Inspection·September 5, 2023

F 0580 Level of Harm - Minimal harm or potential for actual harm Record review of the incident report for Resident # 1, dated 8/23/2023, revealed CNA reported that patient stated to her that he had his coffee in his personal cup brought from home. He had the cup sitting in his lap and it spilled over into lap causing a burn 11/2 abrasion to upper left thigh and redness around the area. Record review of Wound assessment done by the Wound Care Nurse on 8/24/2023 revealed: Residents Affected - Few Length: 4:00 cm, Width 1.00 cm Depth 0.50. Burn Depth: Superficial partial thickness Burn Description: Reddened, Edematous. Record review of Resident #1's nurse's notes and the 24-hour report, dated 8/22/2023, revealed no documentation of Resident #1's burn. Record review of the Bath Assignment Sheet (shower sheet), dated 8/22/2023, revealed When giving Resident #1 a shower, I asked about an open area. He told me his coffee spilled and burn him, but he did not tell anyone about it (upper left thigh). This sheet was sign by CNA B and Charge Nurse LVN A. During an interview with Resident #1 on 8/25/2023 at 10:30 a.m., he said he went to the dining room to get himself a cup of coffee in his coffee cup and was going outside to read the paper. He said, as habit he put the cup in his lap and did not realize the lid was not closed all the way. Then he realized the coffee was burning him. He said he did not tell anyone about the burn because he did not think it was serious. During an interview with the DON on 8/25/2023 at 11:00 a.m. she said CNA B asked her on 8/23/2023 at about 3:30 p.m. what they were doing about Resident #1's burn and she told her she was not aware of Resident #1 having a burn. She said the CNA told her when she was giving Resident #1 a shower on 8/22/2023 around 7:00 p.m. she noticed the area on his groin, and asked him what happened and he told her he had his coffee cup in his lap with coffee he got from the coffee machine last night (8/21/2022) and he forgot to close the opening on the lid, and it spilled over and burned him and he did not tell anyone. She said CNA B told her she reported it to the charge nurse LVN A and documented the burn on the shower sheet. The DON said she assessed the resident on 8/23/2023 and notified the physician and an order was given for treatment. Further interview with the DON revealed the resident sustained a second degree burn to the left groin area. Interview with CNA B on 8/25/2023 at 1:30 p.m. via telephone, she said she was giving Resident #1 a shower on Tuesday evening, 8/22/2023, around 7:00 p.m. and noticed the area on Resident #1's left groin and asked him what happened, and he told her last night (8/21/2023) he had his coffee cup in his lap, and he forgot to close the opening on the lid, and it spilled over and burned him and he did not report it to anyone. She said Resident #1 told her he just went back to his room and changed his clothes. CNA B said she reported the incident to the Charge Nurse LVN A immediately and documented it on the shower sheet (Bath Assignment Sheet). CNA B said she did not report it to the DON because she reported it to the charge nurse. Further interview with CNA B, she said the burn looked fresh it could have happened that morning, as Resident #1 could sometimes get a little confused. She said the top area was removed with redness around the area opened (the top layer of the skin was off). She said she had never had any burn issues with Resident #1 before. She said the resident usually got (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676153 If continuation sheet Page 2 of 11 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 676153 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Heights of League City 2620 W Walker League City, TX 77573 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 0580 his coffee and water by himself and he never generally asked anyone for help. Level of Harm - Minimal harm or potential for actual harm In an interview with LVN A via telephone on 8/28/2023 at 10:32 a.m., she said CNA B reported to her on 08/22/2023 during her shift sometimes after 7:00 p.m. that Resident #1 had a burn to his groin area. She said she assessed the burn to the groin area, and it was red and had a small, opened area. She said she asked Resident #1 what happened, and he told her about 2 days ago he had his coffee cup in his lap and the opening to the lid was not closed and it spilled and burned him, and he did not tell it to anyone. She said she should have called the doctor, but she got busy and did not remember to document or call the doctor. She said, she knew the protocol was to assess, call the doctor, the DON and family. Document in the nurse's progress notes, the 24-hour report and write an incident report. She said normally she would have documented the incident, but she forgot . Residents Affected - Few Observation on 8/28/2023 at 11:00 a.m. revealed