Inspection·May 30, 2024

F 0755 medications related to her liver transplant: Level of Harm - Immediate jeopardy to resident health or safety 1. Tactrolimus (Prograf) 0.5 mg/ml oral suspension, 2 ml (1mg) two times daily for 30 days. The Instructions read, in part, .This medication is very important: It prevents organ rejection. Residents Affected - Some 2. Mycophenolate (Cellcept) 200mg/ml suspension, 2.5 ml (500 mg) two times daily for 360 days. The Instructions read, in part, .This medication is very important: It prevents organ rejection. Record review of CR #1's Physician's Order List (facility) reflected the two anti-rejection medications were not on the list. Record review of a Progress Note, dated 05/22/24 at 12:50 p.m., reflected CR #1 appeared jaundiced. The NP was notified and CBC, BMP, and Ammonia level labs were ordered . Record review of a Progress Note, dated 05/22/24 at 11:02 p.m., reflected the NP called the facility and ordered CR #1 be sent to the hospital due to elevated Ammonia level of 159 micromols per liter. Record review of a Progress Note, dated 05/23/24 at 3:24 a.m., reflected CR #1 was sent to the hospital via ambulance. In an interview on 05/24/24 at 5:10 p.m. the DON said she was notified this morning that CR #1 was sent to the hospital. She said the hospital asked if CR #1 received her anti-rejection medications. The DON said the anti-rejection medications were not entered into the facility order system when the resident was admitted on [DATE]. The DON said when CR #1 was admitted , her payor source was private pay. She said LVN A notified a family member that he needed to bring CR #1's anti-rejection medications. The medications never arrived at the facility. The resident was sent to the hospital yesterday (05/23/24) due to abnormal labs (high Ammonia level), and she appeared jaundiced. She was transferred to the hospital. There were no other residents in the facility that were status-post transplant. The DON said the admission nurse (LVN A) and the Unit Manager (RN B) were both suspended. She said LVN A informed RN B she had difficulty entering CR #1's orders. She said she has begun in-servicing nurses regarding family members bringing or not bringing medications. In an interview via telephone on 05/29/24 at 9:08 a.m., CR #1's family member said CR #1 was still in the hospital. He said the resident was going to have a biopsy conducted to see if the transplanted liver was still being rejected. He said CR #1 had the transplant in July of 2022. He said she was taking the anti-rejection medications prior to going to this facility. He said she was transferred from a hospital to the facility. The family never had the anti-rejection medications. He said he, nor any other family members received a call from the facility asking for medications. She was at a different facility prior to going to that hospital. In an interview via telephone on 05/29/24 at 12:00 p.m. the family member said CR #1 was transferred from the ICU to the transplant unit at the hospital . In an interview via telephone on 05/29/24 at 12:40 p.m. RN B said the protocol for new admissions at the facility was for the Charge Nurse (in this case it would be LVN A) to process the admission. She said the next day the ADON (RN B) would conduct a 'chart check.' RN B said when she conducted the chart check for CR #1 she noticed a couple of medications were not entered into the system . She said she informed the DON, and the DON said to see if the family could bring the medicine in. RN B (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676153 If continuation sheet Page 2 of 6 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 05/30/2024 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 0755 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some said she called the family but could not recall whom she spoke with. She said she did not document the conversation with the DON or family member. She said she waited for the family to bring the medications in, but they did not. She said there was no additional follow-up regarding the medications. In an interview on 05/29/24 at 3:19 p.m., LVN A said she did not verify CR #1's admission orders with the physician or NP. She said she thought RN B had done that. LVN A said she had difficulty entering two medication orders. She said she called the family member and was told another family member had recently passed, and he (the family member) would 'figure it out.' She said she told RN B about the two medications . In an interview via telephone on 05/29/24 at 3:55 p.m. the NP said she was not aware CR #1 was not receiving the two anti-rejection medications. She said not administering the anti-rejection medications for a long period of time could cause organ failure . This was determined to be an Immediate Jeopardy (IJ) on 05/29/24 at 4:00 p.m. The Administrator was notified. The Administrator was provided with the IJ template on 05/29/24 at 4:00 p.m. The following Plan of Removal submitted by the facility and was accepted on 05/30/26 at 2:00 p.m.: PLAN OF REMOVAL Name of facility: _____ [Facility] ID # _____ Date: 5/29/24 Immediate action: F-755 Pharmacy Services 5/24/24 Medication Error report was completed This was completed by _____ [DON] 5/24/24 5/24/24 Charge nurse _____ [LVN A] and ADON _____ [RN B] received disciplinary notice and suspended pending investigation. This was completed by _____ [DON] 5/24/24 5/24/24 Patient was assessed by charge nurse on 5/23/23 patient was noted to have jaundiced eyes and abdomen. Patient lab returned with abnormal values related to liver. MD was notified and was sent to _____ [Hospital] ER. This was completed by _____ [RN B], ADON 5/23/24 Facilities Plan to ensure compliance quickly (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676153 If continuation sheet Page 3 of 6 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 05/30/2024 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 0755 5/24/24 Level of Harm - Immediate jeopardy to resident health or safety Facility reviewed the admission policy/ procedures. No changes were required. Residents Affected - Some 5/29/24 This was completed by _____ Administrator, _____DON 5/24/24 _____ [Medical Director] our medical director and _____ [Pharmacist], _____ [Pharmacy], _____ [Consultant Pharmacist 1], were notified about the plan of removal. This was completed by _____ DON 5/29/24 5/29/24 All licensed nurses will receive in-service on Reconciliations of medications to include faxing the hospital discharge medication list to pharmacy consultant (company name: _____ [Consultant Pharmacist 2], medication transcription on admission, home medication process, 24-hour chart check and follow-up routine. No nurse will report to duty until in-serviced. All new admissions