Inspection·March 7, 2025

F 0678 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few skin slightly warm to touch. Resident re admitted yesterday, no new code status entered in the system and no DNR in the folder noted. Progress notes states that resident was admitted under [Hospice]. Called [Hospice] and spoke to the [Hospice Nurse], notified her of change of condition and enquired on code status. They stated that resident was pending on their side, and they had no code status. Attempted to call [RP A] but call went to voicemail. Called the [ADMIN] and call went to voicemail. CPR started and 911 called. EMTs arrived to find CPR in progress, continued CPR and this nurse attempted to call [RP B] and he picked up, spoke to EMT who stated [RP B] requested to stop CPR and that they had signed a DNR at [Hospital]. CPR ceased and resident pronounced at 3.34am. 4.18am: [Hospice] nurse in the facility residents time of death is 3:34 a.m. Record review of advance directives for the facility census of 123 residents revealed there was 77 Full Code residents and 50 DNR residents. Interview on [DATE] at 2:41 p.m., the ADMIN and Reg. RN said the facility did not have a CPR policy. Reg. RN said the facility had a change in condition policy. Interview on [DATE] at 3:40 p.m., DON said she was notified on [DATE] (early morning hours) by voicemail that CR #1 had a change in condition and 911 was called. The DON said the facility did not have a CPR policy but had a CPR process. She said they did not have a documented policy of the CPR process. She said the CPR process should have been a team effort. The DON said she was told CNA A found CR #1 and notified LVN A. She said she later was informed LVN A left CR #1 after an initial pulse check, which CR #1 did not have a pulse, went to the nurses' station to check the code status. She said because LVN B had not put in CR #1's code status at admission ([DATE]), LVN A had to two separate locations, in the electronic record and a code status binder located at the nurses' station, before the attempted code status verification. Interview on [DATE] at 3:55 p.m., LVN B said she did not put in the code status for CR #1 at admission. She said when LVN A looked for the code status, it was not in the electronic health record or binder for hall 200. She said she was not working when CR #1 was found unresponsive. She said when the code status was unknown, the nurse should verify the code status and start CPR. She said she would leave the resident to check the code status and then tell the team (facility staff) to assist with calling 911 and assist with getting the crash cart. She said she was not trained by the facility staff on how to respond to an unresponsive resident but used her nursing school knowledge. She said she was not sure if there a risk to the resident if staff left an unresponsive resident to check the code status, rather than yell out, alerted staff for help with calling 911, getting the crash cart, and other staff verify the code status. Interview on [DATE] at 4:30 p.m., with LVN A said she was notified by CNA A, CR #1 was unresponsive. LVN A said she went to CR #1's room, attempted to arouse her and checked her pulse. She said CR #1 did not have a pulse. LVN A said she left CR #1 and went to the nurse's station to check CR #1's code status in the electronic health record. She said she told LVN C and LVN D that CR #1 did not have pulse. She said both, LVN A and LVN D looked in the binder and said there was not an advance directive for CR #1 and she should be treated as full code. LVN A said LVN D got the crash cart on the way to CR #1's room along with LVN C. LVN A said she stayed at the nurses' station and called hospice and the hospice representative said the code status was pending. LVN A said called the CR #1's RP and the ADMIN and the calls went to voicemail. LVN A called 911. LVN A said she after she left CR #1's room, looked for the code status, told LVN C and LVN D, and made the phone calls took approximately three minutes. She said she saw LVN C and LVN D perform CPR and EMS arrived in approximately 5-7 minutes after she called. She said EMS took over CPR. She said while EMS performed CPR for (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 03/07/2025 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 0678 Level of Harm - Immediate jeopardy to resident health or safety approximately 15 minutes, CR #1's RP was contacted and advised EMS to discontinue CPR because an out of hospital DNR was signed LVN A said she was not trained by the facility on how to respond to an unresponsive resident when CPR or 911 had to be called. LVN A said she responded as a prudent [acting with or showing care and thought for the future] nurse would do. She said she did not think there was a risk to CR #1 with her response to leave CR #1 and check for the code status herself. She said as a licensed nurse, she had to verify the CR #1's code status. She said she did not consider calling out for assistance. Residents Affected - Few Interview on [DATE] at 4:49 p.m., with LVN C said he was near the nurses' station. LVN C said he saw LVN A at the nurses' station and she said CR #1 did not have a pulse. He said LVN A checked the electronic health record for CR #1's code status. He said LVN A did not find once in the electronic record and then looked in code status binder and there was not one. He said LVN A called multiple people to verify CR #1's code status unsuccessfully. He said