 675495 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laurel Court 3830 Mustang Road Alvin, TX 77511 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some In a telephone interview with LVN C on 06/01/2023 at 1:22 p.m. revealed she usually worked the 2:00 p.m. 10:00 p.m. and 10:00 p.m. - 6:00 a.m. shift, but she rarely worked on weekends. She said one night (she could not recall the date), she was about to pass medications and CR #1 thanked her for caring for him and said he was leaving, but it was dark. LVN C said she asked CR #1 if his family was coming, but he said no, he was leaving. She said she told CR #1 he was there for therapy and that was it, he went back to sleep. LVN C said on another night (she could not recall the day), CR #1 said he was leaving, and she (LVN C) called his RP (he was his own RP, but he did have an emergency contact), but she did not answer. LVN C said earlier on that day, another staff told her CR #1 had gotten outside (eloped) so, that night CR #1 was assigned a sitter (a facility housekeeper and maintenance staff). LVN C said to her knowledge, that was the only night he had a sitter. LVN C said the night he made the cutting motion was the same night she called CR #1's RP. She said they had to watch CR #1 because he would try to elope, and she noticed he went towards one of the doors. LVN C said CR #1 said they (the nurses) would not let him out the front, so he would get out one way or another, then he made cutting motion across his throat. LVN C said she asked CR #1 if that meant he would cut himself, and he said, If you think that's what I'm saying. LVN C said she told CR #1 if that was what he was saying, she would have to call the police. LVN C said CR #1 told her he would go brush his teeth. She said the Administrator said to go talk to CR #1 and ask if he was going to harm himself. LVN C said CR #1 acted like he did not recall doing that (making the cutting motion) or anything that happened that night. LVN C said CR #1 said he was going to bed. LVN C said she did not have the DON's phone number at that time. LVN C said she did not call CR #1's doctor because, to be honest, it slipped her mind. LVN C said she waiting to see if CR #1 would react or do anything else. She said now, she probably would have called the doctor. She said she was not aware of any referral for psych services for CR #1. In a telephone interview with RN D on 06/01/2023 at 1:34 p.m., she stated she was the weekend supervisor and she only worked weekends. She said she interacted with CR #1 on weekends quite a bit. RN D said CR #1 kept wanting to go home and tried to elope several times. RN D said she was never made aware of CR #1's suicidal ideations the weekend before (05/21/2023) his suicide attempt and she worked 6:00 a.m. 10:00 p.m. RN D said she worked on the weekend the ST worked (05/21/2023) but she was never made aware of CR #1 saying he wanted to die. RN D said CR #1 did not seem depressed and he had dementia but was able to have a conversation and express his feelings. RN D said on 05/27/2023, CR #1 made his usual attempts to elope and kept trying. She said eventually, she heard someone calling for a nurse to check on CR #1 and she followed afterwards. RN D said when she got to the library, CR #1 was in there sitting on a chair and LVN A was assessing him. She said she was not made aware that CR #1 had a referral for psych services. RN D said on weekends, they contact the primary care doctor or NP for a referral order and then they contact the provider they refer to. She said they could make a referral over the phone and then fax it in. She said she had never done a referral over the weekend and unless it was an emergency, they would wait until following week to do it. She said if the situation was emergent, she would do the referral or send the resident out. She said if she felt there was an active plan for suicide, she would notify the doctor and keep the resident on 1:1 monitoring until the doctor determined their next step. In an interview with the DON on 06/01/2023 at 2:00 p.m., she said the Administrator called her on 05/26/2023 after CR #1 made the cutting motion across his throat. She said the Administrator told her about CR #1 making the cutting motion, and she asked him if CR #1 had a plan and some other questions. The DON said the Administrator said he would call the facility back to ask those questions and call back if there was anything else. The DON said when the nurse went back in to talk to CR #1, he was no longer (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675495 If continuation sheet Page 8 of 27 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 675495 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laurel Court 3830 Mustang Road Alvin, TX 77511 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 0600 Level of Harm - Immediate jeopardy to resident health or safety expressing suicidal ideations. The DON said in hindsight, she probably should have called CR #1's doctor just in case she wanted her to do anything different. The DON said she had in serviced the nurses on when to communicate with physicians. The DON said she did not know if CR #1's referral was ever sent off to the psych provider. She said the SW handled all referrals and she did not know who to contact about referrals at their psych services provider. She said she believed the Administrator was handling referrals when the SW went on vacation. Residents Affected - Some In a follow up telephone interview with the Administrator on 06/01/2023 at 2:25 p.m., he stated if the SW was out, he would have done referrals but, he was never made aware of CR #1's order or referral. He said CR #1's referral was never sent out. In a telephone interview with the ST on 06/01/2023 at 2:31 p.m. She said CR #1 did not have suicidal ideations. She said CR #1 told her his wife died at the facility 8-9 years prior and then he said, I guess I'm going to die here too. The ST said it was not an ideation. She said she was working with him and showing him how to swallow safer and he said, Lady, why do you care so much, just let me die. She said [TRUNCATED] FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675495 If continuation sheet Page 9 of 27 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 675495 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laurel Court 3830 Mustang Road Alvin, TX 77511 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 - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 11 residents (CR #1) reviewed for accidents and supervision. The facility failed to provide adequate supervision and monitoring for CR #1 when he expressed suicidal ideations and attempted to elope from the facility several times which resulted in actual elopements on 05/23/2023 and 05/27/2023 and an actual suicide attempt on 05/27/2023. An Immediate Jeopardy (IJ) situation was identified on 06/02/2023 at 1:25 p.m. While the IJ was removed on 06/07/2023, the facility remained out of compliance at the severity level of actual harm with a scope identified as pattern due to the facility's need to evaluate the effectiveness of the corrective systems. This failure placed residents with a history of suicidal ideations and exit seeking behaviors at risk of serious harm and possible death from not receiving adequate supervision/monitoring and safety interventions. Findings include: Record review of CR #1's face sheet dated 06/01/2023 revealed he was an [AGE] year-old male who was admitted to the facility on [DATE]. His admitting diagnoses included with Parkinson's Disease (a disease of the central nervous system that affects movement, often including tremors), rhabdomyolysis (a breakdown of muscle tissue that releases a damaging protein into the blood), acute kidney failure (a condition in which the kidneys suddenly cannot filter waste from the blood), weakness, repeated falls, depression (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), and dementia (a condition characterized by progressive or persistent loss of intellectual functioning). CR #1 was also diagnosed with suicidal ideations (often called suicidal thoughts or ideas, is a broad term used to describe a range of contemplations, wishes, and preoccupations with death and suicide). CR #1 was transferred to a local acute care hospital on [DATE]. Record review of CR #1's MDS dated [DATE] revealed he had a BIMS score of 7 (severe cognitive impairment); he felt down, depressed, or hopeless between 7-11 days; he did not experience hallucinations or delusions; he rejected care daily; he wandered daily which placed him at significant risk of getting to potentially dangerous places; he required supervision with no physical assistance for bed mobility, transfers, walking, dressing, and bathing; he required supervision with setup assistance with eating and personal hygiene; he ambulated independently with a walker; he was always continent of bowel and bladder; he experienced coughing or choking during meals or when swallowing medications; and he was prescribed antidepressant medication. Record review of CR #1's care plan updated 05/27/2023 revealed the following: -CR #1 had potential for elopement as evidenced by exit seeking behavior (05/23/2023 exited out the front door). Goals included: Maintain the least restrictive environment while providing safety. Interventions included: Have activities involved with favorite past times. Music. Exercise. Photo