Health inspection·January 15, 2025

F 0689 Level of Harm - Immediate jeopardy to resident health or safety 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 observation, interview and record review the facility failed to ensure each resident received adequate supervision for 1 of 1 resident (Resident #1) reviewed for supervision. Residents Affected - Few The facility failed to ensure Resident #1 did not elope from the facility on [DATE]. Resident #1 was missing from the facility from approximately 5:00 am to 8:00am am until he was located by police. An IJ was identified on [DATE] at 4:10 PM. While the IJ was removed on [DATE] at 7:45AM, the facility remained out of compliance at a level of no actual harm at a scope of isolated with a potential for more than minimal harm, that was not immediate jeopardy, due to the facility's need to evaluate the effectiveness of the corrective systems. This deficient practice placed residents at risk for falls, injuries, dehydration, hospitalization, and death. Findings included: Record review of Resident #1's admission recorded dated [DATE] reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses that included: dementia (brain diseases that cause declining thinking, memory, and reasoning skills), psychosis (mental state where a person's perception of reality is different from other such as hallucinations and delusions), depression (feeling sad, unhappy, or miserable), major depressive disorder (mood disorder that can cause a persistent feeling of sadness and loss of interest), muscle weakness(when your muscle feel tired, weak, or unable to exert their usual force), abnormality of gait and mobility (any deviation from a normal walking pattern, including changes in the rhythm, coordination, and stability of movement), lack of coordination(not being able to move your body smoothly and precisely), and symbolic dysfunction (disorder that affects a person's ability to perceive or perform certain activities). Record review of Resident #1's Annual MDS assessment, dated [DATE], revealed the resident had a BIMS score of 03 indicating the resident had severe cognitive impairment. Resident #1 required supervision or touching assistance in the following areas: personal hygiene, putting on/taking off footwear, lower body dressing, upper body dressing, shower/bathe self, toileting hygiene, and oral hygiene. Record review of an Elopement Risk Assessment dated [DATE], reflected Resident #1 was a risk for elopement. Record review of local weather with outside temperatures for the local area on [DATE] from 5:00am Page 1 of 6 675360 675360 01/15/2025 Woodland Springs Nursing Center 1010 Dallas St Waco, TX 76704

F 0689 8:00am temperatures ranged from 28 degrees to 30 degrees F. Level of Harm - Immediate jeopardy to resident health or safety Record review of progress note, dated [DATE], reflected nurse was made aware of elopement at approx. 0800 that resident was not in room or unit. This nurse made staff aware of situation and head count and search initiated of building and surrounding area of outside perimeter. Resident was seen approximately 0500 near day room and was unable to sit down on couch and returned to room at this time. Call placed to DON, made aware of situation. Call placed to emergency contact, made aware and will keep updated. Residents Affected - Few Record review of progress note, dated [DATE], reflected DON responded to report by charge nurse of suspected elopement. CODE Pink response measure deployed, unable to locate resident facility premises. Administrator and Corporate Team alerted of incident; local PD dispatched for further assistance. Resident located near facility by local PD. Nursing Admin arrived at scene, where Resident #1 refused to be transported back to facility. After several minutes of convincing by the officer on scene, Resident #1 was transported to facility by police car. Upon arrival to the facility, Resident #1 became increasingly irate and agitated, adamantly refusing to return to facility. Resident #1 stated, Don't come near me, I'm not going in there, and if you force me I'll f**k you up and everyone else back there. Police Dept able to eventually de-escalate the situation. Resident #1 demanded that we give him his belongings and release him now! I explained to Resident #1 that we would have to get an order from his physician in order to release him and have a meeting with our Team and his friend to come up with a plan for him to leave safely. Resident #1 began to yell and curse and said, I'm not waiting on a Dr, I'm leaving now, I'm a grown man and it's my choice, I'm not in prison! PD stated, Resident #1 is his own Responsible Party and appears to be alert and cognitive and the facility cannot hold him here against his will. I explained to PD that resident had history of alcohol-induced dementia, and I did not feel comfortable releasing him into the community with no secure discharge plan. Local PD began asking a series of questions to attempt to review his cognitive status. They stated Resident #1 knew his name, the year, his whereabouts, where he was from, and named several people on his contact list. I explained to local PD that LTC settings have clinical assessments used to determine a resident's cognitive status, and PD attempted to assist me with completing this assessment to no avail. Resident #1 grew agitated towards the end of the assessment, began to make threats of physical violence, and did not allow completion. At this time, I requested that the officers encourage Resident #1 to go to the local hospital for further evaluation to rule out infection, abnormal labs, etc. After several moments, Resident #1 was transferred to local hospital via police car. IDT team, ombudsman, medical director, corporate team notified. Record review of progress note, dated [DATE] at 10:31am, reflected the DON spoke w/staff from local hospital re: transfer of Resident #1 to in-patient psychiatric hospital. Stated that another psychiatric evaluation had been completed and per the new psychiatric evaluation, resident did not meet criteria for in-patient psych stay. Local hospital staff stated, Resident #1 continued to refuse to return to the nursing facility and continued to make threats of physical harm if made to return to facility. DON requested that local hospital staff forward clinical updates/evaluation notes and results to e-fax for review as soon as possible, so that resident updates could be discussed with Administrator, Clinical Consultant, IDT Team and appropriate interventions and measures are able to be put in place. Emphasized to local hospital staff that we are willing to accept resident back, however we want to ensure the safety of the residents and staff upon his return. Encouraged local hospital to connect Resident #1 with a counselor or social worker that may be able to help him cope with the emotions that he was experiencing, and acceptance of his need to be in a long-term care setting. DON requested that local hospital stay in close contact with the nursing facility so that we may collaborate on a safe transfer for the resident. Anticipated to connect 675360 Page 2 of 6 675360 01/15/2025 Woodland Springs Nursing Center 1010 Dallas St Waco, TX 76704