LVN J removed the dressing from Resident #1's left groin; A 4x4 foam dressing was over the left groin area, dated 08/28; the dressing had a yellow patch adhered to it. LVN J stated the treatment was, probably Calcium Alginate; and the white substance on wound may be Silvadene cream. The wound was approximately 4 inch long. Clustered wounds were along the crease of the left groin, large, long patch with cream/white colored center, another area had scabs, another area was a dark maroon color (like a superficial scrape); the skin surrounding the entire area was red. No swelling or drainage noted. In an interview on 8/28/2023 at 11:15 a.m. with Resident #1, he said he used the toilet on his own, he said they have asked him to call someone before he goes but sometimes, he needs to go quickly so he does it by himself. He said he had a coffee cup holder on his chair but removed it because it got in his way, and he ended up knocking it off. He had a red cup with a lid, and he demonstrated how it worked. He said he had a habit of forgetting to close the lid, when he carried it around and that was how the coffee spilled on his lap. He did not tell anyone because it was just hot for 3-4 mins and he cleaned it up with paper towel, changed his brief and pants. Interview with the Wound Care Nurse on 8/28/2023 at 12:30 a.m., she said prior to the morning meeting she usually reviewed the nurse's notes and the 24-hour report and shower sheet (Bath Assignment Sheet) for any changes in residents' condition and then discussed them at the morning meeting. She said she reviewed the progress notes and the 24-hour report and there was no documentation regarding Resident #1's burn. She said she reviewed the shower sheet and did not see any check marks on the full body picture on the shower sheet. She said she did not read the documentation at the bottom of the shower sheet for Resident #1 and that was why she missed it. She said everyone was supposed to be checked once a week, document in the electronic health records. She said the nurses had a list (schedule of skin inspections) for their assigned rooms, if wounds were identified, on Mondays when the MD did wound rounds, he would evaluate the wounds. In an interview with LVN F on 08/28/2023 at 5:00 p.m., she said she got the physician's order on 8/23/2023 at 4:15 p.m. for Resident #1's treatment but did not send it to the pharmacy immediately because she was busy. Record review of the physician's order, dated 8/23/2023 at 4.15 p.m., Reflected Silvadene 1% applied topically and covered with nonstick dressing until healed has been entered. Record review of the nurse's notes revealed Resident #1's first treatment was done on 8/23/2023 at 8:59pm. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676153 If continuation sheet Page 3 of 11 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 676153 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Heights of League City 2620 W Walker League City, TX 77573 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 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few In an interview with the NP A was attempted on 9/01/2023 at 5:00 p.m. and she said she was with a patient and the surveyor should call the office. The office was called, and a message was left, and the call was not returned. Record review of the facility's policy and procedure, dated March 2023, on Acute Condition Changes Clinical Protocol read in part . 6. Before contacting the physician about someone with an acute change in condition, the nursing staff will make a detailed observations and collect pertinent information to report to the physician. a. Phone calls to attending or on call physician should be made by an adequately prepared nurse who has collected and organized pertinent information including the resident current symptoms and status FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676153 If continuation sheet Page 4 of 11 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 676153 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Heights of League City 2620 W Walker League City, TX 77573 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure, based on the comprehensive assessment of a resident, that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan and the residents' choices for one of 6 residents (Resident #1) reviewed for quality of care. Residents Affected - Few 1.The facility failed to ensure that hot coffee was maintained at a temperature that could prevent Resident #1 from sustaining a second-degree burn to his left groin. 2. The facility failed to assess and treat Resident #1 in a timely manner after LVN A was notified of a new wound on 8/22/2023 to his groin. 