in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675495 If continuation sheet Page 10 of 27 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 675495 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laurel Court 3830 Mustang Road Alvin, TX 77511 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 - Some Elopement risk book. All staff to be made aware of CR #1's risk status via staff sign-in book and verbal reports. If possible, have family or volunteers visit on a regular basis. Keep doctor and family informed. SW to make regular visits. Reorient/Redirect as needed. Reassess as needed. SW to obtain detailed prior routine of CR #1. -CR #1 was taking psychotropic medications for Depression (Sertraline). Goals included: CR #1 will not experience adverse side effects. Interventions included: Monitor and record any displayed behavior or mood problems. Encourage appropriate behavior, discourage inappropriate behavior. Monitor effectiveness of psychotropic medications. Monitor for involuntary movements and repetitive behaviors and report to doctor. Review medications every three months for possible dose reduction. Allow CR #1 to express feelings. Protect CR #1 from self-harm or harm to others. Monitor for weight loss. Psych consult as needed. -CR #1 had behavioral symptoms not directed toward others (05/27/2023- CR #1 attempted to harm himself by wrapping a phone cord around his neck- 911 was called- will re-evaluate interventions upon return. Goals included: Incidents of self-harm will be decreased. Interventions included: Gently remind CR #1 that behavior is not appropriate. Provide medication as ordered. Record behaviors on Behavior Tracking form. Monitor pattern of behavior (time of day, precipitating factors, specific staff, or situations). Head to toe assessment completed to check for any injuries (no injuries noted). 1 on 1 monitoring until EMS arrived. -CR #1 exhibited wandering behaviors. Goals included: Current level of mobility will be maintained. Interventions included: Assess potential causes for wandering (need for toilet, water, food, pain relief). Provide diversional activities. Record behaviors on Behavior Tracking form. Redirect CR #1's behavior/activity when wandering is observed. -CR #1 had other behavioral symptoms not directed toward others (refusal of care, threatening to break windows. Goals included: Incident will be decreased. Interventions included: Gently remind CR #1 that behavior is not appropriate. Provide medication as ordered. Record behaviors on Behavior Tracking form. Remove from situation; allow time to calm down. -CR #1 was at risk for falls as evidenced by cognitive impairment, fall history, weakness, unsteady gait, and rhabdomyolysis. Goals included: Dignity will be maintained. CR #1 will not experience falls or injuries from falls. Interventions included: Encourage CR #1 to ask for assistance of staff. Ensure call light is in reach, answer promptly. Therapy to evaluate and treat per orders. Anticipate needs, provide prompt assistance. Assure lighting is adequate and areas are free of clutter. Observation and interview of CR #1 at a psychiatric hospital on [DATE] at 9:00 a.m. revealed he was alert, oriented and ambulated independently with a walker. CR #1 said they went by the rules at the facility. He said he sneaked out the front door and tried to go to Whataburger. He said he did not like living there because there was no place to go, and he was the type of guy who liked to go places. He said they (he did not say who they were) would not let him go sit outside because he had a fall outside. He said he wanted to get some fresh air, but the nurses caught him. CR #1 said he did not do anything but sit at the facility because there were no activities he liked. He said two of the nurses stood at the door and would not let him out. He said he was going to get out one way or the other, either they would let him walk out, or kill himself and let the undertaker carry him out. He said the cops picked him up from the facility when he tried to kill himself. CR #1 said he wrapped a telephone cord around his neck. He said he had not been home in a very long time, and he wanted to go home. He said they gave him more medication and he felt better now. He said he did not want to kill (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675495 If continuation sheet Page 11 of 27 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 675495 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laurel Court 3830 Mustang Road Alvin, TX 77511 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 himself anymore, he wanted to go home. Level of Harm - Immediate jeopardy to resident health or safety Record review of CR #1's hospital records dated 05/16/2023 revealed he was admitted to a local acute care hospital via the emergency room on [DATE] after he fell in his home and was on the floor several hours. The document read in part, . Patient states, 'You're wasting your time- I want to die . I don't have any familyThey should have left me on the floor' . Precautions: Falls, Depressed state/ reports, 'I want to die' . Discharge Recommendations: Continue Rehab, Psych Consult. Precautions: Fall, Anxiety/Depression Recommend Psych Consult . Home Medications: . Sertraline (Zoloft) 50 MG tablets daily . Residents Affected - Some Record review of CR #1's hospital records dated 06/02/2023 revealed he was transported to the emergency room by EMS on 05/27/2023. The records read in part, . presenting with EMS after possible strangulation attempt, patient was reported to have been found with a telephone cord around his neck, cyanotic (bluish or grayish color of the skin) appearing face, removed telephone cord and transported to hospital hemodynamically (how your blood flows through your arteries and veins and the forces that affect your blood flow) stable in route. When asked about this, patient reports he was just playing around with cord, had no suicidal intention. Patient would like to leave, does not know why is here, does not want to go back to the facility . patient with history of suicidal ideation . Assessment: Suicidal Attempt . Plan: Admit to floor . Sitter 1:1 . CR #1 was discharged to an inpatient psychiatric hospital on [DATE]. Record review of CR #1's physician's orders for May 2023 revealed he was prescribed Sertraline, 50 mg tablets once daily for depression. Start date: 05/18/2023. Record review of CR #1's MAR for May 2023 revealed he received Sertraline daily as ordered from 05/19/2023 until 05/26/2023. Record review of CR #1's referral for a psychiatry consultation dated 05/21/2023 revealed CR #1's physician gave LVN A verbal orders to refer CR #1 for the consultation on 05/21/2023. The order was electronically signed by LVN A on 05/21/2023 at 8:12 p.m. Record review of CR #1's physician progress notes dated 05/22/2023 revealed, . Chief Complaint: New skilled nursing patient seen and examined for admission visit. Patient sitting on side of bed in no apparent distress. Pleasantly confused. States he lives alone. No suicidal ideation today. States he is ready to go home and wants to go home . Physical Exam: . Psychiatric: Judgement/insight: Poor . Summary of Plans: . Consults: Psychiatry to follow . Diagnosis and Assessment: . Dementia - . Has tried to exit seek multiple occasions since admission . Depression - Consult psych. Continue Zoloft 50 mg daily. Per report, suicidal ideation yesterday. None today. Plan: . Urgent consult on psych to evaluate and treat. Recent history of suicidal ideation. None noted today. States he wants to go home and not be in a nursing home . Record review of CR #1's physician progress notes dated 05/24/2023 revealed, Chief Complaint: Skilled nursing patient seen and examined in follow-up . Per staff, patient was found outside of the facility walking along the sidewalk stating that he wanted to go home . Record review of CR #1's progress notes for May 2023 revealed the following: *On 05/21/2023 at 8:05 p.m. (incident occurred at 5:15 p.m.), LVN A wrote, Resident was being evaluated by ST for swallowing issues that were reported. ST was introducing a mechanical soft diet. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675495 If continuation sheet Page 12 of 27 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 675495 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laurel Court 3830 Mustang Road Alvin, TX 77511 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 - Some Resident stated he did not want to change diets. Asked ST 'What for?' He verbalized to ST that he wanted to die instead because he was tired. Will notify MD and refer resident for Psych evaluation. *On 05/22/2023 at 12:24 p.m., LVN B wrote, . Resident wanders throughout facility via walker. He attempted to exit x2 despite redirection . *On 05/23/2023 at 5:52 a.m., LVN C wrote, During rounds resident was noted to be sitting on the bed and asked this writer to come here. Resident thanked this writer for providing care to him and that he will be leaving today. Asked resident was family coming to get him, he stated no, 'I'm walking. I would walk now but it is dark.' Educated resident on the importance of staying at the facility, resident stated, 'I will think about it .' *On 05/23/2023 at 9:54 a.m., LVN B wrote, . This shift, he eloped out of front door and started to walk down the sidewalk. This nurse and other nurses on duty spoke with resident and attempted to provide redirection. After some time, resident agreed to come back inside. Resident still upset, threatening to break windows. Administrator speaking with RP at this time to make a discharge decision. *On 05/24/2023 at 3:33 a.m., LVN C wrote, . Resident is in bed resting quietly at this time, sitter is sitting outside of door . *On 05/26/2023 at 8:10 p.m., LVN C wrote, Resident is walking around asking staff to help him leave, staff redirects resident. Currently resident is in his room stating that he is leaving as soon as he finds a window to go out of. All staff notified to keep an eye on resident due to him stating he is going to leave. *On 05/27/2023 at 2:31 a.m. (incident occurred 05/26/2023 at 8:50 p.m.), LVN C wrote, This writer seen resident going towards the back door. This writer and another began to stand between resident and the door. Resident asked staff if we could move so he could leave. Asked resident where he was going, he stated, home to his bed because he had things to do. This writer explained to resident that I could not let him leave and I was responsible for his wellbeing. Resident stepped closer to staff and asked resident to please step back, he did. Resident continued to stand at the door. Resident then stated that he was going to leave one way or another, resident made a cutting sign (gesture) towards his neck. Asked resident what that was, he stated, 'Could you just let me leave?' Call placed to Administrator, advised resident that he would have to go to his room, or I will call 911, orders given from management. Aide offered popcorn, resident stated he guessed he would go brush his teeth and go to bed. Administrator called and asked if I could interview resident to see if he was a danger to himself. When interviewing resident, he could not recall making a cutting sign at his throat, resident also stated that he will never hurt himself, notified Administrator, resident is currently in bed resting quietly . rounds are made every 2 hours. *On 05/27/2023 at 10:12 a.m. (incident occurred at 9:15 a.m.), LVN A wrote, Receptionist was walking towards nursing station when she noted resident sitting in library. When she attempted to approach resident sitting in library, she noted that the resident had the phone cord wrapped around him and attempting to tighten it harder. Receptionist stated that the resident was turning blue when she ran in to intervene and remove the cord from the resident's neck. The Receptionist called for help and LVN E reached out to me on the way to assist resident and Receptionist. *On 05/27/2023 at 10:16 a.m., LVN A wrote, . Assessed resident. Resident stabilized after removing cord from neck and having to sit down. Stated wanted to leave. Asked if he was attempting to kill (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675495 If continuation sheet Page 13 of 27 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 675495 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laurel Court 3830 Mustang Road Alvin, TX 77511 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 - Some himself and he stated, 'If that's the only way out then, yes?' Called 911 to have resident transferred to hospital for psych evaluation . RN D spoke with family and advised that resident was being sent out to hospital for Psych evaluation due to suicide attempt. Family stated that it was not the first time the resident has attempted suicide . Record review of CR #1's, Elopement Risk Assessment dated 05/22/2023 revealed LVN F determined CR #1 was a moderate risk for elopements based on his cognitive impairment and wandering behaviors. Action included, Implement Elopement Risk care plan; Implement Frequent Monitoring Form (form was not completed) to determine elopement risk or until Interdisciplinary Team reviews and makes recommendation. Record review of CR #1's, Elopement Risk Assessment dated 05/23/2023 revealed RN G determined CR #1 was an imminent risk for elopements based on his ambulation status, wandering behaviors, and his intentional or unintentional attempts to leave the community. Action included, Implement Elopement Risk care plan; Implement Frequent Monitoring Form (form was not completed) to determine elopement risk or until Interdisciplinary Team reviews and makes recommendation. In an interview with the DON and the Regional Director of Clinical Services on 06/01/2023 at 9:45 a.m., the Regional Director of Clinical Services stated the DON was new to the facility and regional staff was not always in the building. The Regional Director of Clinical Services stated, based on what they knew, CR #1 had no previous suicidal ideations. The Regional Director of Clinical Services said CR #1's wife passed away in the facility many years prior and he had no other family other than a neighbor who helped him out prior to admission. The Regional Director of Clinical Services said CR #1's neighbor stated he (CR #1) previously talked about wanting to die. The DON stated to their (administration) knowledge, CR #1 spoke with the ST and referenced dying. The DON said CR #1's physician was notified and ordered an urgent referral for psychiatric services, but psych services was not able to see CR #1 before the suicide attempt. The Regional Director of Clinical Services stated CR #1's physician spoke with LVN A and that is where it ended. The Regional Director of Clinical Services stated LVN A was educated because something like that (suicidal ideations) should be escalated to the top (DON and Administrator). The Regional Director of Clinical Services said LVN A did not let anybody else know about the conversation between CR #1 and the ST. The Regional Director of Clinical Services said CR #1's physician documented his suicidal ideations and that she wanted an urgent psych consult. The Regional Director of Clinical Services said the incident was not communicated to the top (administration), so they did not have an opportunity to follow-up on the referral. The facility's elopement policy was requested, but the wandering policy was provided. In an interview with the VP of Clinical Operations on 06/01/2023 at 11:00 a.m., she stated the facility did an emergency QAPI on 05/27/2023, after CR #1 attempted suicide. She said all staff involved were counseled and in-serviced. She said nursing staff talked to each resident who could speak and used a special psychiatric tool given to them by a psych provider to interview about depression and suicide. She said the residents who could not talk were assessed head to toe to insure nothing was out of the ordinary for them. She said the Administrator was suspended because their investigation found he may have known about CR #1's prior history of depression. In a telephone interview with the Administrator on 06/01/2023 at 11:45 a.m., he stated he knew CR #1 kept saying he wanted to go home because he wanted to shampoo his carpet at home. He said it was not out of the ordinary for residents to express desires to go home. The Administrator said CR #1 had previously been admitted to the facility for rehab and he (CR #1) wanted attention, that was it. The Administrator said CR #1 was not depressed and he just wanted to go home and do chores. The (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675495 If continuation sheet Page 14 of 27 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 675495 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laurel Court 3830 Mustang Road Alvin, TX 77511 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 - Some Administrator said CR #1's depression, suicidal ideations, or behaviors were never brought to his attention prior to admission, and he never spoke to CR #1's family before or after his admission. The Administrator said the night before the suicide attempt (05/26/2023), LVN C called him around 10:00 p.m. He said he thought LVN C texted him, or he missed her call and then she texted saying CR #1 was trying to leave the building and that he wanted to kill himself. The Administrator said he sent LVN C a text to call 911, but she sent a text or called him, saying CR #1 was doing fine after they gave him popcorn. The Administrator said he called the LVN C back and she said CR #1 was fine and brushing his teeth. The Administrator said he told LVN C he needed to know what CR #1's state of mind was. He said LVN C said CR #1 could not even recall what he said earlier. He said he told LVN C to put CR #1 on monitoring (no monitoring was documented) and notify him if anything changed. He said he did not receive any more calls that night until incident on Saturday, 05/27/2023 when LVN A called and said CR #1 tried to hurt himself. In a telephone interview with LVN A on 06/01/2023 at 11:59 a.m., he stated he was a charge nurse and he only worked weekends. He said on 05/21/2023, the ST approached him and said CR #1 had difficulty swallowing and she wanted to down grade his diet (to a mechanical soft diet). He said the ST told him CR #1 refused the food she used to assess him and said he (CR #1) was tired and wanted to die. LVN A said he went to follow-up with CR #1 in his room and asked about his diet. LVN A said he wanted CR #1 to say in his own words how he felt, but he did not express a desire to die to him. LVN A said he did not ask CR #1 about what he said to the ST. LVN A said he called CR #1's doctor and got an order for a psych consultation and he documented the situation. LVN A said the order was not an urgent order. He said orders for psychiatric services were usually