Health inspection·April 21, 2024

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property were reported immediately, but no later than 2 hours after the allegation was made, in events that caused the allegation involved abuse or resulted in serious bodily injury to the Administrator of the facility and other officials, which included to the State Survey Agency, for 1 of 9 residents (Resident #3) reviewed for reporting abuse and neglect. LVN F failed to report to the administrator and HHSC an allegation of sexual abuse made by Resident #3 on 02/05/24. This failure could place residents at risk for harm to include neglect, a diminished quality of life, and possible death. Findings include: Record review of Resident #3's admission record reflected a [AGE] year-old male initially admitted to the facility on [DATE]. Resident #3 had diagnoses which included Alzheimer's (degenerative brain disorder causing problems with memory, thinking, and behavior), dementia (group of symptoms that affects memory, thinking and interferes with daily life) and schizoaffective disorder (a mental disorder that is marked by a combination of schizophrenia symptoms, such as hallucinations or delusions, and mood disorder symptoms, such as depression or mania). Record Review of Resident #3's care plan reflected problem [Resident #3] has a behavior problem . [Resident #3] is apt to hear voices in his head, he will call his [RP] to leave voicemails about the FBI and working for the mafia, he says he is 'losing his mind' . [Resident #3] is apt to make delusions allegations reaching out to attorneys and government officials . [Resident #3] will make false claims against staff members. Record Review of Resident #3's MDS assessment, dated 02/22/24, reflected a BIMS score of 11/15, which indicated moderate cognitive impairment. Record review of Nurse note, dated 02/05/24 at 02:35 PM, authored by LVN F, reflected, resident was on resident phone south station I heard resident talking stating that [the DON] came to him wanting to have sex . During an interview on 04/18/24 at 03:24 PM, ADON E revealed Resident #3 was always making Page 1 of 19 675380 675380 04/21/2024 Windsor Nursing and Rehabilitation Center of Segui 1219 Eastwood Dr Seguin, TX 78155

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few accusations. She further revealed he would use the phone frequently trying to report accusations, but there was not truth to these accusations due to history of hallucinations. She further revealed this was care planned. During an interview on 04/19/24 at 12:24 PM, the Administrator revealed Resident #3 would make inappropriate comments to staff members, his RP and providers. During an interview on 04/19/24 at 12:55 PM, the DON revealed Resident #3 did not bring up any abuse allegations. She noted the resident had inappropriate behaviors. During an interview on 04/19/24 at 02:10 PM, the Administrator revealed he could not recall any allegations made by Resident #3. He read the nursing note, dated 02/05/24 at 02:35 PM, and revealed he would not report this to the state agency but would do an internal investigation to see if the allegation was valid. He further revealed the resident was allowed to have sexual relations with anyone he chooses. He revealed he would report if the resident had an allegation of abuse after internal investigation, but he was not aware of this nursing note. During an interview on 04/19/24 at 02:46 PM, the DON was doing some medication changes and behaviors were escalating. She further revealed she did not recall LVN F reporting this allegation of sexual abuse to her. The DON tried to review nursing notes daily but did not recall this specific nursing note. She further revealed had she known about this allegation she would speak with the Administrator and the team. She would have asked the Social Worker to interview the resident and kept her distance. When asked if the DON would report this to the state, she did not say yes. Attempted interview on 04/19/24 at 03:52 PM with LVN F was unsuccessful. A voicemail was left. No call back. During an interview on 04/19/24 at 02:03 PM, ADON E revealed she reported Resident #3's abuse allegations to the appropriate nursing staff and the Administrator. She further revealed she expected the Administrator to report these allegations to the state agency and do an appropriate investigation. She revealed this needed to be investigated to ensure resident's safety. During an interview on 4/19/2024 at 2:30 PM, the SW stated he would report the nurse note on 02/05/24 at 02:35 PM that mentioned the DON, to the Administrator as an alleged sexual abuse. Attempted interview with Resident #3's RP was unsuccessful. A voicemail left on 04/19/24 at 01:47 PM. No call back. Record review of the facility's policy Abuse, Neglect and Exploitation, dated 08/15/22, reflected the following: IV. Identification of Abuse, Neglect and Exploitation B. Possible indicators of abuse include, but are not limited to: 1. Resident, staff or family report of abuse . VII. Reporting/Response 675380 Page 2 of 19 675380 04/21/2024 Windsor Nursing and Rehabilitation Center of Segui 1219 Eastwood Dr Seguin, TX 78155

