Health inspection·April 26, 2025

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review failed to ensure the resident environment remains as free of accident hazards as is possible; and Each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 1 residents (Resident #1) reviewed for accidents and supervision, in that: Resident #1 eloped on 11/3/2024 out of facility and was across a 35 per mile street, at store near gas pumps, near a highway, that was 40 miles per hour. On 11/2/2024 Resident #1 attempted to elope, before a nurse stopped Resident #1 from going outside. An IJ was identified on 4/25/2025. The IJ template was provided to the facility on 4/25/2025 at 6:41 PM. While the IJ was removed on 4/26/2025 at 7:53 PM. The facility remained out of compliance at a scope of isolated and severity level of no actual harm with a potential for more than minimal harm that is not an immediate jeopardy due to facility's need to evaluate the plan of removal. This failure could place residents at risk of severe injury or even death. The Findings were: Record review of the provider investigation intake #543029 was documented the incident date was 11/3/2024 at 3:00 PM, with Resident #1 missing resident. Record review of the provider investigation intake #543029 was documented Resident #1 was a hospice respite resident, she was interviewed, independently ambulatory, not able to make informed decisions. Record review of Resident #1's admission Record, dated 4/23/2025, was documented she was admitted on [DATE] and was discharged on 11/6/2024. Further review revealed Resident #1 was at facility for respite care with a diagnosis of dementia (a broad term describing a decline in mental abilities, including memory, thinking, and reasoning, that significantly impacts daily life). Record review of Resident #1's discharge MDS, dated [DATE], was documented a planned discharge, admission was 11/1/2024, her BIMS score was 5/15 (severely cognitively impaired), and behavior was present, fluctuates of inattention and disorganized thinking, section for behaviors Resident #1 had delusions, wandering occurred 1 to 3 days. Resident #1 had dementia, Resident #1 was 59 inches and weighs 101 pounds and was on hospice care. Resident #1 was independent with walking 50 feet with two turns. Record review of Resident #1's baseline care plan, dated 11/1/2024, was documented discharge goals was for return to the community and receive respite care. The baseline care plan was documented Page 1 of 10 455676 455676 04/26/2025 Community Care Center of Hondo 2001 Ave E Hondo, TX 78861

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Resident #1 was independent with walking 10 feet, chair/bed to chair transfer, sit to stand, lying to sitting on side of bed, sit to lying, roll left to right, eating, did not use mobility devices, resident was alert. cognitively impaired, always continent with bowel/bladder, skin was intact with no skin breakdown, and respite for 5 days by LVN A. Record review of Resident #1's care plan, dated 11/3/2025, was documented Resident #1 has had an episode of elopement and was a risk for wandering/elopement identified, initiated 11/3/2025. Interventions included identify triggers for wandering/elopement, identify if there is a certain time of day wandering /elopement, identify if there is a pattern and purpose of wandering, identify wandering/elopement de-escalation behaviors, provide care in a calm and reassuring manner, provide 1:1 supervision as elopement prevention and provide reorientation to surrounding environment. Record review of Resident #1's Elopement Risk Evaluation, dated 11/1/2024, had scored 0 by LVN A. Elopement risk assessment was marked as a yes for resident wanders, and resident wanders aimlessly or non-goal directed. Record review of Elopement Risk Evaluation score of 0 meant no risk. Record review of Resident #1's progress note, dated 11/1/2024 at 4:13 PM, was document Resident #1 arrived at 10 AM with family. Resident #1 was alert and oriented x1 and in good spirits. Resident #1 had dementia diagnoses and ambulated without assistance. Resident #1 wonders, needs supervision, easily re-directed and was very forgetful. Record review of Resident #1's 24-hour report, dated 11/1/2025, was documented Resident #1 was a new admission, hospice resident, respite for 5 days, diagnosis of Dementia, forgetful, pleasant, wonders, easily re-directed, ambulates without assistive devices, and required supervision. Record review of Resident #1's progress note, dated 11/02/24 at 6:31 AM, was documented Resident #1 was adjusting well to facility, was easily re-directed, wonders need continued monitor related to elopement risk/confusion. Record review of Resident #1's progress note, dated 11/02/24 at 4:12 PM, was documented Resident #1 was alert, forgetful and confused at times. Resident #1 was able to communicate well with staff and friendly. Record review of Resident #1's progress note, dated 11/02/24 at 10:56 PM, stated that resident was easily re-directed earlier in the day but became increasingly agitated and was placed on monitoring by LVN B related to an elopement attempt. LVN B stated she thought Resident #1 was still getting used to facility and she informed the oncoming nurse. Record review of Resident #1's 24-hour report, dated 11/2/2025, was documented Resident #1 was a hospice resident, diagnosis of Dementia, forgetful, pleasant, wonders, easily re-directed, ambulates without assistive devices, and required supervision. No changes Record review of Resident #1's progress note, dated 11/03/24, Resident #1 attended an activity with a church group. When the church group walked out, Resident #1 walked out with them. LVN A noticed Resident #1 was missing before dinner. LVN A notified staff to search for Resident #1. RN C found Resident #1 at grocery store gas pumps across the 2-lane road from the facility and near 4 lane highway. A head-to-toe assessment was done by LVN A upon Resident #1's return to the facility, and she was placed on 1:1 until her discharge on [DATE]. 455676 Page 2 of 10 455676 04/26/2025 Community Care Center of Hondo 2001 Ave E Hondo, TX 78861