LVN D and CNA (agency unknown) got the crash cart and went to CR #1's room. He said after LVN A found a code status for CR #1 from her February 2025 admission, which stated CR #1 was a full code. He said he went to CR #1's room. He said CNA (agency unknown) was holding the ambu bag (medical device that forces air into the lungs) and LVN D was in the process of connecting the oxygen. He said he started chest compressions. He said he was not able to recall how long he provided CPR before EMS arrived and they took over. He said he left out of the room immediately after EMS took over. He said he remembered LVN A was in the room with EMS. He said the CNA (agency unknown) and LVN D left out of the room after him too. He said the facility had not trained him on a code or protocol to follow when a resident was found unresponsive. He said he used his nurse knowledge on how to respond. He said there could have been a delay in responding to the resident when the code status was being verified in various ways before the CPR process was started. Interview on [DATE] at 1:36 p.m. with RN A said she was the weekend supervisor and duties included reviewing admissions and ensured they were accurate. She said the admissions process protocol was a checklist that included verification of code status. She said the facility had not trained her on the process after a resident was found unresponsive. Interview on [DATE] at 6:23 p.m. with CNA A said she went into CR #1's room, observed her and attempted to find a pulse. She said she left the room at a fast pace and notified LVN A that CR #1 was unresponsive. CNA A (agency staff) said LVN A went to CR #1's room and came back to the nurses' station to check CR #1's code status. She said when LVN A returned to the station she told another nurse (name unknown to CNA A) about CR #1. CNA A said both of the nurses looked through papers and tried to find the code status for CR #1. She said there was a male nurse at the nurses' station (name unknown to CNA A). She said LVN A told her to go and clean CR #1's face with CNA B. She said she went back to the room. She said LVN C and LVN D came into the room. She said she could not remember how long it was. She said CNA B assisted with the ambu bag. She said the male nurse (LVN C) did chest compressions and LVN D connected the oxygen. She said she did not assist. She said she had not been trained by the facility on how to assist with an unresponsive resident who needed CPR. Interview on [DATE] at 7:31 p.m. with LVN D said she was at the nurse's station and LVN A told her CR #1 was not breathing. LVN D said she flipped through the code status binder and did not see anything for [CR #1]. She said LVN A checked the electronic health record for CR #1 and did not see a code status for the resident. LVN D said she and LVN C went to the room where there was two cnas (CNA A and CNA B). LVN D said LVN C came to the room and assisted with chest compressions. LVN D said she connected the oxygen to the ambu bag that was help by CNA B. She said the event occurred at approximately between 3:00 a.m. and 3:30 a.m. She said she had been trained to check the code status books. (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 03/07/2025 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 0678 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few She said there was one binder for each hall. She said the new company took over the facility and she had not been trained on a code or the protocol when a resident was found unresponsive. She said everything happened fast and she did not think there was a risk to the resident. Interview on [DATE]at 8:34 a.m. with CNA B said she saw LVN D get the crash cart and she followed her into CR #1's room. She said LVN C came in and assisted with chest compressions. She said she held the ambu bag. She said she was not able to recall how long CPR was performed. She said left after CNA A took over the ambu bag and she went back to her assigned hall. She said she was not trained on the CPR protocol. Record review of American Heart Association dated [DATE] (https://cpr.heart.org/en/resources/what-is-cpr) revealed the following in part: Check for responsiveness. Shout for nearby help Activate emergency response (via mobile device - if appropriate) Get AED and emergency equipment (send someone to do so) . Record review of the facility policy for Changes in Resident Condition (date implemented 5/2017 and revised 1/2023) revealed the policy did not address what steps the facility staff should take when a resident is found unresponsive. Record review of the facility policy for Advanced Directive (date implemented 2/2017 and revised 1/2023) revealed in part the following: .The medical record and resident plan of care should reflect the resident's wishes as well as the physician orders in order to meet the directives described . it is the community's responsibility. to ensure that it has current copies of all advance directives. Record review of facility in-service for Admissions/Re-Admissions dated [DATE] revealed the following in part: .Full-Code will be applied to all resident without a completed and signed OOH DNR . An IJ was identified on [DATE]. The IJ template was provided to the ADMIN on [DATE] at 12:16 p.m. The following Plan of Removal submitted by the facility was accepted on [DATE] at 7:32 a.m.: Allegation: The facility failed to ensure that a resident received CPR in accordance with professional standards of practice.