F 0609 A. The facility will have written procedures that include: Level of Harm - Minimal harm or potential for actual harm 1. Report of all alleged violations to the Administrator, state agency . a. Immediately, but not later than 2 hours after the allegation is made; if the events that cause the allegation involve abuse or result in serious bodily injury Residents Affected - Few 675380 Page 3 of 19 675380 04/21/2024 Windsor Nursing and Rehabilitation Center of Segui 1219 Eastwood Dr Seguin, TX 78155

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 3 of 12 residents (Residents #2, #4 and #5) reviewed for care plans. The facility failed to develop person-centered care plan to include interventions to prevent elopement for Residents #2, #4 and #5. This failure could place residents at risk of not having their needs met. The findings include: 1. Record review of Resident #2's admission record, dated 04/18/24, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #2 had diagnoses which included Alzheimer's (degenerative brain disorder causing problems with memory, thinking, and behavior), difficulty in walking and cerebral infarction (condition that results in the death of brain tissue due to lack of blood and oxygen supply). Record review of Resident #2's care plan, undated, reflected problem [Resident #2] scored 6 or above on wandering assessment is at risk for elopement., dated 12/19/23 with interventions complete wandering risk tool and fall risk assessment. Record review of Resident #2's quarterly MDS assessment, dated 03/01/24, reflected the resident was not a wanderer and had a BIMS score of 03/15, which indicated severe cognitive impairment. Record review of 03/01/24 Social Services-Wandering Evaluation- V 1 reflected Resident #2 had a moderate risk score for elopement. Record review of Resident #2's Psychiatric Services note, dated 02/09/24, reflected Resident #2 had a diagnosis of Dementia . with other behavioral disturbance [unsafe wandering, exit-seeking] .Resident frequently says she needs to go home . poor safety awareness. 2. Record review of Resident #4's admission record reflected a [AGE] year-old male initially admitted to the facility on [DATE]. Resident #4 had diagnoses which included dementia (group of symptoms that affects memory, thinking and interferes with daily life), major depressive disorder, alcohol abuse, and paranoid schizophrenia (serious mental disorder in which people interpret reality abnormally). Record review of Resident #4's care plan reflected problem [Resident #4] scored 6 or above on wandering assessment is at risk for elopement., dated 12/19/23 with interventions complete wandering risk tool and fall risk assessment. Record Review of Resident #4's quarterly MDS assessment, dated 02/28/24, reflected the resident was not a wanderer and had a BIMS score of 10/15, which indicated moderate cognitive impairment. 675380 Page 4 of 19 675380 04/21/2024 Windsor Nursing and Rehabilitation Center of Segui 1219 Eastwood Dr Seguin, TX 78155

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record Review of Resident #4's SOCIAL SERVICES-Wandering Evaluation- V 1 dated 02/28/24 reflected Resident #4 had a moderate risk score for elopement. 3. Record Review of Resident #5's admission record reflected a [AGE] year-old female initially admitted to the facility on [DATE]. Resident #5 had diagnoses which included Alzheimer's (degenerative brain disorder causing problems with memory, thinking, and behavior), impulsiveness, mild cognitive impairment and generalized anxiety disorder. Record review of Resident #5's care plan reflected problem [Resident #5] scored 6 or above on wandering assessment is at risk for elopement., dated 12/20/23 with interventions complete wandering risk tool and fall risk assessment. Record review of Resident #5's quarterly MDS assessment, dated 01/26/24 reflected the resident had wandering behavior in the last 1 to 3 days and had a BIMS score of 03/15, which indicated severe cognitive impairment. Record review of Resident #5's social services-Wandering Evaluation- V 1, dated 01/26/24, reflected Resident #5 had a moderate risk score for elopement. During an interview on 04/18/24 at 12:20 PM, the Social Worker revealed Resident #2 had interventions to be distracted to not elope, but this was not care planned and should be care planned to prevent elopement. He did not mention who should care plan this but it should be care planned. During an interview on 04/19/24 at 09:38 AM, LVN F revealed if a resident was exit seeking, she would have to look at the specific resident's care plan for interventions to keep the resident safe. During an interview on 04/19/24 at 10:13 AM, Resident #2's RP did not have any concerns with Resident #2 trying to leave the facility, but every time the RP left she made sure to tell the nurses what to do in order to prevent Resident #2 from trying to exit the facility, which included re-direct her and don't let her go past the nurse's desk. She further revealed she expected the nurses to prevent Resident #2 from trying to head to the exit doors. During an interview on 04/19/24 at 11:05 AM, ADON E revealed there was no policy or procedure to follow for when residents were transitioned from the secure unit to other hallways in the facility. She further revealed there was no documentation other than signing a consent form for transitioning out of the secure unit. She stated there were no specific interventions for Resident #2 to prevent her from eloping and there should be specific interventions for any resident transitioning out of the secure unit. She was able to verbalize what interventions she did for Resident #2 even though they were not documented on Resident #2's care plan. During an interview on 04/19/24 at 12:55 PM, the DON revealed she was not aware if there were any policies for residents that move from the secure unit to other hallways in the facility. She further revealed she knew they did a trial run for residents that moved out of the secure unit and family was involved. During an interview on 04/19/24 at 12:45 PM, ADON G revealed when a resident came off the secure unit, the nursing staff will communicate through nurse's report and verbally but was not aware of any policies to follow for this transition. 675380 Page 5 of 19 675380 04/21/2024 Windsor Nursing and Rehabilitation Center of Segui 1219 Eastwood Dr Seguin, TX 78155