turned in to the SW. LVN A said he slipped the referral under the SW's door on Sunday, 05/21/2023, and he did not hear anything else about CR #1's referral after that. He said he did not relay this information to the DON, the Administrator, or anybody else. He said he did not know the SW was on vacation, but had he known, he would have taken the referral order to someone else. He said no special monitoring or intervention was initiated for CR #1. LVN A said that next weekend, 05/27/2023, CR #1 said he wanted to go home, but that was nothing out of ordinary from his usual agitation. He said on 05/27/2023, he heard another nurse call his name and he ran to the library room and saw CR #1 there with the Receptionist. He said by the time he got to the library, other staff had removed the phone cord from CR #1's neck and he (CR #1) was just shaking. He said he got someone to stay with CR #1 while he called his doctor for an order to send him out and he called CR #1's family and the Administrator. LVN A said the police arrived while he was assessing CR #1 and CR #1 told the officer, Oh, I tried to kill myself, but it was nothing big. LVN A said the officer asked CR #1 again if he wanted to kill himself and CR #1 said yes. LVN A said he did not assign CR #1 a sitter the previous weekend when he initially expressing suicidal ideations. He said RN D called CR #1's family (after the suicide attempt) who said CR #1 had a history of suicidal ideations and had done this (attempted suicide) before. He said CR #1's family never mentioned prior to him having the cord around his neck that he had a history of suicide attempts. LVN A said after he was in-serviced (after CR #1's suicide attempt), he realized he should have expedited the information about the suicidal ideations and referral to the DON or management to let them know what was stated. In a telephone interview with CR #1's NP on 06/01/2023 at 12:33 p.m., she stated she visited CR #1 on 05/22/2023, after he was admitted on [DATE]. She said she was notified about CR #1's suicidal ideations on 05/21/2023 and when she saw him on 05/22/2023, she asked him about the day before. She said she asked him if he still wanted to harm himself and he said no, he just wanted to go home and did not want to be in the facility. The NP said she documented in her notes that she put in an urgent request for psych services. The (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675495 If continuation sheet Page 15 of 27 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 675495 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laurel Court 3830 Mustang Road Alvin, TX 77511 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 - Some NP said the order was urgent based on CR #1's history of depression. She said she was familiar with the facility's referral process and the request had to be submitted to the SW then sent thru the referral portal. She said the process took a little while, so it was urgent to be done timely. She said she knew the psych provider saw patients at the facility on Mondays, so she knew CR #1 probably would not have been seen Monday, 05/22/2023. She said she was not aware CR #1's discharging facility recommended he be evaluated by psych services. She said had CR #1 exhibited behaviors, the facility staff could have notified psych for medication if needed. The NP said she had no prior knowledge of CR #1's history of suicidal ideations. She said she saw CR #1 again on 05/24/2023 and staff notified her CR #1 had eloped. She said she was not notified of any other incident of suicidal ideations. She said had staff notified her or the on-call doctor that CR #1 made a throat cutting motion (on the morning of 05/27/2023), she would have sent him out to the hospital at that time. In an interview with the SW on 06/01/2023 at 1:00 p.m., she stated, usually, the NP or doctor would write an order and the nurse would print the order and give it to her. She said she sent an email to the psychiatric provider and made the referral. The SW said the process usually only took one day and the provider came on Mondays. She said she never received a referral or request for CR #1 to receive psych services. She said she was on vacation 05/14/2023 - 05/24/2023. She said when she returned from vacation, she did not see any request for CR #1 under her door. The SW said nobody ever asked her about any referral for CR #1. She said the facility's nurses could do the referrals if she was not here. The SW said if the psych provider was in the building and the nurses let them know someone needed to be seen, psych would have evaluated CR #1 even without the referral. She said if the referral was already in their computer system, they could have given it to him (psych) and he could have sent the referral to his (psych) office. The SW provided a copy of CR #1's order for psych services from the computer system and said the order did not say anything about urgency. She said she never saw a psych referral mention urgency. She said that (06/01/2023) was the first time she saw CR #1's referral for psych services. Observation of the facility on 06/01/2023 at 1:30 p.m. revealed the library was located in a room (not open to the rest of the building) between the reception desk (front entrance) and the nurse's station. Further observation revealed someone would have to pass the entrance to the library to see if anyone was inside the library. There was a telephone with a cord on a small table next to a chair. In a telephone interview with LVN C on 06/01/2023 at 1:22 p.m. revealed she usually worked the 2:00 p.m. 10:00 p.m. and 10:00 p.m. - 6:00 a.m. shift, but she rarely worked on weekends. She said one night (she could not recall the date), she was about to pass medications and CR #1 thanked her for caring for him and said he was leaving, but it was dark. LVN C said she asked CR #1 if his family was coming, but he said no, he was leaving. She said she told CR #1 he was there for therapy and that was it, he went back to sleep. LVN C said on another night (she could not recall the day), CR #1 said he was leaving, and she (LVN C) called his RP (he was his own RP, but he did have an emergency contact), but she did not answer. LVN C said earlier on that day, another staff told her CR #1 had gotten outside (eloped) so, that night CR #1 was assigned a sitter (a facility housekeeper and maintenance staff). LVN C said to her knowledge, that was the only night he had a sitter. LVN C said the night he made the cutting motion was the same night she called CR #1's RP. She said they had to watch CR #1 because he would try to elope, and she noticed he went towards one of the doors. LVN C said CR #1 said they (the nurses) would not let him out the front, so he would get out one way or another, then he made cutting motion across his throat. LVN C said she asked CR #1 if that meant he would cut himself, and he said, If you think that's what I'm saying. LVN C said she told CR #1 if that was what he was saying, she would have to call the police. LVN C said CR #1 told her (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675495 If continuation sheet Page 16 of 27 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 675495 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laurel Court 3830 Mustang Road Alvin, TX 77511 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 - Some he would go brush his teeth. She said the Administrator said to go talk to CR #1 and ask if he was going to harm himself. LVN C said CR #1 acted like he did not recall doing that (making the cutting motion) or anything that happened that night. LVN C said CR #1 said he was going to bed. LVN C said she did not have the DON's phone number at that time. LVN C said she did not call CR #1's doctor because, to be honest, it slipped her mind. LVN C said she waiting to see if CR #1 would react or do anything else. She said now, she probably would have called the doctor. She said she was not aware of any referral for psych services for CR #1. In a telephone interview with RN D on 06/01/2023 at 1:34 p.m., she stated she was the weekend supervisor and she only worked weekends. She said she interacted with CR #1 on weekends quite a bit. RN D said CR #1 kept wanting to go home and tried to elope several times. RN D said she was never made aware of CR #1's suicidal ideations the weekend before (05/21/2023) his suicide attempt and she worked 6:00 a.m. 10:00 p.m. RN D said she worked on the weekend the ST worked (05/21/2023) but she was never made aware of CR #1 saying he wanted to die. RN D said CR #1 did not seem depressed and he had dementia but was able to have a conversation and express his feelings. RN D said on 05/27/2023, CR #1 made his usual attempts to elope and kept trying. She said eventually, she heard someone calling for a nurse to check on CR #1 and she followed afterwards. RN D said when she got to the library, CR #1 was in there sitting on a chair and LVN A was assessing him. She said she was not made aware that CR #1 had a referral for psych services. RN D said on weekends, they contact the primary care doctor or NP for a referral order and then they contact the provider they refer to. She said they could make a referral over the phone and then fax it in. She said she had never done a referral over the weekend and unless it was an emergency, they would wait until following week to do it. She said if the situation was emergent, she would do the referral or send