Inspection·July 10, 2025

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few the street on the ground. Front desk quickly rushed to scene with phone in had calling administrator. By the time she made it to scene EMS and ADNS was on site. She then returned to facility and notified Nurse of what had happened. Activity Director stated that while working front desk a lot of family and new hires were there and she did not see resident go out the door, after redirecting her x2. Resident was transported to ER for further evaluation. MD and RP were notified. Record review of progress notes of CR #1 dated 1/3/2025, nurse notes indicated CR #1 returned to facility via EMS on 01/02/25 at 7:21PM. RP, NP, and DON notified of return. Resident has no new orders. Resident vitals 130/79, 73, 94% O2, 18, 97.5. Resident has laceration to nose with 3 sutures, closed fracture to left wrist with splint in place, and closed fracture to nasal bone. Resident has no complaints of pain or discomfort at this time. Resident was put on 1:1 with CNA at CR #1 bedside and as CR #1 walked around facility. Record review of CR #1's nurses notes dated 1/3/2025 at 12:19AM indicated CR #1 Resident continues 1:1 service. Resident currently walking around facility with sitter. Resident states she is waiting on her mom to pick her up. Resident redirected to bed. Record review of nurse progress notes CR#1 revealed CR#1 was on 1:1 until discharge date of 01/08/2025. Interview on 07/08/2025 at 2:45PM with Activity Director who said around 1:30PM on 01/02/2025 CR #1 went out the front door like she does all the time to sit on the front porch, it was very busy that day there was new hires and trainings going on. CR #1 usually just sits in the front and then comes back into the building. That day a unidentified person came into the facility and reported that it was a lady sitting in the median that look like she was from the nursing home I went outside to check and it was CR #1 in the median and she was sitting on the ground. I came and got the charge nurse, and the administrator was called also, and the EMS was already there when we all arrived. CR #1 look like she had a cut on her forehead, and she was put into the ambulance. I know I saw CR #1 in the dining room when she had just come back from the therapy. If a resident was exit seeking and got out, they could get hurt or be lost and be in danger. Interview on 07/08/2025 at 4:30PM with the Unit manager who stated CR #1 had a history of looking for her mom. She would always have a bag with her stating she was looking for mom she would sit on the front porch all the time but would come back. Along with the receptionist and nursing staff it was our responsibility to check on all residents all the time while they are sitting outside in the front or the back of the facility. The receptionist should always call and ask if a resident was able to be outside by themselves. If a resident gets out it could be serious. Interview on 07/08/2025 at 5:30PM with previous Assistant Director of Nursing who said that day of 1/2/2025. I was working, and she was on the porch but was found at the car wash next door. When I got there the EMS was there and CR #1 was being accessed by the paramedics and was transported to the hospital for further evaluations. CR #1 had a laceration to her head, it had blood on it, and she was alert. When CR#1 came back that night, I called her FM who said she was received a call earlier. On 1/3/2025 (CR # 1) was put on a 1;1. She said the Activity Director, or the receptionist should have asked a nurse prior to letting CR #1 out of the building. It's something major if a resident that get out the building with memory issues because they can get hurt or worse. Interview on 07/08/2025 at 5:45PM with CNA A who said she saw CR #1 sitting outside around 11:30 am and tried to convince her to come inside because it was cold, and CR #1 resisted to return into the facility. CNA A said she tried to get another CNA to help to bring CR #1 to the facility, but she started to become aggressive. So, I let the front desk lady know, and I returned to the floor. Interview on 07/09/2025 at 11:30 AM with the regional nurse who stated that the facility conducted in-services on a quarterly basis prior to incident with CR #1 and after incident with CR #1 in-services were done monthly along with elopement drills which was done on 1/31/2025 with another drill planned for 7/31/2025. Elopement drills (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 07/10/2025 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete are done every 6 months per company policy. Record review of facility's Elopement policy dated Revised May 2024 revealed the Following: Review of the facilities meeting documentation reflected they completed an AD HOC QAPI on 01/03/25 which was attended by the Administrator, DON, and Medical Director. The following was discussed:1. Elopement wandering/leaving the facility training.2. Abuse/neglect training,3. Resident right rights training4. Updated the elopement book Performance improvement plan with immediate intervention which included: 1. Head count, 2. Resident returned to facility at 9:20 PM on the same day from the hospital ER3. Medical Director/RP notified.4. Head to assessment completed.5. Exit Seeking Tool was completed.6. Audit on all residents to identify residents at risk for elopement. 7. CR #1 was transferred to a secure facility.8. Elopement binder reviewed and updated.9. Residents' BIMS updated in binder. Review of Components of the PIP/QAPI dated 01/03/2025 were reviewed by the survey team. The QAPI recommendations were completed and included the following: The front door and all side/back doors are locked 24 hours a day. Residents are closely monitored that are seating in front porch area every 15 minutes by the receptionist. Facility is in the process of hiring hospitality aide to assist with the facility concierge program. Inservice was done the day of incident and every month after incident. Any residents that are at risk for elopement are evaluated upon admission and if necessary, will be placed on 1:1. Facility conducted elopement drill on 1/31/2025. Per company policy elopement drills are recurrence every 6 months. Record review of facility's elopement policy dated 01/03/2025 Record review of facility's grievance log did not reveal any concerns for potential elopement. Record review on 07/08/2025 of all elopement in-services and drills were conducted on 1/3/2025 and thereafter every 3 months. Completed with no concerns. Record review of incident and accidents did reveal resident with a potential to elope, resident was placed on 1:1 until discharged . Record review of facility's Reporting incidents and accidents in-service acknowledgement dated 05/24/2024 revealed nursing staff including RN and LVN's, MA's, and CNA's received training for how to investigate and follow up on incidents and accidents and completing incident and accident documentation. Record review of facility's Ensuring doors are locked behind staff entering and exiting facility in-service acknowledgement dated 7/31/2024 revealed nursing staff/nursing administration received education on alarms sounds and doors security. The signature page included Administration, DON, all nursing staff who was assigned for duty the afternoon of the elopement and thereafter education was provided for current and new staff. Record review of facility's Abuse and Neglect in-service acknowledgement dated 1/3/2025 revealed nursing staff received education on being expected to follow federal guidelines for ANE, prevention of ANE, reporting of ANE, and investigating allegations of ANE. The signature page included ADON, the nurse who was assigned to CR #1 on 1/31/2025 the afternoon of the elopement. On 07/09/2025 at 3:18 pm, facility administrator was notified of past noncompliance IJ. A plan of removal was not requested. An IJ template was provided to the administrator via email with signature requested. The noncompliance began on 01/02/2025 and ended on 01/31/2025. The facility corrected the noncompliance before the investigation began. Event ID: Facility ID: 676153 If continuation sheet Page 3 of 3