Inspection·May 9, 2024

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few revealed Resident #1 was listed as having a positive PE TMHP PASRR eligibility status, was marked as No for MI, Yes for ID, and Yes for DD and Yes for specialized services. Record review on 5/9/24 at 2:12 p.m., of PASRR Comprehensive Service Plan (PCSP) Form dated 03/22/23 indicated Resident #1 would be receiving Specialized Assessment PT (physical therapy), coded as 2=New, Day habilitation, coded as 2=New, Habilitation Coordinating coded as 2=New, and Independent Living Skills Training, coded as 2=New. The form was signed as attended by Resident #1, MDS Coordinator A and LA-IDD, on 03/22/23. Record review on 5/9/24 at 2:33 p.m., of facility provided email dated 8/16/24 at 11:12 a.m. that MDS Coordinator A sent to PASRR compliance unit revealed the following: Subject: Re: Follow up to compliance phone call PASRR information, MDS Coordinator A said that the PCSP dated 3/22/23 had some incorrect services listed and for the PASRR compliance unit to advise her on what to do. Observation and interview on 5/8/24 at 10:43 a.m., revealed Resident #1 seated in her specialized wheelchair and easily arousable to verbal stimuli. Resident #1 had a slower speech pattern and spastic movements or tremors of arms and legs. Resident #1 said that she had no care concerns and that she received all services she wanted but could not articulate what those services were. Resident #1 said she received her medications but did not know what specific medications she had been taking. Interview with DON on 5/9/24 at 11:10 a.m., said that MDS Coordinator A was no longer worked as the MDS Coordinator and that MDS Coordinator A never told anyone about the email she had received from PASRR Compliance. The DON said that she had read the email after IT was able to access MDS Coordinator A's emails. The DON said that MDS Coordinator A was the person responsible for ensuring any PASRR related forms or documents were submitted accurately and timely. The DON said that MDS Coordinator A was no longer working at the facility as an MDS Coordinator and was now a charge nurse. The DON said that not having the appropriate PASRR forms completed accurately and timely could result in the resident not receiving the necessary PASRR services. Interview with MDS Coordinator B on 5/9/24 at 3:23 p.m., said that she had worked as an MDS Coordinator during the time MDS Coordinator A worked at the facility as an MDS Coordinator. MDS Coordinator B said that MDS Coordinator A never told her about the communication emails, telephone calls or contact she had received from the PASRR Compliance Unit. MDS Coordinator B said that she would have helped MDS Coordinator A submit the appropriate documents on time, if MDS Coordinator A had told her about the issue. MDS Coordinator B said that each MDS Coordinator had their own assignments, and that Resident #1 was not one of her residents to complete assessments on at that time. Telephone interview on 5/9/24 at 5:41 p.m., MDS Coordinator A said that although she did not remember specific dates and times, she had received the email from the PASRR Compliance Unit. MDS Coordinator A said that she told the DON, Former Administrator and MDS Coordinator B about the communication and forms request from the PASRR Compliance Unit regarding Resident #1. MDS Coordinator A said she could not remember when and then said they all should have known about it because they discussed it in their daily facility IDT morning meetings. MDS Coordinator A said that she was fairly certain she had completed whatever PASRR forms Resident #1 needed within the required timeframe and then said that she remembered not being sure what to do because the original form was incorrectly marked and that she had sent an email to the PASRR people asking what to do and never heard back from them. MDS Coordinator A said that she thought she completed the forms because Resident #1 received all her services. MDS Coordinator A said she completed the forms, then said she thought she completed the forms (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676153 If continuation sheet Page 2 of 3 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 05/09/2024 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete and then said she was not sure which forms she was supposed to submit for Resident #1. MDS Coordinator A said that she had been trained to perform her job duties as an MDS Coordinator prior to performing her job duties and said she could have asked MDS Coordinator B for help if she were confused or unsure of what to do and could not remember if she had. Record review of the facility's Preadmission Screening (PASRR) policy and procedure dated 11/2017 revealed in part: 10. Initiate delivery of specialized services within 20 business days of the IDT meeting date. Event ID: Facility ID: 676153 If continuation sheet Page 3 of 3