3. The facility's wound care nurse failed to thoroughly review Resident #1's shower sheets which identified a new wound to the left groin This failure could place residents at risk of second degree burn and decline in quality of life. Findings included: Resident #1 Record review of Resident #1's admission face sheet, dated 8/25/2023, revealed an [AGE] year-old male who was admitted to the facility on [DATE] and readmitted [DATE]. His diagnoses included right eye cataract (blurry vision), dysphagia (difficulty swallowing), retinal hemorrhage left eye (bleeding from the blood vessel in the retina), sepsis (infection), dementia (memory loss), anxiety disorder (feeling of fear, dread and uneasiness), abnormalities of gait and mobility (unusual walking pattern and hypertension (high blood pressure). Record review of Resident #1's quarterly MDS dated [DATE] revealed a BIMS score of 7 indicating that the resident has cognitive issues. For Section B1000: Vision: Resident was coded as a 2 indicating the resident was moderately impaired- that is limited vision. For Functional Status G0110: Activities of Daily Living (ADL)assistance the resident was coded for Transfer and Toilet use as 2/2 indicating he was limited assistance with one-person physical assist. For bed mobility, dressing and personal hygiene the resident was coded 3/2 indicating he was extensive assistance with one-person physical assist. For eating he was coded as 1/1 indicating he needed supervision with set up only. For bowel he was coded as occasionally incontinent and for bladder he was coded as frequently incontinent. Record review of Resident #1's care plan dated 8/8/2023 revealed the care plan goal was to maintain adequate nutritional status and good oral hygiene daily and ongoing over the next 90 days. Interventions are to Monitor assistance needed with nutritional intake and notify the physician of changes and assist resident as needed. Record review of the incident report for Resident # 1 dated 8/23/2023 revealed CNA reported that patient stated to her that he had his coffee in his personal cup brought from home. He had the cup sitting in his lap and it spilled over into lap causing a burn 11/2 abrasion to upper left thigh and redness around the area. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676153 If continuation sheet Page 5 of 11 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 676153 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Heights of League City 2620 W Walker League City, TX 77573 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview with Resident #1 on 8/25/2023 at 10:30 a.m., he said he went to the dining room to get himself a cup of coffee in his coffee cup and was going outside to read the paper. He said, as habit he put the cup in his lap and did not realize the lid was not closed all the way. Then he realized the coffee was burning him. He said he did not tell anyone about the burn because he did not think it was serious. During an interview with the DON on 8/25/2023 at 11:00 a.m. she said CNA B asked her on 8/23/2023 at about 3:30 p.m. what they were doing about Resident #1's burn and she told her she was not aware of Resident #1 having a burn. She said the CNA B told her when she was giving Resident #1 a shower on 8/22/2023 around 7:00 p.m. she noticed the area on his groin, and asked him what happened and he told her he had his coffee cup in his lap with coffee he got from the coffee machine last night (8/21/2022) and he forgot to close the opening on the lid, and it spilled over and burned him and he did not tell anyone. She said CNA B told her she reported it to Charge Nurse LVN A and documented the burn on the shower sheet. The DON said she assessed the resident on 8/23/2023 and notified the physician and an order was given for treatment. Further interview with the DON revealed the resident sustained a second degree burn to the left groin area. Interview with CNA B on 8/25/2023 at 1:30 p.m. via telephone, she said she was giving Resident #1 a shower on Tuesday evening, 8/22/2023, around 7:00 p.m. and noticed the area on Resident #1's left groin and asked him what happened, and he told her last night (8/21/2023) he had his coffee cup in his lap, and he forgot to close the opening on the lid, and it spilled over and burned him and he did not report it to anyone. She said Resident #1 told her he just went back to his room and changed his clothes. CNA B said she reported the incident to the Charge Nurse LVN A immediately and documented it on the shower sheet (Bath Assignment Sheet). CNA B said she did not report it to the DON because she reported it to the charge nurse. Further interview with CNA B, she said the burn looked fresh it could have happened that morning, as Resident #1 could sometimes get a little confused. She said the top area was removed with redness around the area opened (the top layer of the skin was off). She said she had never had any burn issues with Resident #1 before. She said the resident usually got his coffee and water by himself and he never generally asked anyone for help. Record review of Resident #1's nurse's notes and the 24-hour report dated 8/22/2023 revealed no documentation