F678 CPR IJ Plan of Removal for F678 (continued on next page) 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 03/07/2025 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 0678 [DATE] Level of Harm - Immediate jeopardy to resident health or safety [Facility Name]o f Removal Residents Affected - Few Immediate Response:

F678 Cardiopulmonary Resuscitation Corporate nurse educated the Administrator/Director of Nursing/Assistant Director of Nursing/Social Worker on the expected practice of confirming all new admissions have advance directives elections indicated within the medical record. o 1. All residents should have a code status election physician's order in place upon admission. o 2. Any resident who has an advance directive election change should have the election documented and a physician's order should be obtained at the time the election has been voiced. DNR elections will be honored upon the resident/representative having voiced the advanced directive care election and if DNR the OOH-DNR form will be initiated and completed timely, then uploaded into the electronic health record. o 3. Licensed Nurses both on-coming, and off-going nurses will review/audit the code status designation for any new admission, re-admission and new order or changes to code status during the 24-hour report. Any identified discrepancies or absence of code status will be reported to the attending MD, DNS and/or ADMIN. Should there not be an election of advanced directives or code status, will result in the individual being full code until otherwise directed. o 4.The Administrator/Director of Nursing/Assistant Director of Nursing/Social Worker will conduct an initial review of the admission/readmission orders to validate that the advanced directive election for code status is in place. This audit will take place the next business day during the morning meeting and the RN Supervisor on duty will conduct the audit on the weekends. In the absence of the RN Supervisor on duty, the Director of Nursing or Assistant Director of Nursing will be responsible for conducting the audit to validate code status election orders are in place. Any discrepancies will be immediately clarified with the resident, authorized representative and the appropriate order will be obtained by the attending physician. Date completed: [DATE] Corporate nurse educated the Administrator/Director of Nursing/Assistant Director of Nursing on response times when performing immediate assessments/interventions for residents with changes in condition. Anytime a resident experiences a change in condition and it appears the heart has stopped, pulseless or not breathing, with a Full Code Order or No code status, you must immediately initiate the (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 03/07/2025 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 0678 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few CPR process, until the code status is validated. The other present licensed nurses in the community must assist with the change in condition by immediately verifying code status, calling 911, notifying MD and RP. As well as assisting with the required paperwork for a hospital transfer. Date completed: [DATE] The Administrator/Director of Nursing/Assistant Director of Nursing conduct re-education with the identified nurses as well as all other licensed nurses regarding the expected practice of confirming all new admissions, re-admissions have advance directives elections indicated within the medical record. o 1. All residents should have a code status election physician's order in place upon admission or re-admission. All licensed nurses will receive the education regarding the process of reconciling physician orders into the electronic health record accurately and timely to include but not limited to code status upon admission, re-admission and any changes in code status election/advanced directives. No nurse will be allowed to work until the in-service training has been completed. o 2. Any resident who has an advance directive election change should have the election documented and a physician's order should be obtained at the time the election has been voiced. o DNR elections will be honored upon the resident/representative having voiced the advanced directive care election and if DNR the OOH-DNR form will be initiated and completed with physician's signatures timely (next business day, not to exceed 3 business days), then uploaded into the electronic health record. o Nurses are expected to validate the code status election within the electronic health record orders to determine code status ordered, upon identifying that a resident presents with altered signs of life, i.e. absence of detectable vital signs, no s/s of life. Nurse should immediately validate code status order in order to confirm advance directive/code status election prior to initiating CPR. After code status has been swiftly confirmed, the nurse should adhere to the code status election (Full Code = swiftly initiating CPR accordingly or DNR-do not resuscitate the nurse would swift proceed with notifications of no s/s of life to the physician and representative. If full code: The available licensed nurses within the community should assist with the code status response by swiftly verifying the code status order, implementing CPR according to the physician's order, calling 911, and notification to MD and RP, as well as assisting with the required paperwork for a hospital transfer. If you find a resident is found unresponsive, the nurse must yell for help, and then proceed to validate the code status, if the cart with the computer is at the door of the room. In the event the cart is not at the door of the room, the charge nurse must also yell for a team member to bring the computer, the crash cart, and the AED machine. Nurses are expected to immediately review the code status orders within the electronic health (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 03/07/2025 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 0678 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few record in order to identify the resident's