Health inspection·July 31, 2025

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few notified by charge nurse LVN B that floor staff has been unable to locate Resident #3 and all current members of staff on unit C continue to look for him. The DON assisted the search. After 5 minutes of looking for the resident, a code purple was called, and the entire team began looking for the resident on and off the property. The DON called the ADMIN and informed her of the elopement. The DON called 911 at 6:50 AM. A resident flyer with personal information was copied for police and staff members. Record review of Resident #3's Nurse Note, dated 5.14.25 and created at 12:02 AM, authored by DON, revealed Resident #3 was located and brought back to the facility by the police department. He received a full head to toe assessment. Skin noted to be intact with no bruises, scrapes, or bumps noted. A neurological assessment remains at baseline. DR G was informed of the elopement and safe return with no new orders obtained. Resident placed on line-of-site (sic) monitoring to prevent reoccurrence. Nursing staff received updates and in-service training. Record review of Resident #3's Nurse Note, dated 5.14.25 and created at 12:59 PM, authored by charge nurse LVN C, revealed Resident #3 was located and brought back to the facility by the police department. A full head to toe assessment was completed. Skin noted to be intact with no bruises, scrapes, or bumps noted. A neurological assessment remains at baseline. The resident denies pain or discomfort. The RP was notified of Resident #3's return and bed change to a room closer to the nurse's station. No new orders from the NP and per the DON, the resident was placed on line-of-site (sic) monitoring and neuro checks for 72 hours. Record review of Resident #3's Nurse Note, dated 5.15.25 and created at 6:48 AM, authored by LVN B, revealed staff was on 1-to-1 monitoring and 30-minute visual checks were in place. Resident #3 will continue to be monitored for exit-seeking behaviors. Record review of Resident #3's Nurse Note, dated 5.15.25 and created at 12:59 PM, authored by charge nurse LVN C, revealed staff continue to monitor Resident #3 for elopement behaviors on day 2/3. Resident #3 continues to wander through the MCU and expresses verbally that he wishes to go outside for a walk, was seen walking up to multiple exit doors but is easily redirected. Record review of Resident #3's Nurse Notes, dated 5.16.25 and created at 6:30 AM, authored by LVN B, and dated 5.16.25 and created at 2:11 PM, authored by LVN C, revealed 30-minute checks were in place as Resident #3 continues to wander, walk up to multiple exit doors, and voice if he can go outside. Record review of Resident #3's Nurse Note, dated 5.17.25 and created at 3:40 AM, authored by charge nurse LVN D, revealed staff continue to monitor Resident #3 for elopement behaviors on day 3/3. Resident #3 continues to wander through the MCU and expresses verbally that he wishes to go outside for a walk, was seen walking up to multiple exit doors but is easily redirected. Record review of elopement investigation report for Resident #3's, dated 5.14.25 authored by the ADMIN revealed, the resident eloped on 5.14.25 at around 5:45 AM. CNA A responded to the unit C-back door alarm after returning from another unit. CNA A turned the door alarm off and returned to assisting her coworker with rounding. CNA A noticed that Resident #3 was missing from the secured area and began to look for the resident. At 6:20 AM, CNA A notified LVN B that she cannot find the resident. At 6:25 AM, LVN B notified the DON that they cannot find Resident #3. At 6:30 AM, residents in the secured unit are counted and Resident #3 was the only one not accounted for. At 6:35 AM, the DON notified the ADMIN. At 6:40 AM, the ADMIN initiated a search for Resident #3 in the facility. At 6:50 AM, the DON called the police to report a missing resident as well as assigning available staff to search an extended zone. At 7:25 AM, the facility received a call from Resident #3s RP who stated that the resident was found by the police. At 7:40 AM, the resident was returned by the police. The ADMIN suspended CNA A and terminated her employment. Additional actions the facility took to correct the immediacy (prior to the surveyor entrance) included bi-weekly elopement drills, education was provided to the Admissions/Marketing team to ensure all residents were prescreened for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455533 If continuation sheet Page 2 of 4 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 455533 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/31/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windcrest Nursing and Rehabilitation 8800 Fourwinds Dr Windcrest, TX 78239 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 wandering/elopement risk, and a 6-foot wooden fence with a keypad locked gate was constructed outside of the unit C-back secure exit door on 6.4.2025. Activation of the fire alarm system disables the lock. During an observation and interview on 7.27.25 at 4:41 AM with Resident #3, he stated the employees treat him good. He also revealed that other residents treat him good. He revealed that he did not need assistance with showers stating, no I can do it myself. Resident #3 was sitting at a table in the dining room on the secured unit, had on shoes, and was well-groomed. At 4:45 PM, Resident #3 got up and walked out of the dining room. During an observation and interview on 7.30.25 at 11:30 AM, Resident #3 was sitting in the dining area alone with a drink watching TV. He was groomed and calm. During an observation on 7.31.25 at 8:59 AM of Resident #3 revealed his room to be clean and call light on his bed. Resident was not in his room and was observed sitting in the dining room at a table with several other residents and appeared with a calm demeanor. During an interview on 7.30.25 at 5:45 PM, the ADMIN revealed that Resident #3 was residing in a secure unit and was an elopement risk. Regarding the elopement incident for Resident #3 that occurred on 5.14.25, the ADMIN stated, around 5:45 am the door alarm was sounding in the facility C wing back door end of hall and the aide CNA A told me that she put the code in