of Resident #1's burn. Record review of the Bath Assignment Sheet (shower sheet) dated 8/22/2023 revealed When giving Resident #1 a shower, I asked about an open area. He told me his coffee spilled and burn him, but he did not tell anyone about it (upper left thigh). This sheet was sign by CNA B and Charge Nurse LVN A. Record review of NP A notes dated 08/24/2023: Staff called yesterday, reported patient spill coffee on himself with burn to his left thigh. Photo reviewed. Partial thickness, open blister with grandulation tissue noted some DTI: Silvadene Cream and non stick dressing was ordered until healed. Wound care consult if any worsening. Record review of Wound assessment done by the Wound Care Nurse on 8/24/2023 revealed: Length: 4:00 cm, Width 1.00 cm Depth 0.50. Burn Depth: Superficial partial thickness Burn Description: Reddened, Edematous. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676153 If continuation sheet Page 6 of 11 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 676153 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Heights of League City 2620 W Walker League City, TX 77573 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview with LVN A via telephone on 8/28/2023 at 10:32 a.m. she said CNA B reported to her on 08/22/2023 after 7:00 p.m. during her shift that Resident #1 has a burn to his groin area. She said she assessed the burn to the groin area, and it was red and had a small open area. She said she asked the resident what happened, and he told her about 2 days ago he had his coffee cup in his lap and the opening to the lid was not closed and it spilled and burn him, and he said did not tell it to anyone. She said she should have called the doctor, but she got busy and did not remember to document in the progress or the 24-hour report or call the doctor. She said, she knew the protocol was to assess the resident, call the doctor, DON and family. Document in the nurse's progress notes, the 24-hour report and write an incident report. She said normally she would have documented the incident and write an incident report. Interview with the Wound Care Nurse on 8/28/2023 at 12:30 a.m., she said prior to the morning meeting she usually reviewed the nurse's notes and the 24-hour report and shower sheet (Bath Assignment Sheet) for any changes in residents' condition and then discussed them at the morning meeting. She said she reviewed the progress notes and the 24-hour report and there was no documentation regarding Resident #1's burn. She said she reviewed the shower sheet and did not see any check marks on the full body picture on the shower sheet. She said she did not read the documentation at the bottom of the shower sheet for Resident #1 and that was why she missed it. She said everyone was supposed to be checked once a week, document in the electronic health records. She said the nurses had a list (schedule of skin inspections) for their assigned rooms, if wounds were identified, on Mondays when the MD did wound rounds, he would evaluate the wounds. Interview with LVN F on 8/28/2023 at 5:00 p.m. she said she got the order on 8/23/2023 at 4:15 p.m. for Resident #1's treatment but did not send it to the pharmacy immediately because she was busy. She said treatment order should be sent off in a timely manner and if the treatment order was for an emergency, they usually send it off immediately. Record review of the physician's order, dated 8/23/2023 at 4.15 p.m., Reflected Silvadene 1% applied topically and covered with nonstick dressing until healed has been entered. Record review of the nurse's notes revealed Resident #1's first treatment was done on 8/23/2023 at 8:59pm. Record review of Wound care assessment done by Wound Care Doctor 8/28/2023 revealed There is no indication of pain, Burn wound of the Left Groin Full Thickness. Wound (L) 6 x (W) 1.3 x (D) 0.3 Surface area 7.80 cm open ulceration and area of 5.46 cm Exudate: Light serous. Wound detail: Coffee spilt burn Dressing treatment: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676153 If continuation sheet Page 7 of 11 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 676153 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Heights of League City 2620 W Walker League City, TX 77573 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 0684 Primary dressing. Level of Harm - Minimal harm or potential for actual harm Silver Sulfadiazine apply once daily for 30 days. Xeroform gauze apply once daily for 30 days. Residents Affected - Few An interview with the NP A was attempted on 9/01/2023 at 5:00 p.m. and she said she was with a patient and the surveyor should call the office. The office was called, and a message was left, and the call was not returned. Observation on 8/25/2023 at 10:00 a.m. the internal temperature of the coffee machine was 140 degrees F and the coffee temperature in the cup was 135 degrees F. On 8/28/2023 at 11:30 a.m. the internal temperature was 145 degrees F, and the actual coffee temperature in the cup was 135 degrees F. Record review of the facility's policy and procedure, dated March 2023, on Acute Condition Changes Clinical Protocol read in part .2. Nurses shall assess and document/report the following baseline information: a. Vital signs b. Neurological status c. Current level of pain, and any recent changes in pain level. 