the resident out. She said if she felt there was an active plan for suicide, she would notify the doctor and keep the resident on 1:1 monitoring until the doctor determined their next step. In an interview with the DON on 06/01/2023 at 2:00 p.m., she said the Administrator called her on 05/26/2023 after CR #1 made the cutting motion across his throat. She said the Administrator told her about CR #1 making the cutting motion, and she asked him if CR #1 had a plan and some other questions. The DON said the Administrator said he would call the facility back to ask those questions and call back if there was anything else. The DON said when the nurse went back in to talk to CR #1, he was no longer expressing suicidal ideations. The DON said in hindsight, she probably should have called CR #1's doctor just in case she wanted her to do anything different. The DON said she had in serviced the nurses on when to communicate with physicians. The DON said she did not know if CR #1's referral was ever sent off to the psych provider. She said the SW handled all referrals and she did not know who to contact about referrals at their psych services provider. She said she believed the Administrator was handling referrals when the SW went on vacation. In a follow up telephone interview with the Administrator on 06/01/2023 at 2:25 p.m., he stated if the SW was out, he would have done referrals but, he was never made aware of CR #1's order or referral. He said CR #1's referral was never sent out. In a telephone interview with the ST on 06/01/2023 at 2:31 p.m. She said CR #1 did not have suicidal ideations. She said CR #1 told her his wife died at the facility 8-9 years prior and then he said, I guess I'm going to die here too. The ST said it was not an ideation. She said she was working with him and showing him how to swallow safer and he said, Lady, why do you care so much, just let me die. She said CR #1 had diagnosis of depression already, but for her, the words he said to her were resistance from him to do the swallowing exercises and he had a lack of desire to get better. She said she told the charge nurse (LVN A) about it. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675495 If continuation sheet Page 17 of 27 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 675495 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laurel Court 3830 Mustang Road Alvin, TX 77511 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 In an interview with the Regional Director of Clinical Services on 06/01/2023 at 2:52 p.m., he stated had CR #1's referral been escalated to the appropriate staff like it should have been, CR #1 would have received the help he needed before he attempted suicide. In a telephone interview with the Receptionist[TRUNCATED] Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675495 If continuation sheet Page 18 of 27 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 675495 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laurel Court 3830 Mustang Road Alvin, TX 77511 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 0742 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident who displayed or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder, received appropriate treatment and services to correct the assessed problem or to attain the highest practicable mental and psychosocial well-being for 1 of 11 residents (CR #1) reviewed for psychosocial concerns. The facility failed to initiate safety interventions or provide CR #1 with psychiatric services after his physician ordered an urgent consultation when he expressed suicidal ideations and attempted to elope from the facility several times and resulted in an actual suicide attempt on 05/27/2023. The facility failed to review and follow recommendations from CR #1's discharging facility for a psychiatric consultation. An Immediate Jeopardy (IJ) situation was identified on 06/02/2023 at 1:25 p.m. While the IJ was removed on 06/07/2023, the facility remained out of compliance at the severity level of actual harm with a scope identified as pattern due to the facility's need to evaluate the effectiveness of the corrective systems. These failures placed residents with a history of depression or suicidal ideations at risk of experiencing emotional distress, psychiatric episodes, and possible death from not receiving adequate care, interventions, and psychiatric services. Findings include: Record review of CR #1's face sheet dated 06/01/2023 revealed he was an [AGE] year-old male who was admitted to the facility on [DATE]. His admitting diagnoses included with Parkinson's Disease (a disease of the central nervous system that affects movement, often including tremors), rhabdomyolysis (a breakdown of muscle tissue that releases a damaging protein into the blood), acute kidney failure (a condition in which the kidneys suddenly cannot filter waste from the blood), weakness, repeated falls, depression (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), and dementia (a condition characterized by progressive or persistent loss of intellectual functioning). CR #1 was also diagnosed with suicidal ideations (often called suicidal thoughts or ideas, is a broad term used to describe a range of contemplations, wishes, and preoccupations with death and suicide). CR #1 was transferred to a local acute care hospital on [DATE]. Record review of CR #1's MDS dated [DATE] revealed he had a BIMS score of 7 (severe cognitive impairment); he felt down, depressed, or hopeless between 7-11 days; he did not experience hallucinations or delusions; he rejected care daily; he wandered daily which placed him at significant risk of getting to potentially dangerous places; he required supervision with no physical assistance for bed mobility, transfers, walking, dressing, and bathing; he required supervision with setup assistance with eating and personal hygiene; he ambulated independently with a walker; he was always continent of bowel and bladder; he experienced coughing or choking during meals or when swallowing medications; and he was prescribed antidepressant medication. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675495 If continuation sheet Page 19 of 27 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 675495 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laurel Court 3830 Mustang Road Alvin, TX 77511 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 0742 Record review of CR #1's care plan updated 05/27/2023 revealed the following: Level of Harm - Immediate jeopardy to resident health or safety -CR #1 had potential for elopement as evidenced by exit seeking behavior (05/23/2023 exited out the front door). Goals included: Maintain the least restrictive environment while providing safety. Interventions included: Have activities involved with favorite past times. Music. Exercise. Photo in Elopement risk book. All staff to be made aware of CR #1's risk status via staff sign-in book and verbal reports. If possible, have family or volunteers visit on a regular basis. Keep doctor and family informed. SW to make regular visits. Reorient/Redirect as needed. Reassess as needed. SW to obtain detailed prior routine of CR #1. Residents Affected - Some -CR #1 was taking psychotropic medications for Depression (Sertraline). Goals included: CR #1 will not experience adverse side effects. Interventions included: Monitor and record any displayed behavior or mood problems. Encourage appropriate behavior, discourage inappropriate behavior. Monitor effectiveness of psychotropic medications. Monitor for involuntary movements and repetitive behaviors and report to doctor. Review medications every three months for possible dose reduction. Allow CR #1 to express feelings. Protect CR #1 from self-harm or harm to others. Monitor for weight loss. Psych consult as needed. -CR #1 had behavioral symptoms not directed toward others (05/27/2023- CR #1 attempted to harm himself by wrapping a phone cord around his neck- 911 was called- will re-evaluate interventions upon return. Goals included: Incidents of self-harm will be decreased. Interventions included: Gently remind CR #1 that behavior is not appropriate. Provide medication as ordered. Record behaviors on Behavior Tracking form. Monitor pattern of behavior (time of day, precipitating factors, specific staff, or situations). Head to toe assessment completed to check for any injuries (no injuries noted). 