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Record review of Resident #1's 24-hour report, dated 11/3/2025, was documented Resident #1 was a hospice resident, diagnosis of Dementia, forgetful, pleasant, wonders, easily re-directed, ambulates without assistive devices, and required supervision. Resident #1 was combative 3 episodes. Elopement- resident was brought back to facility safe/unharmed. no distress noted. in good spirits. 1:1 until further notice. ADM notified. Record review of Resident #1's 24-hour report, dated 11/4/2025, was documented Resident #1 was a hospice resident, diagnosis of Dementia, forgetful, pleasant, wonders, easily re-directed, ambulates with supervision due to elopement risk. Resident #1 had 1:1 care redirectable compliant. Record review of Resident #1's 24-hour report, dated 11/6/2025, was documented Resident #1 was a hospice resident, diagnosis of Dementia, forgetful, pleasant, wonders, easily re-directed, ambulates with supervision due to elopement risk. Resident #1 had 1:1 care redirectable compliant. Resident discharged today. Record review of the Elopement drill-in-service included 14 staff signatures. Record review of the staff list provided by facility included 51 staff that worked. full time at the facility. Interview on 4/24/2025 at 3:58 PM with LVN B stated she worked the night shift for the last 8 years. LVN B stated she was not working the day Resident #1 Eloped to store. LVN B stated the night before elopement, Resident #1 was close to the unlocked front door and attempted to elope that night, on 11/3/2025. LVN B stated she was monitoring and staff taking turns watching Resident #1 between monitoring and providing care to other residents. LVN B stated she notified LVN A on the on-coming shift about Resident #1's behaviors and wondering. LVN B stated Resident #1 was not attempting to go out the front door at the end of her shift, in the morning. LVN B stated she was not aware that Resident #1 wondered and had behaviors. LVN B stated the nurse before her shift only told her Resident #1 was on respite. Interview on 4/23/2025 at 1:05 PM with LVN A stated Resident #1 was forgetful, confused easily re-directed, disoriented to the facility, and would go into resident rooms. LVN A stated Resident #1 did not have a wander guard (no wander guard system in facility), was ambulatory, and spoke eloquent. LVN A stated Resident #1 was last seen at the church services, on Sunday. LVN A stated the church services was completed, and was not sure where Resident #1 was, she notified staff inside the facility, but no staff had seen her. LVN A stated she notified RN C that Resident #1 was missing, and she notified the ADM, DON, ADON, MD, hospice. LVN A stated RN C searched the perimeter of the facility with her and had found Resident #1 at the store, near the gas pumps. LVN A stated she stayed at the facility to provide care to residents and about 10 minutes later RN C drove up with Resident #1. LVN A stated she did conduct a head-to-toe assessment and Resident #1 did not have any injuries. LVN A stated Resident #1 had told her she was going shopping. LVN A stated she placed Resident #1 on 1:1 with staff for the rest of her shift and let the on-coming nurse know about the Elopement with Resident #1. Interview on 4/23/2025 at 1:39 PM with CNA V stated LVN A had notified her that Resident #1 was missing, and she took the facility van to search for Resident #1. CNA V stated RN C had found Resident #1 and brought her back to the facility from the store across from the facility. CNA V stated Resident #1 walked across the 2-lane street and across the store, that was near a 4-lane highway. CNA V 455676 Page 3 of 10 455676 04/26/2025 Community Care Center of Hondo 2001 Ave E Hondo, TX 78861