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few [DATE] after the nursing facility IDT meeting and local hospital doctor rounds/team meeting to discuss further. Record review of Resident #1's care plan, dated [DATE], revealed Resident #1 was care planned for risk of side effects/complications from antidepressant use related to depression, deep vein thrombosis, difficulty making decisions dementia associated with alcoholism with behavioral disturbance, placed in secure unit d/t history of elopement, physically aggressive behavior, h/o of wandering, and impaired comprehension. Record review of a police report date [DATE], revealed the local pd was notified Resident #1 was missing at 8:33am on [DATE]. The record review also revealed Resident #1 was located at 10:16am on [DATE]. An interview with the MD on [DATE] at 1:11pm, revealed the MD was told that Resident #1 departed through a window, the doors had an alarm but not the windows. The MD stated Resident #1's elopement could have caused Resident #1 harm from hypothermia(a condition that occurs when body temperature drops below 95 degrees Fahrenheit or 35 degrees Celsius.) or possible death. The MD stated Resident #1's elopement was unacceptable. An interview with the DON on [DATE] at 11:27am, revealed the DON stated she was informed by the charge nurse that Resident #1 was noticed missing around 7:30am on [DATE]. The DON stated a CNA noticed that Resident #1 wasn't in his normal seat for breakfast. DON stated the staff then checked all of the rooms, smoking area, rest room and therapy room but Resident #1 could not be found. The DON stated staff searched all over the facility inside and outside. The DON stated she advised staff to go to Resident #1 room and it was noticed that his window was ajar. The DON stated that's when the local PD was notified Resident #1 was missing. The DON stated Resident #1 was found 4-5 away blocks from the facility by the local PD and returned. The DON stated once Resident #1 was in the parking lot of the facility having behaviors, so the local PD took him to a local hospital for an evaluation. The DON stated that Resident #1 did not qualify for inpatient stay and was return to the facility later the same day. The DON stated that some negative outcomes of Resident #1's elopement could have been the resident could have been injured or died. The DON stated that expectations for residents' supervision to be carried out appropriately, all residents were safe, and their needs are being met. An observation and interview with Resident #1 on [DATE] at 12:25pm, revealed that Resident #1 stated that he was feeling good and did not have any thought of leaving the facility. Resident #1 did not state how he left the facility. Resident #1 was in his room lying in bed at the time of the interview. An interview with CNA A on [DATE] at 2:42pm, revealed that CNA A stated she worked on [DATE] when Resident #1 eloped. CNA A stated she usually laid eyes on all residents when the shift started but not on that day because she was running late so she just went to working. CNA A stated that around breakfast time she noticed she had seen Resident #1 in the common area, so she went to Resident #1's room and opened the door but he wasn't there. CNA A stated she checked the common area and his room twice but couldn't locate Resident #1. CNA A stated she then notified the nurse that Resident #1 was missing. CNA A stated her, and the nurse went to Resident #1's room that was when the nurse noticed Resident #1's window was open. CNA A stated that Resident #1 could have been hurt or died due to his elopement. Review of the facility's Safety and Supervision of Resident policy, dated [DATE], revealed Our 675360 Page 3 of 6 675360 01/15/2025 Woodland Springs Nursing Center 1010 Dallas St Waco, TX 76704