will be reviewed in clinical meeting by ADON/Unit managers for medication reconciliation and availability utilizing the admission audit tool that includes admissions orders completed and verified. (check for transcription errors), medication availability, and fax medication regimen review to _____ [Consultant Pharmacist 1] (our consultant company) for review. DON will spot check admission audit tool & Review _____ [Consultant Pharmacist 1] Review Report for Recommendations. All new admissions will be reviewed by the Department head nursing on call for holidays and weekends utilizing a charge nurse in facility as the second person. This was completed by _____ DON 5/30/24 5/29/24 A root cause analysis was completed by IDT team This was completed by IDT 5/29/24 5/29/24 An audit will be completed on all admissions in the last 30 days for medication reconciliation accuracy. No other discrepancies were identified. This was completed by _____ DON 5/29/24 5/30/24 All new admissions will be reviewed in clinical meeting by ADON/Unit managers for medication reconciliation and availability utilizing the admission audit tool that includes admissions orders completed and verified (check for transcription errors), medication availability, and fax medication regimen review to _____ [Consultant Pharmacist 1] (our consultant company) for review. ADON/Unit Manager in clinical meeting will completed medication reconciliation together (one will read off the hospital (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676153 If continuation sheet Page 4 of 6 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 05/30/2024 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 0755 Level of Harm - Immediate jeopardy to resident health or safety discharge orders and the other with review orders in the AHT system.) All new admissions will be reviewed by the Department head nursing on call for holidays and weekends utilizing a charge nurse in facility as the second person. DON will spot check admission audit tool & Review _____ [Consultant Pharmacist 1] Review Report for Recommendations. Ongoing Residents Affected - Some Monitoring of the Plan of Removal included the following: In an interview on 05/30/24 at 2:30 p.m. with the DON revealed she conducted a medication order audit for all of the facility admissions of the past 30 days. She said a Root Cause Analysis was completed. In an interview on 05/30/24 at 3:10 p.m. with LVN C revealed she received the in-service. She said the in-service was to introduce the new admissions packet that included new processes regarding medications. She said the medications were to be verified by the doctor and a copy of the list was to be faxed to the pharmacy. She said if the resident's family had the medications but did not provide them, order them from the pharmacy. In an interview on 05/30/24 at 3:15 p.m. LVN D said the in-service was about admissions. She said the orders were to be verified by the physician, then faxed to the pharmacy. She said if a family member had the medications, ask them to bring them. If they did not, call the DON and order from the pharmacy. For transplant medications she would call the transplant doctor's office to see where they were to be obtained. In an interview on 05/30/24 at 3:20 p.m., LVN E said the in-service was about admissions. She said the orders were to be verified with the physician and then faxed to the pharmacy. She said if a resident's family had the medications at home but did not provide them, call the pharmacy and order them. In an interview on 05/30/24 at 3:30 p.m., LVN A said there was a new form for medications upon admission. She said the other facility discharge orders were to be verified and faxed to the pharmacy. She said if medications were with the family, she was to call them, and follow-up to make sure the medications arrived. Call the pharmacy if not. In an interview on 05/30/24 at 3:40 p.m., LVN F said after the medication list was verified with the physician it was to be faxed to the pharmacy. If the family had the medications, call them. If the family did not bring them, call the DON and order from the pharmacy. In an interview on 05/30/24 at 4:20 p.m. RN B said the orders were to be faxed to the pharmacy after they were verified with the physician. She said if the family did not bring in home medications, she was to check the Pyxis and call the DON, then order from the pharmacy. She said she was re-training with the DON today and will be training at another facility next week. In an interview on 05/30/24 at 4:25 p.m. LVN G said after the medication orders were verified with the physician, the list was to be faxed to the pharmacy. If the family did not bring the medications, she would call the DON and order from the pharmacy. In an interview on 05/30/24 at 4:30 p.m., LVN H said after the orders were verified with the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676153 If continuation sheet Page 5 of 6 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 05/30/2024 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 0755 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some physician they were to be faxed to the pharmacy. If the family did not bring medications, call the DON, the Unit Manager, and let the incoming nurse know. Record review of Resident #2's admission orders, dated 04/26/24, and May 2024 MAR reflected no discrepancies. Record review of Resident #3's admission orders, dated 05/24/24, and May 2024 MAR reflected no discrepancies. Record review of Resident #4's admission orders, dated 05/14/24, and May 2024 MAR reflected no discrepancies. Record review of Resident #5's admission Audit Tool reflected it was completed with no errors noted. Record review of Resident #6's admission Audit Tool reflected it was completed with no errors noted. Record review of the Medication Error Report, dated 05/23/24, reflected it was completed. Record review of the Disciplinary Notices for LVN A and RN B was conducted . Record review of the facility's policy and procedures for new admissions was reviewed. Record review provided verification that the Medical Director and Pharmacist were notified. Record review of the in-services reflected all of the nurses onof the facility-provided staff list had been provided education . The facility implemented a medication reconciliation list of the hospital discharge medication orders form that was to be faxed to the pharmacy. Record review of the admission Audit Tool did not reflect any concerns. The Administrator and the DON were informed the Immediate Jeopardy was removed on 05/03/24 at 5:13 p.m. The facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that was not immediate jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676153 If continuation sheet Page 6 of 6