F 0689 stated there had been no elopements before or after Resident #1 eloped. Level of Harm - Immediate jeopardy to resident health or safety Interview on 4/23/2025 at 2:27 PM with RN C stated she went to get Resident #1 for dinner and asked staff if they had seen the resident. LVN A searched the activity room and inside the facility. RN C searched the outside perimeter, and found Resident #1 at the grocery store, near the gas pumps. LVN A stated Resident #1 was missing for 15-20 minutes. LVN A placed Resident #1 on 1:1 monitoring with staff. Residents Affected - Few Interview on 4/23/2025 at 3:36 PM with ADM stated Resident #1 was missing form facility for 10-15 minutes and was found by RN C. The ADM stated the Maintenance Supervisor stated he was working that day, Sunday in the front yard and saw an elderly women leave the church group. Interview on 4/23/20025 at 3:41 PM with the Maintenance Supervisor stated he was working, that Sunday. The Maintenance supervisor stated he was raking the leaves and saw the church group leave the facility but did not know a resident was with the church group. The Maintained Supervisor stated he went inside the facility, and LVN A had notified they had a missing resident that was with church group. The Maintenance supervisor stated, and he started searching for Resident #1. Interview on 4/24/25 at 9:56 AM with ADON stated she was not aware of Resident #1's attempt to elope on 11/02/24. ADON stated her expectations would be for nurse to call her. ADON stated they did not have a wander guard system and the front doors were not locked. ADON stated she would expect the nurse to re-evaluate Resident #1 for elopement risk. ADON stated if she had known about the attempt to elope, she would have initiated the 1:1 sooner. ADON stated if she was aware of Resident #1's wandering behavior, she would have told the nurses to monitor resident 30 minutes to every 1 hour daily. Interview on 4/24/2025 at 1:00 PM with the ADON stated in the morning staff meetings they review the 24-hour reports. The ADON stated they did have an elopement book and Resident #1's picture, admission record was placed in the elopement book. The ADON stated she was not sure when Resident #1 was placed in the Elopement book. The ADON stated the expectation for nurses was to do another Elopement Assessment after an Elopement, she was not sure why Resident #1 did not have one in her chart. Interview on ADON stated Resident #1 was missing for 5 minutes, and LVN A did notify her about the elopement. Interview on 4/24/2025 at 1:50 PM with the ADM stated they had conducted an elopement drill/in-service for staff on the Elopement policy. Interview on 4/26/2025 at 5:00 PM with the Administrator stated, as a result of the elopement, the facility no longer accepts respite care residents who are independently ambulatory and have advanced Alzheimer's. They also make it clear to families during early admission process that they do not have the physical barriers or staffing levels to manage a resident who wanders/exit seeks. An attempted interview on 4/25/2025 at 9:14 AM with family of Resident #1 did not answer, left a voicemail with no return call. Record review of Elopement Policy dated 2001 was documented The facility will identify residents who. are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. Policy Interpretation and Implementation 455676 Page 4 of 10 455676 04/26/2025 Community Care Center of Hondo 2001 Ave E Hondo, TX 78861

F 0689 Level of Harm - Immediate jeopardy to resident health or safety 1. If identified as at risk for wandering, elopement, or other safety issues, the resident's care plan Will include strategies and interventions to maintain the resident's safety. o 2. If an employee observes a resident leaving the premises, he/she would: Residents Affected - Few a. attempt to prevent the resident from leaving in a manner. b. get help from other staff members in the immediate vicinity, if necessary; and . c. instruct another staff member to inform the charge nurse or director of nursing services that a resident is attempting to leave or has left the premises. 3. If a resident is missing, initiate the elopement/missing resident emergency procedure: . a. Determine if the resident is out on an authorized leave or pass; b. If the resident as not authorized to leave, initiate a search of the building(s) and premises; and c.If the resident is not located, notify the administrator and the director of nursing services, ·the resident's legal representative, the attending physician, law enforcement officials, and (as necessary) volunteer agencies (i.e., emergency management, rescue squads, etc.). 4. When the resident returns to the facility; the director of nursing services or charge nurse shall: a. examine the resident for injuries. b. contact the attending physician and report findings and conditions of the resident. c. notify the resident's legal representative (sponsor); d. notify search teams that the resident has been located. e. complete and file an incident report; and f. document relevant information in the resident's medical record. The Administrator was notified of an IJ on 4/25/2025 at 6:41 PM and was given a copy of the IJ Template and a Plan of Removal (POR) was requested. The Plan of Removal accepted on 4/26/2025 at 7:53 PM and included the following: Plan of Removal for Immediate Jeopardy Related to Resident Elopement (F689) 455676 Page 5 of 10 455676 04/26/2025 Community Care Center of Hondo 2001 Ave E Hondo, TX 78861