F 0689 Level of Harm - Immediate jeopardy to resident health or safety facility strives to make the environment as free from accident hazards as possible, Resident safety and supervision and assistance to prevent accidents are facility wide priorities. Policy Interpretation and Implementation Facility Oriented Approach to Safety Residents Affected - Few 1. Our facility-oriented approach to safety addresses risks for groups of residents. Resident Risks and Environmental Hazards 1. Due to their complexity and scope, certain resident risk factors and environmental hazards are addressed in dedicated policies and procedures. These risk factors and environmental hazards include the following: e. unsafe wandering . This was determined to be an Immediate Jeopardy on [DATE] at 4:10 pm. The DON was notified. The DON was provided with the IJ template on [DATE] at 4:10 pm. The Plan of Removal was accepted on [DATE] at 7:45 am and included the following: All listed items will be completed by [DATE] with continued follow-up: 1. Elopement, wandering residents, emergency Response: Missing Resident, Abuse and Neglect, Window Alarms Recognition, Response and Maintenance policy and procedure review was facilitated by DON with all facility staff. [DATE]. 2. The DON or designee will audit new admissions for elopement risk and ensure appropriate interventions are in place. 3. The facility will implement census checks every 4 hours until further review, facility wide. Charge Nurses and/or Designee will be responsible for completion. 4. Window alarms were placed on each window in the secure unit by the Maintenance/Life Safety Team. Completed [DATE]. Placement and checking function will be performed by Charge Nurse/designee each shift. 675360 Page 4 of 6 675360 01/15/2025 Woodland Springs Nursing Center 1010 Dallas St Waco, TX 76704

F 0689 5. Level of Harm - Immediate jeopardy to resident health or safety Every resident will have an updated wandering risk scale completed by Charge Nurse/designee by [DATE]. Residents Affected - Few New hires will receive education on wandering, elopement, and resident safety by the DON, Director of Social Services, or designee(s). 6. 7. Any resident that attempts to leave or wishing to leave will be reported to the DON/designee and new interventions will be put in place at that time. 8. Twice a week, for 3 months or until the pattern of compliance is maintained, the DON/designee will check the monitoring logs to ensure compliance, any non-compliance will be reported to the facility administrator. 9. A Quality Assurance Performance Improvement (QAPI) Performance Improvement Project (PIP) was implemented to review and interpret all audit findings on [DATE]. Members of the IDT Team including DON, ADON, Director of Rehab, Maintenance Director, Admission/Marketing Team, Social Services Director, Activities Director, Business of Manager, and Central Supply Director. All findings will be discussed at the monthly QAA meeting for a minimum of three months or until the pattern of compliance is maintained. Monitoring for Plan of Removal was completed on [DATE] as follows: Record review on [DATE] at 9:00am, reflected staff were inserviced on elopement, wandering residents, emergency Response: Missing Resident, Abuse and Neglect, Window Alarms Recognition, Response and Maintenance policy. 48 staff were inserviced on elopement, wandering residents, emergency Response: Missing Resident, Abuse and Neglect, Window Alarms Recognition, Response and Maintenance policy Record review on [DATE] at 10:35am, reflected all 89 residents had updated wandering assessments. Record review on [DATE] at 10:40am, reflected census check were being completed every four hours. Observation on [DATE] at 9:30am, reflected window alarms on all windows in the secure unit were working. There were 12 rooms on the secure unit. Each alarm was triggered and could be heard from a far distance. Staff responded to the window alarms appropriately. During interviews on [DATE] from 9:50 am - 11:45 am with six staff members (2 6am - 2pm LVNs, 2 6am-2pm CNAs, 2 2pm-10pm LVNs 2 2pm-10pm CNAs, 2 10pm-6am LVNs, and 2 10pm-6am CNAs), who were able to 675360 Page 5 of 6 675360 01/15/2025 Woodland Springs Nursing Center 1010 Dallas St Waco, TX 76704

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few articulate information from the following in-services: Elopement, wandering residents, emergency Response: Missing Resident, Abuse and Neglect, Window Alarms Recognition, Response and Maintenance policy and procedure. All staff interviewed stated if any residents that attempt to leave or wishing to leave they would report it to the DON/designee immediately. During an interview with the DON on [DATE] at 11:50am, revealed the DON stated the facility had not any new admissions, no new hires, and no resident had attempted to leave or wished to leave since Resident #1's elopement. The DON stated that all patio furniture was removed from the smoking area due to Resident #1 elopement. The DON stated that with the information gather it was likely that Resident #1 used the patio furniture to get over the fence to elope. While the IJ was removed on [DATE] at 7:45AM, the facility remained at a level of no actual harm at a scope of isolated that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. 675360 Page 6 of 6