code status. This should be immediately with the closest nurse's station computer or closest laptop available. The nurse should respond with urgency, immediately confirming code status and implementing resuscitative measures accordingly. o Nurses are expected to document findings, interventions/response and notifications within the medical record. o Nurses are expected to notify the Administrator and/or Director of Nurses for all emergent events, deaths within the facility, significant changes in condition and any concerns regarding CPR emergent response as well as any resident without an identified code status election order. Date Completed: [DATE] The Administrator/Director of Nursing/Assistant Director of Nursing conduct re-education with the identified nurses initially then re-education is provided to all licensed nurses regarding on response times when performing immediate assessments/interventions for residents with changes in condition. Anytime a resident experiences a change in condition and it appears the heart has stopped, pulseless or not breathing, with a Full Code Order or No code status, you must immediately initiate CPR until the code status is validated. The other present licensed nurses in the community must assist with the change in condition by immediately verifying code status, calling 911, notifying MD and RP. As well as assisting with the required paperwork for a hospital transfer. Date completed: [DATE] Director of Nursing/Assistant Director of Nursing conducted an audit to validate all orders have been entered into [facility electronic record system] accurately and timely from [DATE]-[DATE]. Outcome: 1 of 123 residents did not have designated advanced directive/code status orders in place. Issue was resolved, physician provided orders as per resident/representative's code status election. Date completed: [DATE] The Administrator/Director of Nursing/Assistant Director of Nursing out of an abundance of caution, provided re-education to all team members on Abuse /Neglect and Residents Rights. Date completed:[DATE] Going forward the identified trainings above will also be conducted with new hires accordingly. Community will ensure all staff on leave/agency/PRN staff are in serviced prior to working their shift. Community will ensure administrative nursing staff in the community to provide in-service/education prior team members working their assigned shift. These trainings will also be conducted with new hires. (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 03/07/2025 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 0678 Risk: Level of Harm - Immediate jeopardy to resident health or safety All residents who currently admit or re-admit to the community have the potential to be affected by this practice. Residents Affected - Few Community will ensure all staff on leave/agency/PRN staff are in serviced prior to working their shift. Community will ensure administrative nursing staff in the community to provide in-service/education prior team members working their assigned shift. These trainings will also be conducted with new hires. Systemic Response: Director of Nursing/Assistant Director of Nursing conducted 100% re-education was extended to all nurses regarding the expected practice of confirming all new admissions have advance directives elections indicated within the medical record. The Administrator/Director of Nursing/Assistant Director of Nursing conduct re-education with the identified nurses as well as all other licensed nurses regarding the expected practice of confirming all new admissions, re-admissions have advance directives elections indicated within the medical record. o All residents should have a code status election physician's order in place upon admission or re-admission. All licensed nurses educated regarding the process of reconciling physician orders into the electronic health record accurately and timely to include but not limited to code status upon admission, re-admission and any changes in code status election/advanced directives. o Any resident who has an advance directive election change should have the election documented and a physician's order should be obtained at the time the election has been voiced. o DNR elections will be honored upon the resident/representative having voiced the advanced directive care election and if DNR the OOH-DNR form will be initiated and completed with physician's signatures timely (next business day, not to exceed 3 business days), then uploaded into the electronic health record. o Code Status Response: Upon a resident being identified with an acute change of condition; thus, presenting with no signs of life, the absence of vital signs the nurse will: Nurses are expected to validate the code status election prior to initiating CPR by revieing the code status order within the electronic health record. The nurse should immediately alert staff for (continued on next page) 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 03/07/2025 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 0678 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few assistance and all available nursing staff should immediately respond to that location. The nurse will alert staff by utilizing the call light system, phone and /or verbally calling for emergency response assistance to that location. Upon identifying the code status election via the physician's order, the nurse should then proceed with initiating CPR. If the person is designated as Full Code as per the code status order. The available nurses within the community should assist with the code status response by swiftly verifying the code status order, implementing CPR according to the physician's order, calling 911, and/or conducting proper notification to MD and RP, as well as assisting with the required paperwork for a hospital transfer. Should the resident be designated as DNR-do not resuscitate per physician's order and as per the resident's/representative's wishes, the nurse/nurses would proceed with conducting the proper notifications of no s/s of life to the physician and representative. In the event there is no