3. Direct care staff, including Nursing Assistants will be trained in recognizing subtle but significant changes in the resident (for example changes in skin color or condition) and how to communicate these changes to the nurse. 6. Before contacting the physician about someone with an acute change in condition, the nursing staff will make a detailed observations and collect pertinent information to report to the physician. a. Phone calls to attending or on call physician should be made by an adequately prepared nurse who has collected and organized pertinent information including the resident current symptoms and status. b. Nursing staff are encouraged to use SBAR communication form and progress notes. Treatment Management 1. The physician will help identify and authorize appropriated treatment. Monitoring and Follow-Up 1. The staff will monitor and document the resident's progress and responses to treatment, and the physician will adjust treatment accordingly FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676153 If continuation sheet Page 8 of 11 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 676153 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Heights of League City 2620 W Walker League City, TX 77573 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 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview and record review, the facility failed to ensure the environment remained free of accident hazards and each resident received adequate supervision and assistance to prevent accidents for 1 of 6 residents (Resident#1) reviewed for accidents and hazards. The facility failed to ensure hot coffee was maintained at a temperature that prevented Resident #1 from sustaining a second-degree burn to his left groin. This failure could place residents at risk of second degree burns and a decline in quality of life. Findings Included Resident #1 Record review of Resident #1's admission face sheet, dated 8/25/2023, revealed an [AGE] year-old male who was admitted to the facility on [DATE] and readmitted [DATE]. His diagnoses included right eye cataract (blurry vision), dysphagia (difficulty swallowing), retinal hemorrhage left eye (bleeding from the blood vessel in the retina), sepsis (infection), dementia (memory loss), anxiety disorder (feeling of fear, dread and uneasiness), abnormalities of gait and mobility (unusual walking pattern and hypertension (high blood pressure). Record review of Resident #1's quarterly MDS dated [DATE] revealed a BIMS score of 7 indicating that the resident has cognitive issues. For Section B1000: Vision: Resident was coded as a 2 indicating the resident was moderately impaired- that is limited vision. For Functional Status G0110: Activities of Daily Living (ADL)assistance the resident was coded for Transfer and Toilet use as 2/2 indicating he was limited assistance with one-person physical assist. For bed mobility, dressing and personal hygiene the resident was coded 3/2 indicating he was extensive assistance with one-person physical assist. For eating he was coded as 1/1 indicating he needed supervision with set up only. For bowel he was coded as occasionally incontinent and for bladder he was coded as frequently incontinent. Record review of Resident #1's care plan dated 8/8/2023 revealed the care plan goal was to maintain adequate nutritional status and good oral hygiene daily and ongoing over the next 90 days. Interventions are to Monitor assistance needed with nutritional intake and notify the physician of changes and assist resident as needed. Record review of the incident report for Resident # 1 dated 8/23/2023 revealed CNA reported that patient stated to her that he had his coffee in his personal cup brought from home. He had the cup sitting in his lap and it spilled over into lap causing a burn 11/2 abrasion to upper left thigh and redness around the area. Record review of Resident #1's nurse's notes and the 24-hour report dated 8/22/2023 revealed no documentation of Resident #1's burn. Record review of the Bath Assignment Sheet (shower sheet) dated 8/22/2023 revealed When giving Resident #1 a shower, I asked about an open area. He told me his coffee spilled and burn him, but he did not tell anyone about it (upper left thigh). This sheet was sign by CNA B and Charge Nurse LVN A. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676153 If continuation sheet Page 9 of 11 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 676153 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Heights of League City 2620 W Walker League City, TX 77573 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 - Actual harm Residents Affected - Few During an interview with Resident #1 on 8/25/2023 at 10:30 a.m., he said he went to the dining room to get himself a cup of coffee in his coffee cup brought from home and was going outside to read the paper. He said, as habit he put the cup in his lap and did not realize the lid was not closed all the way. He then realized the coffee was burning him. He said he did not tell anyone about the burn because he did not think it was serious. Interview with the Dietary Manager on 8/25/2023 at 10:00 a.m., she said sometimes Resident #1 got his coffee by himself. She said she was not aware of the burn until 8/23/2023. She said when she heard about the burn, she checked the coffee machine, and the internal temperature on the thermometer was 170 degrees F and the actual coffee temperature in the cup was 149 degrees F. She said they did not know what the coffee temperature was when the resident got burned, because they never took coffee temperature, prior to the incident . Observation on 8/25/2023 at 10:00 a.m. revealed the internal temperature of the coffee machine was 140 degrees F and the coffee temperature in the cup was 135 degrees F. In an interview with Resident #1 on 08/25/2023 at 10:30 a.m., he said he went to the dining room to get himself a cup of coffee in his coffee cup and was going outside to read the paper. He said, as habit he put the cup in his lap and did not realize the lid was not closed all the way. Then the next thing he realized the coffee was burning him. He said he did not tell anyone about the burn because he did not think it was serious . During an interview with the DON on 8/25/2023 at 11:00 a.m., she said CNA B asked her on 8/23/2023 about 3:30 p.m. what they were doing about Resident #1's burn and she told her she was not aware of Resident #1 having a burn. She said the CNA told herwhen she was giving Resident #1 a shower on 8/22/2023 around 7:00 p.m. she noticed the area on his groin and asked him what happened and he told her he had his coffee cup in his lap with coffee he got from the coffee machine last night (8/21/2022) and he forgot to close the opening on the lid, and it spilled over and burned him and he did not tell anyone. She said the CNA B told her she reported it to the charge nurse and documented the burn on the shower sheet. The DON said she assessed the resident and notified the physician and an order was given for treatment. Further interview with the DON revealed the resident sustained a second degree burn to the left groin area. Interview with CNA B on 8/25/2023 at 1:30 p.m. via telephone, she said she was giving Resident #1 a shower on 8/22/2023 around 7:00p.m. and noticed the area on Resident #1's left groin and asked him what happened. CNA B said, Resident #1 told her last night (8/21/2023) that he had his coffee cup in his lap, and he forgot to close the opening on the lid of the cup, and it spilled over and burned him, and he did not report it to anyone. She said he told her he just went back to his room and changed his clothes. She said she reported it LVN A and documented it on the shower sheet. She said she did not report it to the DON because she reported it to LVN A. Observation on 8/28/2023 at 11:45 a.m. the internal temperature of the coffee was 145 degrees F, and the actual coffee temperature in the cup was 135 degrees F. During an interview on 8/28/2023 at 11:45 a.m. with the Dietary Manager, she said she was going to have the company who in-serviced the coffee machine adjust the internal temperature coffee machine to 140 degrees F. She said she was going to ensure it won't get higher than 140 degrees Fahrenheit and residents would get their coffee at a safe temperature level. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676153 If continuation sheet Page 10 of 11 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 676153 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Heights of League City 2620 W Walker League City, TX 77573 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 Observation on 08/30/2023 at 4:15 pm. of the internal temperature of the coffee machine revealed it was set at 140 degrees F. and the temperature of the coffee was 138 degrees F. Level of Harm - Actual harm Residents Affected - Few In an interview with the Dietary Manager on 8/30/2023 at 4:15 p.m., she said they were dispensing coffee from the coffee machine to the Eco Air pot where they could monitor the coffee temperature better. She said staff were supposed to take the temperature of the coffee before it was sent to the dining room and document on the temperature log. Record review of facility policy and procedure on Safety of Hot Liquids, dated 06/2017, read in part . Maintaining hot liquid serving temperature of not more than 140 degrees Fahrenheit'. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676153 If continuation sheet Page 11 of 11