1 on 1 monitoring until EMS arrived. -CR #1 exhibited wandering behaviors. Goals included: Current level of mobility will be maintained. Interventions included: Assess potential causes for wandering (need for toilet, water, food, pain relief). Provide diversional activities. Record behaviors on Behavior Tracking form. Redirect CR #1's behavior/activity when wandering is observed. -CR #1 had other behavioral symptoms not directed toward others (refusal of care, threatening to break windows. Goals included: Incident will be decreased. Interventions included: Gently remind CR #1 that behavior is not appropriate. Provide medication as ordered. Record behaviors on Behavior Tracking form. Remove from situation; allow time to calm down. -CR #1 was at risk for falls as evidenced by cognitive impairment, fall history, weakness, unsteady gait, and rhabdomyolysis. Goals included: Dignity will be maintained. CR #1 will not experience falls or injuries from falls. Interventions included: Encourage CR #1 to ask for assistance of staff. Ensure call light is in reach, answer promptly. Therapy to evaluate and treat per orders. Anticipate needs, provide prompt assistance. Assure lighting is adequate and areas are free of clutter. Observation and interview of CR #1 at a psychiatric hospital on [DATE] at 9:00 a.m. revealed he was alert, oriented and ambulated independently with a walker. CR #1 said they went by the rules at the facility. He said he sneaked out the front door and tried to go to Whataburger. He said he did not like living there because there was no place to go, and he was the type of guy who liked to go places. He said they (he did not say who they were) would not let him go sit outside because he had a fall outside. He said he wanted to get some fresh air, but the nurses caught him. CR #1 said he did not do anything but sit at the facility because there were no activities he liked. He said two of the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675495 If continuation sheet Page 20 of 27 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 675495 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laurel Court 3830 Mustang Road Alvin, TX 77511 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 0742 Level of Harm - Immediate jeopardy to resident health or safety nurses stood at the door and would not let him out. He said he was going to get out one way or the other, either they would let him walk out, or kill himself and let the undertaker carry him out. He said the cops picked him up from the facility when he tried to kill himself. CR #1 said he wrapped a telephone cord around his neck. He said he had not been home in a very long time, and he wanted to go home. He said they gave him more medication and he felt better now. He said he did not want to kill himself anymore, he wanted to go home. Residents Affected - Some Record review of CR #1's hospital records dated 05/16/2023 revealed he was admitted to a local acute care hospital via the emergency room on [DATE] after he fell in his home and was on the floor several hours. The document read in part, . Patient states, 'You're wasting your time- I want to die . I don't have any familyThey should have left me on the floor' . Precautions: Falls, Depressed state/ reports, 'I want to die' . Discharge Recommendations: Continue Rehab, Psych Consult. Precautions: Fall, Anxiety/Depression Recommend Psych Consult . Home Medications: . Sertraline (Zoloft) 50 MG tablets daily . Record review of CR #1's hospital records dated 06/02/2023 revealed he was transported to the emergency room by EMS on 05/27/2023. The records read in part, . presenting with EMS after possible strangulation attempt, patient was reported to have been found with a telephone cord around his neck, cyanotic (bluish or grayish color of the skin) appearing face, removed telephone cord and transported to hospital hemodynamically (how your blood flows through your arteries and veins and the forces that affect your blood flow) stable in route. When asked about this, patient reports he was just playing around with cord, had no suicidal intention. Patient would like to leave, does not know why is here, does not want to go back to the facility . patient with history of suicidal ideation . Assessment: Suicidal Attempt . Plan: Admit to floor . Sitter 1:1 . CR #1 was discharged to an inpatient psychiatric hospital on [DATE]. Record review of CR #1's physician's orders for May 2023 revealed he was prescribed Sertraline, 50 mg tablets once daily for depression. Start date: 05/18/2023. Record review of CR #1's MAR for May 2023 revealed he received Sertraline daily as ordered from 05/19/2023 until 05/26/2023. Record review of CR #1's referral for a psychiatry consultation dated 05/21/2023 revealed CR #1's physician gave LVN A verbal orders to refer CR #1 for the consultation on 05/21/2023. The order was electronically signed by LVN A on 05/21/2023 at 8:12 p.m. Record review of CR #1's physician progress notes dated 05/22/2023 revealed, . Chief Complaint: New skilled nursing patient seen and examined for admission visit. Patient sitting on side of bed in no apparent distress. Pleasantly confused. States he lives alone. No suicidal ideation today. States he is ready to go home and wants to go home . Physical Exam: . Psychiatric: Judgement/insight: Poor . Summary of Plans: . Consults: Psychiatry to follow . Diagnosis and Assessment: . Dementia - . Has tried to exit seek multiple occasions since admission . Depression - Consult psych. Continue Zoloft 50 mg daily. Per report, suicidal ideation yesterday. None today. Plan: . Urgent consult on psych to evaluate and treat. Recent history of suicidal ideation. None noted today. States he wants to go home and not be in a nursing home . Record review of CR #1's physician progress notes dated 05/24/2023 revealed, Chief Complaint: Skilled nursing patient seen and examined in follow-up . Per staff, patient was found outside of the facility walking along the sidewalk stating that he wanted to go home . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675495 If continuation sheet Page 21 of 27 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 675495 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laurel Court 3830 Mustang Road Alvin, TX 77511 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 0742 Record review of CR #1's progress notes for May 2023 revealed the following: Level of Harm - Immediate jeopardy to resident health or safety *On 05/21/2023 at 8:05 p.m. (incident occurred at 5:15 p.m.), LVN A wrote, Resident was being evaluated by ST for swallowing issues that were reported. ST was introducing a mechanical soft diet. Resident stated he did not want to change diets. Asked ST 'What for?' He verbalized to ST that he wanted to die instead because he was tired. Will notify MD and refer resident for Psych evaluation. Residents Affected - Some *On 05/22/2023 at 12:24 p.m., LVN B wrote, . Resident wanders throughout facility via walker. He attempted to exit x2 despite redirection . *On 05/23/2023 at 5:52 a.m., LVN C wrote, During rounds resident was noted to be sitting on the bed and asked this writer to come here. Resident thanked this writer for providing care to him and that he will be leaving today. Asked resident was family coming to get him, he stated no, 'I'm walking. I would walk now but it is dark.' Educated resident on the importance of staying at the facility, resident stated, 'I will think about it .' *On 05/23/2023 at 9:54 a.m., LVN B wrote, . This shift, he eloped out of front door and started to walk down the sidewalk. This nurse and other nurses on duty spoke with resident and attempted to provide redirection. After some time, resident agreed to come back inside. Resident still upset, threatening to break windows. Administrator speaking with RP at this time to make a discharge decision. *On 05/24/2023 at 3:33 a.m., LVN C wrote, . Resident is in bed resting quietly at this time, sitter is sitting outside of door . *On 05/26/2023 at 8:10 p.m., LVN C wrote, Resident is walking around asking staff to help him leave, staff redirects resident. Currently resident is in his room stating that he is leaving as soon as he finds a window to go out of. All staff notified to keep an eye on resident due to him stating he is going to leave. *On 05/27/2023 at 2:31 a.m. (incident occurred 05/26/2023 at 8:50 p.m.), LVN C wrote, This writer seen resident going towards the back door. This writer and another began to stand between resident and the door. Resident asked staff if we could move so he could leave. Asked resident where he was going, he stated, home to his bed because he had things to do. This writer explained to resident that I could not let him leave and I was responsible for his wellbeing. Resident stepped closer to staff and asked resident to please step back, he did. Resident continued to stand at the door. Resident then stated that he was going to leave one way or another, resident made a cutting sign (gesture) towards his neck. Asked resident what that was, he stated, 'Could you just let me leave?' Call placed to Administrator, advised resident that he would have to go to his room, or I will call 911, orders given from management. Aide offered popcorn, resident stated he guessed he would go brush his teeth and go to bed. Administrator called and asked if I could interview resident to see if he was a danger to himself. When interviewing resident, he could not recall making a cutting sign at his throat, resident also stated that he will never hurt himself, notified Administrator, resident is currently in bed resting quietly . rounds are made every 2 hours. *On 05/27/2023 at 10:12 a.m. (incident occurred at 9:15 a.m.), LVN A wrote, Receptionist was walking towards nursing station when she noted resident sitting in library. When she attempted to approach resident sitting in library, she noted that the resident had the phone cord wrapped around him and attempting to tighten it harder. Receptionist stated that the resident was turning blue when she ran in to intervene and remove the cord from the resident's neck. The Receptionist called for help and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675495 If continuation sheet Page 22 of 27 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 675495 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laurel Court 3830 Mustang Road Alvin, TX 77511 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 0742 LVN E reached out to me on the way to