F 0689 Facility Name: [name] Level of Harm - Immediate jeopardy to resident health or safety Facility ID Number: 004531 Residents Affected - Few Resident Involved: [name] Date of Immediate Jeopardy Identification: 4-25-2025 Date of Elopement: 11-3-2025 Date of Return: 11-3-2025 1. On 4/25/2025 the Administrator and Director Nursing notified the Medical Director of Immediate Jeopardy. Medical Director reviewed the facility's Elopement Policy & Procedure and approved its continued use. At the time of this Plan of Removal, resident no longer resides in the facility. 2. On 4/25/2025, the facility conducted an Elopement Assessment on all current residents to identify elopement risks. 3. The facility implemented a change to its Elopement Assessment protocol to require nursing staff to perform elopement assessments on day 1, day 3, and day 5 for all new admissions, followed by quarterly assessments. A new elopement assessment will also be required for residents who are demonstrating new elopement or exit seeking behavior. Residents demonstrating changes of conditions in wandering or exit seeking behavior will be assessed through both clinical and physical methods to determine the cause in their change of condition. The facility will implement appropriate measures to mitigate the risk of elopement appropriate to the resident's needs and risk factors, to include but not limited to: Diagnostic testing Increased supervision Family Intervention Discharge to acute setting for further testing Medication Reviews and adjustments Discharge to appropriate setting Referral to psychological services Any changes of behavior or conditions that increase the resident's risk of elopement must be reported to the Director of Nursing or the Assistant Director of Nursing. 4. The facility DON or her/his designee will monitor compliance to its new elopement assessment 455676 Page 6 of 10 455676 04/26/2025 Community Care Center of Hondo 2001 Ave E Hondo, TX 78861

F 0689 Level of Harm - Immediate jeopardy to resident health or safety protocol by reviewing new admission documentation during its daily clinical review for 4 weeks to ensure compliance. Any discrepancies or deviations from this protocol will be addressed by the DON and/or her designee for compliance. 5. Ad-Hoc QAPI meeting was held on 4-25-2025 with the Medical Director, Facility Administrator, Director of Nursing, and Assistant Director of Nursing to review the deficiency and the plan for removal of immediacy. Residents Affected - Few The verification of the Plan of Removal is as follows: 1. Interview on 4/26/25 at 11:15 AM with the DON stated for the Ad-Hoc QUAPI meeting the ADM and ADON were present, and the Medical Director was in a conference call and reviewed the Elopement policy and discussed the IJ and plan of removal. Record review of Ad hoc meeting on 4/25/25 called MD on phone, conference call attendees were ADM, DON and ADON. Resident #1- At the time of elopement, staff located resident in seven minutes and returned her to the facility. Resident was assessed and found free of any injury and/or distress. Record review of Resident #1's face sheet dated 4/26/25 revealed she was admitted on respite on 11/1/24 and discharged on 11/6/24. Notification - The facility notified resident's responsible party and physician. At the time of the incident, the facility staff notified facility administrator and Director of Nursing. Record review of Resident #1's progress notes dated 11/3/25 at 19:46 was documented LVN A notified the ADM, family, RP, DON and ADON regarding Resident #1's Elopement and placed her on 1:1 care. On 11-4-2024, the facility staff conducted a head count to ensure all residents were accounted for and in the facility. Interview on 4/26/25 at 5:21 PM with ADM and DON stated they talked to 2 charge nurses, and they did a head count to confirm all residents were in the building. 2. Observation on 4/26/25 at 12pm revealed Elopement policy, Elopement binder and Elopement Assessment policy at each nurse's station. (2 nurse's stations). Record review of 51 residents had Elopement Assessment completed on 4/25/25. Record review of current resident list was document with a census of 51. On 4/25/2025, the facility provided education and a copy of the facility's Elopement Policy and Procedure. Facility management verified all staff members received and understood the Elopement Policy and Procedure. Upon confirming receipt, staff members were asked to verbalize their understanding of policy. Record review of the policy on Elopement were emailed to staff and were signed acknowledging they receive the policy. 455676 Page 7 of 10 455676 04/26/2025 Community Care Center of Hondo 2001 Ave E Hondo, TX 78861