identified code status / advanced directives CPR should be initiated. Resuscitative measures should then only be ceased upon the resident's representative's instruction to stop CPR, confirm the person wished to be DNR and as instructed by physician and/or EMS-medical response team. Director of Nurses/Assistant Director of Nurses will conduct training for licensed nurses, aids and medication aids regarding the process for confirming and implementing CPR. Nursing team members will not work until in-service training has been received. Mock Code Drills: Director of Nurses/Assistant Director of Nurses will conduct monthly mock code response of both full code and DNR on various shifts. The DNS/ADNS will determine competency by evaluating the mock emergency drill. Mock code conducted on [DATE]. It was done correctly. All team members followed the Code Status Process with the Mock Code. Will conduct another mock code on [DATE] the day shift. This will be ongoing and monthly. Date to be completed: [DATE]. o Nurses are expected to document findings, interventions/response and notifications within the medical record. o Licensed Nurses both on-coming, and off-going nurses will review/audit the code status designation for any new admission, re-admission and new order or changes to code status during the 24-hour report. Any identified discrepancies or absence of code status will be reported to the attending MD, DNS and/or ADMIN. Should there not be an election of advanced directives or code status, will result in the individual being full code until otherwise directed. o Nurses are expected to notify the Administrator and/or Director of Nurses for all emergent events, deaths within the facility, significant changes in condition and any concerns regarding CPR emergent (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 03/07/2025 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 0678 response as well as any resident without an identified code status election order. Level of Harm - Immediate jeopardy to resident health or safety o All Staff: Any staff member should immediately respond to a code status response with the Crash Cart along with the AED to the bedside of identified resident accordingly. Residents Affected - Few Date Completed: [DATE] The Administrator/Director of Nursing/Assistant Director of Nursing out of an abundance of caution, provided re-education to all team members on Abuse /Neglect and Residents Rights. Date completed:[DATE] Going forward the identified trainings above will also be conducted with new hires accordingly. Community will ensure all staff on leave/agency/PRN staff are in serviced prior to working their shift. Community will ensure administrative nursing staff in the community to provide in-service/education prior team members working their assigned shift. These trainings will also be conducted with new hires. Going forward the identified trainings above will also be conducted with new hires accordingly. Monitoring: The Administrator/Director of Nursing/Assistant Director of Nursing/Social Worker will make weekly random audits validating the electronic health record for accurate code status orders as well as appropriate OOH-DNR form within the medical record. This audit will be conducted 1-7 days a week for the next 2 months. The findings will be reviewed and reported to the QAPI committee, to validate compliance or to identify additional training needs. The Director of nurses/Assistant Director of Nurses will conduct weekly skills validations of order entry as well as interview nurses to review the expected practice of validating code status upon admission, validating code status order entry as well as expected process for an emergent response when a significant change in condition (absence of signs of life, no detectable vital signs) has been identified, as well as general interviews with all staff regarding expected response of responding with the crash cart to the designated room accordingly. This expected validation observations and interviews will take place 1-7 days a week for the next 2 months. Mock Code Drills: Director of Nurses/Assistant Director of Nurses will conduct monthly mock code response of both full code and DNR on various shifts at least once a month for the next 2 months. Director of Nurses/Assistant Director of Nurses will review all admission/re-admission orders daily in the clinical meeting to validate orders are transcribed as per required code status admission orders and will review all orders daily in the clinical meeting to validate compliance of code status election has the appropriate code status election physician's order in place. This expected validation observations and interviews will take place 1-7 days a week for the next 2 months. HR/Director of Nurses will conduct CPR certification audit at least once a month for the next 2 (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 03/07/2025 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 0678 months. Level of Harm - Immediate jeopardy to resident health or safety This corrective action plan will remain in place for the next 2 months to ensure compliance or to identify any further training needs. Findings of those observations will be reported to the QAPI committee during monthly meeting for the next 2 months to establish compliance or identify additional trainings and oversight is required. Residents Affected - Few All audits will be placed in a binder and kept for review by HHSC for the revisit to validate to compliance. The Administrator/Director of Nursing and Medical Director conducted a Ad Hoc QAPI meeting to review this situation, and the immediate corrective action plan implemented. Date of ADHOC : Monitoring of the plan of removal included the following: Record review of In-Service for Administrative Nurses on Advance Directives dated [DATE] revealed DON, ADON A, ADON B, MDS A, MDS B, MDS C, were provided education by Reg. RN regarding Advance Directives and CPR process. Record review of In-Service for Administrative Nurses on &quot[TRUNCATED] FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676153 If continuation sheet Page 11 of 11