assist resident and Receptionist. Level of Harm - Immediate jeopardy to resident health or safety *On 05/27/2023 at 10:16 a.m., LVN A wrote, . Assessed resident. Resident stabilized after removing cord from neck and having to sit down. Stated wanted to leave. Asked if he was attempting to kill himself and he stated, 'If that's the only way out then, yes?' Called 911 to have resident transferred to hospital for psych evaluation . RN D spoke with family and advised that resident was being sent out to hospital for Psych evaluation due to suicide attempt. Family stated that it was not the first time the resident has attempted suicide . Residents Affected - Some Record review of CR #1's, Elopement Risk Assessment dated 05/22/2023 revealed LVN F determined CR #1 was a moderate risk for elopements based on his cognitive impairment and wandering behaviors. Action included, Implement Elopement Risk care plan; Implement Frequent Monitoring Form (form was not completed) to determine elopement risk or until Interdisciplinary Team reviews and makes recommendation. Record review of CR #1's, Elopement Risk Assessment dated 05/23/2023 revealed RN G determined CR #1 was an imminent risk for elopements based on his ambulation status, wandering behaviors, and his intentional or unintentional attempts to leave the community. Action included, Implement Elopement Risk care plan; Implement Frequent Monitoring Form (form was not completed) to determine elopement risk or until Interdisciplinary Team reviews and makes recommendation. In an interview with the DON and the Regional Director of Clinical Services on 06/01/2023 at 9:45 a.m., the Regional Director of Clinical Services stated the DON was new to the facility and regional staff was not always in the building. The Regional Director of Clinical Services stated, based on what they knew, CR #1 had no previous suicidal ideations. The Regional Director of Clinical Services said CR #1's wife passed away in the facility many years prior and he had no other family other than a neighbor who helped him out prior to admission. The Regional Director of Clinical Services said CR #1's neighbor stated he (CR #1) previously talked about wanting to die. The DON stated to their (administration) knowledge, CR #1 spoke with the ST and referenced dying. The DON said CR #1's physician was notified and ordered an urgent referral for psychiatric services, but psych services was not able to see CR #1 before the suicide attempt. The Regional Director of Clinical Services stated CR #1's physician spoke with LVN A and that is where it ended. The Regional Director of Clinical Services stated LVN A was educated because something like that (suicidal ideations) should be escalated to the top (DON and Administrator). The Regional Director of Clinical Services said LVN A did not let anybody else know about the conversation between CR #1 and the ST. The Regional Director of Clinical Services said CR #1's physician documented his suicidal ideations and that she wanted an urgent psych consult. The Regional Director of Clinical Services said the incident was not communicated to the top (administration), so they did not have an opportunity to follow-up on the referral. The facility's elopement policy was requested, but the wandering policy was provided. In an interview with the VP of Clinical Operations on 06/01/2023 at 11:00 a.m., she stated the facility did an emergency QAPI on 05/27/2023, after CR #1 attempted suicide. She said all staff involved were counseled and in-serviced. She said nursing staff talked to each resident who could speak and used a special psychiatric tool given to them by a psych provider to interview about depression and suicide. She said the residents who could not talk were assessed head to toe to insure nothing was out of the ordinary for them. She said the Administrator was suspended because their investigation found he may have known about CR #1's prior history of depression. In a telephone interview with the Administrator on 06/01/2023 at 11:45 a.m., he stated he knew CR (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675495 If continuation sheet Page 23 of 27 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 675495 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laurel Court 3830 Mustang Road Alvin, TX 77511 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 0742 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some #1 kept saying he wanted to go home because he wanted to shampoo his carpet at home. He said it was not out of the ordinary for residents to express desires to go home. The Administrator said CR #1 had previously been admitted to the facility for rehab and he (CR #1) wanted attention, that was it. The Administrator said CR #1 was not depressed and he just wanted to go home and do chores. The Administrator said CR #1's depression, suicidal ideations, or behaviors were never brought to his attention prior to admission, and he never spoke to CR #1's family before or after his admission. The Administrator said the night before the suicide attempt (05/26/2023), LVN C called him around 10:00 p.m. He said he thought LVN C texted him, or he missed her call and then she texted saying CR #1 was trying to leave the building and that he wanted to kill himself. The Administrator said he sent LVN C a text to call 911, but she sent a text or called him, saying CR #1 was doing fine after they gave him popcorn. The Administrator said he called the LVN C back and she said CR #1 was fine and brushing his teeth. The Administrator said he told LVN C he needed to know what CR #1's state of mind was. He said LVN C said CR #1 could not even recall what he said earlier. He said he told LVN C to put CR #1 on monitoring (no monitoring was documented) and notify him if anything changed. He said he did not receive any more calls that night until incident on Saturday, 05/27/2023 when LVN A called and said CR #1 tried to hurt himself. In a telephone interview with LVN A on 06/01/2023 at 11:59 a.m., he stated he was a charge nurse and he only worked weekends. He said on 05/21/2023, the ST approached him and said CR #1 had difficulty swallowing and she wanted to down grade his diet (to a mechanical soft diet). He said the ST told him CR #1 refused the food she used to assess him and said he (CR #1) was tired and wanted to die. LVN A said he went to follow-up with CR #1 in his room and asked about his diet. LVN A said he wanted CR #1 to say in his own words how he felt, but he did not express a desire to die to him. LVN A said he did not ask CR #1 about what he said to the ST. LVN A said he called CR #1's doctor and got an order for a psych consultation and he documented the situation. LVN A said the order was not an urgent order. He said orders for psychiatric services were usually turned in to the SW. LVN A said he slipped the referral under the SW's door on Sunday, 05/21/2023, and he did not hear anything else about CR #1's referral after that. He said he did not relay this information to the DON, the Administrator, or anybody else. He said he did not know the SW was on vacation, but had he known, he would have taken the referral order to someone else. He said no special monitoring or intervention was initiated for CR #1. LVN A said that next weekend, 05/27/2023, CR #1 said he wanted to go home, but that was nothing out of ordinary from his usual agitation. He said on 05/27/2023, he heard another nurse call his name and he ran to the library room and saw CR #1 there with the Receptionist. He said by the time he got to the library, other staff had removed the phone cord from CR #1's neck and he (CR #1) was just shaking. He said he got someone to stay with CR #1 while he called his doctor for an order to send him out and he called CR #1's family and the Administrator. LVN A said the police arrived while he was assessing CR #1 and CR #1 told the officer, Oh, I tried to kill myself, but it was nothing big. LVN A said the officer asked CR #1 again if he wanted to kill himself and CR #1 said yes. LVN A said he did not assign CR #1 a sitter the previous weekend when he initially expressing suicidal ideations. He said RN D called CR #1's family (after the suicide attempt) who said CR #1 had a history of suicidal ideations and had done this (attempted suicide) before. He said CR #1's family never mentioned prior to him having the cord around his neck that he had a history of suicide attempts. LVN A said after he was in-serviced (after CR #1's suicide attempt), he realized he should have expedited the information about the suicidal ideations and referral to the DON or management to let them know what was stated. In a telephone interview with CR #1's NP on 06/01/2023 at 12:33 p.m., she stated she visited CR #1 on 05/22/2023, after he was admitted (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675495 If continuation sheet Page 24 of 27 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 675495 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laurel Court 3830 Mustang Road Alvin, TX 77511 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 0742 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some on [DATE]. She said she was notified about CR #1's suicidal ideations on 05/21/2023 and when she saw him on 05/22/2023, she asked him about the day before. She said she asked him if he still wanted to harm himself and he said no, he just wanted to go home and did not want to be in the facility. The