and turned off the alarm and began helping her colleague with rounds. The ADMIN asked if she looked outside, and she said no. During the investigation, the church camera next door caught him going toward the front of the facility on the outside of the facility at 5:47 am. At 6:00 am CNA A realized he was missing because she went to his room and did not see him in the bed and started looking for him and in between that time she is looking for him around 6:10am he was seen at the (gas station) and asked the attendee for a soda and the attendee gave him a fountain drink and the attendee said he then went outside and was sitting outside for about 10 minutes. Around 6:20am he was seen leaving the (gas station) by the attendee and pointed toward the (bus station). Around 6:20am the CNA A told her nurse LVN B that Resident #3 was missing. At approximately 6:25am the nurse called the DON and notified him. He was the DON at that time. The DON was in facility, and she went to the unit and looked for the resident and then called me around 6:35am. At 6:40am I arrived, and I spoke with CNA A and LVN B about what happened and that is when she told me she heard the alarm and turned it off and went to help her fellow aide with rounding and I talked to LVN B who said he had just found out about it from CNA A. I directed staff and assigned staff to conduct a facility search internal and external. Around 6:50am the DON called the police to report a missing resident. The police arrived between 6:55-7:15 and during that time we developed flyers with his pictures and more staff arrived and I assigned them zones to look external around the area. Around 7:15am the church next door came over and showed me the video of Resident #3 walking by the front at 5:47am. At 7:25am the facility received a call from (police department) stating the police department found him. He was found at the renting vans location in front of the (bus station) which was about 4-minute walk from the (gas station) which is .4 miles from the facility. The police brought him back to the facility at 7:40am. When he returned, we completed a full head to toe assessment, and he had no bumps, scrapes, or bruises and was very pleasant spirits. The ADMIN revealed that two elopement in-services were conducted for staff prior to this incident. CNA A received in-servicing on elopement and door alarms on 3.12.2025 and signed the sign-in sheet. The ADMIN revealed exit doors will alarm for 15 seconds while the bar was being pushed before unlocking. Once unlocked, the alarm will continue to sound until reset by keypad. Staff has access to codes at each door. The ADMIN stated that the expectation of staff when a door alarm sounds, was that they react and look outside and look to see if anyone went out the door when a door alarm sounds. The ADMIN stated that the harm that could come to a resident when door alarms are silenced without investigating for possible elopement could (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455533 If continuation sheet Page 3 of 4 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 455533 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/31/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windcrest Nursing and Rehabilitation 8800 Fourwinds Dr Windcrest, TX 78239 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 cause death if we don't find them. An interview with CMA E on 7.28.25 at 9:41 AM revealed Resident #3 always looked outside and would sometimes push on the doors to test them. An interview with LVN C on 7.28.25 at 4:10 PM revealed that she worked at the facility for 2.5 years and worked in the memory care unit. She revealed that Resident #3 always wanted to go outside and go for walks. When Resident #3 first entered the facility, staff would have to redirect him and find activities to keep him busy. An interview on 7.31.2025 at 9:45am with the Administrator revealed the fence on the outside of the unit C-back exit door was installed on 6.4.2025 and residents at risk for elopement on the unit started on 1-hour observation until the new fence was installed. The administrator stated elopement drills were ongoing with staff and there have been no further elopements. The administrator stated Resident #3 expressed wanting to leave at times and remains an elopement risk and continues to reside on the secure unit. Interviews on 7.31.2025 between 8:45 AM and 2 PM with 1 RN, 4 LVNs, 3 CNAs, and an Admissions/Marketing staff member from various shifts demonstrated that they were knowledgeable of what to do when a door alarm was activated, understood elopement precautions, and had received training on elopement procedures. Record review of the Ad Hoc QAPI held on 5.14.2025 regarding Resident #3's elopement from the memory care unit revealed the document was signed by the Administrator, DON, Medical Director, Regional Director of Operations and an RN. Record review of the facility's Elopement/Code Purple in-service dated 5.14.2025 defined elopement as A situation in which a resident leaves the premises without the facility's knowledge and supervision. It is the responsibility of ALL TEAM MEMBERS to direct residents away from exit doors for their safety. the facility's interior or exterior grounds. CNAs and nurses need to conduct one-hour visual checks on all When a resident is missing, staff are to notify the charge nurse immediately (if unable to locate the DON). Charge nurse is to initiate a Code Purple. Record review of facility in-service on the topic of Elopement/Code Purple conducted on 5.14.25 by the DON revealed 80 staff members received the training (100% of staff trained). Record review of doors and locks maintenance check logs dated 3.31.25 7.25.25 revealed exit doors with alarms were checked for operation and passed. Record review or facility's Wandering and Elopement Prevention policy, undated, read The facility will identify residents who are at risk of unsafe wandering and stive to prevent harm while maintaining the least restrictive environment for residents. During exit conference on 7.31.25 at 3:51 PM, Administrator was informed that evidence revealed a F689 past non-compliance IJ (immediate jeopardy) for elopement of Resident #3. Event ID: Facility ID: 455533 If continuation sheet Page 4 of 4