F 0689 Record review of in-service for Elopement policy dated 4/25/25 had 64 staff signatures. Level of Harm - Immediate jeopardy to resident health or safety All staff: Residents Affected - Few Training was on Wandering and Elopement, what to do if resident leaves the facility-try to re-direct and be kind, if combative will notify/call nurse/staff to help. If resident missing from facility, first find out if went out on pass with family at each nurse's station, search of the resident in building count resident, notify ADM, DON, and ask staff in the building. If not in building need to notify MD, family and police, staff check out the outside perimeter and beyond. To be the eyes and ears of the facility and be aware of resident coming and going. They have Policy and Elopement book at each nurse station and which resident is at risk. Nursing staff get reported from previous staff of new residents. DON emailed the staff policy and staff had to sign to confirm they received the email policy on Elopement/Wandering: Interviews on 4/26/25 between 11 AM- 4:45 PM: D- Dietary Manager E- Dietary Cook F- Dietary aid G- CNA H- CNA I- Housekeeping J- OT K-CMA P- Laundry, before a CNA Q- Housekeeping/laundry supervisor R- HR S- Maintenance T- Housekeeping U- CNA V- [NAME], CAN Y- CNA (Night shift) Z- CNA (Night shift) 455676 Page 8 of 10 455676 04/26/2025 Community Care Center of Hondo 2001 Ave E Hondo, TX 78861

F 0689 AA-, prn, OT Level of Harm - Immediate jeopardy to resident health or safety CC CNA Residents Affected - Few FF- PT, prn wknds, stated she did get training by DON. EE-, OT, prn 3. Observation on 4/25/25 with nursing in-service on Elopement/Wandering and Assessments. The observation was led by the DON and 4 nurses were present. Record review of Elopement assessment dated [DATE] was documented 13, plus the DON that led the in-service, form nursing department. Interviews with staff on Elopements review policy and educate staff on how to proceed in case of Elopement and only Nursing staff: -Elopement Assessments in-services dated 4/25/2025. Record review of current staff list dated 4/25/25 revealed a total of 64 total staff, 51 current staff and included 14 nurses, that worked routinely and as needed. Interviewed staff the 2 shifts and staff stated they rotate weekend shifts. Interview on 4/26/25 at 11:03 AM with the DON nurses were educated on the Elopement Assessment -Educate on New changes related to when Elopement Assessment will be conducted. Interviews on 4/26/25 between 11 AM- 4:45 PM: Interviewees stated they were trained on Elopement and Assessments. Elopement assessments were to be done on admission, day 3, day 5, quarterly, prn. Nursing was to check for change of condition, notify the DON, MD, and family. If resident was missing check to see if they are out on pass, complete a head count, search inside the facility and outside. Notify RP, ADM, MD, DON and ADON and police. When the resident returned, document elopement assessment, progress notes incident report, and complete any treatment from MD if any injuries. Notify the RP, ADM, MD, DON and ADON and police once the resident is found. Staff stated they also, received an email from ADM/DON on elopement and signed that they received the policy. A- LVN B- LVN L- RN M- ADON N- LVN O- MDS, LVN W- LVN (Night shift) 455676 Page 9 of 10 455676 04/26/2025 Community Care Center of Hondo 2001 Ave E Hondo, TX 78861

F 0689 X- LVN (Night shift) Level of Harm - Immediate jeopardy to resident health or safety BB- LVN Residents Affected - Few Record review of the Elopement in-services revealed All facility nurses were provided education of this new requirement on 4/25/2025. DD- LVN prn, Record review of the staffing list dated 4/26/25 was documented the facility had 14 nurses. 4. Record review of Elopement Assessment Monitoring for New/re-admit Residents sheet was in POR binder, included 1 resident. The 1 re-admit resident elopement assessment was completed on 4/26/25. Resident was admitted on [DATE]. The Elopement Assessment Monitoring included a section for Day 1, Day 3, and Day 5, and included dates of completion section. Interview on 4/26/25 at 3:34 PM with ADON stated she will fill out the monitoring sheet for new/re-admit and change of condition regarding elopements. 5. Interview on 4/26/25 at 11:15 AM with the DON stated for the Ad-Hoc QUAPI meeting the ADM and ADON were present, and the Medical Director was in a conference call and reviewed the Elopement policy and discussed the IJ and plan of removal. Interview on 4/26/25 at 5:38 PM the MD stated he was told by the DON that they had an IJ for F689 on Elopement and participated in the Ad-hoc QUAPI mtg. Record review of Adhoc meeting on 4/25/25 revealed the MD was called on phone, conference call attendees were ADM, DON and ADON. The Administrator will be responsible for ensuring this plan is completed on 4-25-2025. Interview on 4/26/25 at 5:16 PM with ADM confirmed the POR binder was completed by each section and ensured the MD was in agreement with the Elopement policy and plan. Also, conducted elopement assessments for each resident and ensured all staff were educated on Elopement. On 4/26/2025 at 7:53 PM, the Administrator was notified the IJ was removed. However, the facility remained out of compliance at a scope of isolated and severity level of no actual harm with a potential for more than minimal harm that is not an immediate jeopardy due to facility's need to monitor the implementation and effectiveness of its plan of removal. 455676 Page 10 of 10