NP said she documented in her notes that she put in an urgent request for psych services. The NP said the order was urgent based on CR #1's history of depression. She said she was familiar with the facility's referral process and the request had to be submitted to the SW then sent thru the referral portal. She said the process took a little while, so it was urgent to be done timely. She said she knew the psych provider saw patients at the facility on Mondays, so she knew CR #1 probably would not have been seen Monday, 05/22/2023. She said she was not aware CR #1's discharging facility recommended he be evaluated by psych services. She said had CR #1 exhibited behaviors, the facility staff could have notified psych for medication if needed. The NP said she had no prior knowledge of CR #1's history of suicidal ideations. She said she saw CR #1 again on 05/24/2023 and staff notified her CR #1 had eloped. She said she was not notified of any other incident of suicidal ideations. She said had staff notified her or the on-call doctor that CR #1 made a throat cutting motion (on the morning of 05/27/2023), she would have sent him out to the hospital at that time. In an interview with the SW on 06/01/2023 at 1:00 p.m., she stated, usually, the NP or doctor would write an order and the nurse would print the order and give it to her. She said she sent an email to the psychiatric provider and made the referral. The SW said the process usually only took one day and the provider came on Mondays. She said she never received a referral or request for CR #1 to receive psych services. She said she was on vacation 05/14/2023 - 05/24/2023. She said when she returned from vacation, she did not see any request for CR #1 under her door. The SW said nobody ever asked her about any referral for CR #1. She said the facility's nurses could do the referrals if she was not here. The SW said if the psych provider was in the building and the nurses let them know someone needed to be seen, psych would have evaluated CR #1 even without the referral. She said if the referral was already in their computer system, they could have given it to him (psych) and he could have sent the referral to his (psych) office. The SW provided a copy of CR #1's order for psych services from the computer system and said the order did not say anything about urgency. She said she never saw a psych referral mention urgency. She said that (06/01/2023) was the first time she saw CR #1's referral for psych services. Observation of the facility on 06/01/2023 at 1:30 p.m. revealed the library was located in a room (not open to the rest of the building) between the reception desk (front entrance) and the nurse's station. Further observation revealed someone would have to pass the entrance to the library to see if anyone was inside the library. There was a telephone with a cord on a small table next to a chair. In a telephone interview with LVN C on 06/01/2023 at 1:22 p.m. revealed she usually worked the 2:00 p.m. 10:00 p.m. and 10:00 p.m. - 6:00 a.m. shift, but she rarely worked on weekends. She said one night (she could not recall the date), she was about to pass medications and CR #1 thanked her for caring for him and said he was leaving, but it was dark. LVN C said she asked CR #1 if his family was coming, but he said no, he was leaving. She said she told CR #1 he was there for therapy and that was it, he went back to sleep. LVN C said on another night (she could not recall the day), CR #1 said he was leaving, and she (LVN C) called his RP (he was his own RP, but he did have an emergency contact), but she did not answer. LVN C said earlier on that day, another staff told her CR #1 had gotten outside (eloped) so, that night CR #1 was assigned a sitter (a facility housekeeper and maintenance staff). LVN C said to her knowledge, that was the only night he had a sitter. LVN C said the night he made the cutting motion was the same night she called CR #1's RP. She said they had to watch CR #1 because he would try to elope, and she noticed he went towards one of the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675495 If continuation sheet Page 25 of 27 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 675495 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laurel Court 3830 Mustang Road Alvin, TX 77511 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 0742 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some doors. LVN C said CR #1 said they (the nurses) would not let him out the front, so he would get out one way or another, then he made cutting motion across his throat. LVN C said she asked CR #1 if that meant he would cut himself, and he said, If you think that's what I'm saying. LVN C said she told CR #1 if that was what he was saying, she would have to call the police. LVN C said CR #1 told her he would go brush his teeth. She said the Administrator said to go talk to CR #1 and ask if he was going to harm himself. LVN C said CR #1 acted like he did not recall doing that (making the cutting motion) or anything that happened that night. LVN C said CR #1 said he was going to bed. LVN C said she did not have the DON's phone number at that time. LVN C said she did not call CR #1's doctor because, to be honest, it slipped her mind. LVN C said she waiting to see if CR #1 would react or do anything else. She said now, she probably would have called the doctor. She said she was not aware of any referral for psych services for CR #1. In a telephone interview with RN D on 06/01/2023 at 1:34 p.m., she stated she was the weekend supervisor and she only worked weekends. She said she interacted with CR #1 on weekends quite a bit. RN D said CR #1 kept wanting to go home and tried to elope several times. RN D said she was never made aware of CR #1's suicidal ideations the weekend before (05/21/2023) his suicide attempt and she worked 6:00 a.m. 10:00 p.m. RN D said she worked on the weekend the ST worked (05/21/2023) but she was never made aware of CR #1 saying he wanted to die. RN D said CR #1 did not seem depressed and he had dementia but was able to have a conversation and express his feelings. RN D said on 05/27/2023, CR #1 made his usual attempts to elope and kept trying. She said eventually, she heard someone calling for a nurse to check on CR #1 and she followed afterwards. RN D said when she got to the library, CR #1 was in there sitting on a chair and LVN A was assessing him. She said she was not made aware that CR #1 had a referral for psych services. RN D said on weekends, they contact the primary care doctor or NP for a referral order and then they contact the provider they refer to. She said they could make a referral over the phone and then fax it in. She said she had never done a referral over the weekend and unless it was an emergency, they would wait until following week to do it. She said if the situation was emergent, she would do the referral or send the resident out. She said if she felt there was an active plan for suicide, she would notify the doctor and keep the resident on 1:1 monitoring until the doctor determined their next step. In an interview with the DON on 06/01/2023 at 2:00 p.m., she said the Administrator called her on 05/26/2023 after CR #1 made the cutting motion across his throat. She said the Administrator told her about CR #1 making the cutting motion, and she asked him if CR #1 had a plan and some other questions. The DON said the Administrator said he would call the facility back to ask those questions and call back if there was anything else. The DON said when the nurse went back in to talk to CR #1, he was no longer expressing suicidal ideations. The DON said in hindsight, she probably should have called CR #1's doctor just in case she wanted her to do anything different. The DON said she had in serviced the nurses on when to communicate with physicians. The DON said she did not know if CR #1's referral was ever sent off to the psych provider. She said the SW handled all referrals and she did not know who to contact about referrals at their psych services provider. She said she believed the Administrator was handling referrals when the SW went on vacation. In a follow up telephone interview with the Administrator on 06/01/2023 at 2:25 p.m., he stated if the SW was out, he would have done referrals but, he was never made aware of CR #1's order or referral. He said CR #1's referral was never sent out. In a telephone interview with the ST on 06/01/2023 at 2:31 p.m. She said CR #1 did not have suicidal ideations. She said CR #1 told her his wife died at the facility 8-9 years prior and then he said, I guess I'm going to die here too. The ST said it was not an ideation. She said she was working (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675495 If continuation sheet Page 26 of 27 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 675495 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laurel Court 3830 Mustang Road Alvin, TX 77511 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 0742 Level of Harm - Immediate jeopardy to resident health or safety with him and showing him how to swallow safer and he said, Lady, why do you care so much, just let me die. She said CR #1 had diagnosis of depression already, but for her, the words he said to her were resistance from him to do the swallowing exercises and he had a lack of[TRUNCATED] Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675495 If continuation sheet Page 27 of 27