F 0656 Level of Harm - Minimal harm or potential for actual harm During an interview and record review on 04/19/24 at 01:30 PM, the ADON E revealed there were no progress notes documented when Resident #2 transitioned from the secure unit to the 400-hallway. She further revealed Resident #2 moved to 400-hallway from the secure unit 04/01/2023. Record review of the nursing notes from 02/2023 to 05/2023 revealed no nursing note of the resident transitioning from secure unit to 400 hallway. Residents Affected - Some During an interview on 04/19/24 at 02:15 PM, the Administrator revealed he did not have a policy to take residents out of the secure unit to put them in the other hallways in the facility. He revealed there was discussion with the IDT when a resident left the secure unit to reside in another hallway in the facility. He revealed his expectation was for documentation at least once a day for the resident's adjustment and it's the nurse's standard of practice to check on residents frequently. He revealed care plans should be as person-centered as possible. He further revealed interventions would be discussed in morning meetings as an IDT and care plans updated accordingly. During an interview on 04/18/24 at 03:24 PM, ADON E revealed the interventions listed for Resident #2's problem of being at risk for elopement (completing tool and doing fall risk assessment) would not be an appropriate intervention to prevent Resident #2 from eloping. She further revealed appropriate interventions were needed so CNA and nurses knew about resident care and how to keep the resident safe. She knew some interventions for Resident #2 could be re-direction and distracting her with activities. She further revealed Resident #2 packed her bags and stated she was leaving the facility frequently. During an interview on 04/18/24 at 03:49 PM, MDS nurse C revealed she reviewed residents' care plans and there could be a more personalized intervention to prevent elopement. During an interview on 04/19/24 at 09:38 AM, CNA D revealed he was unsure if Residents #4 and #5 were at risk for elopement and he was unaware of any interventions to do to prevent elopement for these residents. He further revealed Resident #2 was at risk for elopement, however he was not aware of interventions for Resident #2 and would go to the nurse for help. During an interview on 04/20/24 at 06:41 PM, NP Y (on call NP for the facility) revealed if a resident was exit-seeking, the expectation was for the facility to protect the resident and keep them safe. She revealed the residents of the facility could run into the car because of the street in front of the facility. She further revealed the interventions in the care plan, for those at risk for elopement, should be to prevent elopements. She suggested some interventions could include psychiatric evaluation, redirect resident, or keep them busy with activities. When looking at Resident #2's interventions due to being at risk for elopement, she revealed fall risk assessment was not an intervention for elopement and any assessment was not enough to stop an elopement from happening. She further revealed care plan interventions should be individualized because every resident was different. Record review of the facility's policy Comprehensive Care Plans, dated 10/24/22, reflected The comprehensive care plan will describe, at a minimum .The services that are to be furnished to attain and maintain the resident's highest practicable physical, mental, and psychosocial well-being Resident specific interventions that reflect the resident's needs and preferences. Record review of the facility's policy Elopements and Wandering Residents, dated 11/21/22, reflected, The facility shall establish and utilize systemic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks, and 675380 Page 6 of 19 675380 04/21/2024 Windsor Nursing and Rehabilitation Center of Segui 1219 Eastwood Dr Seguin, TX 78155

F 0656 monitoring for effectiveness and modifying interventions when necessary . Level of Harm - Minimal harm or potential for actual harm 4. Monitoring and Managing Residents at Risk for Elopement or Unsafe Wandering a. Residents Affected - Some Residents will be assessed for risk of elopement and unsafe wandering upon admission and throughout their stay by the interdisciplinary care plan team. b. The interdisciplinary team will evaluate the unique factors contributing to risk in order to develop a person-centered care plan. c. Interventions to increase staff awareness of the resident's risk, modify the resident's behavior, or to minimize risks associated with hazards will be added to the resident's care plan and communicated to appropriate staff. 675380 Page 7 of 19 675380 04/21/2024 Windsor Nursing and Rehabilitation Center of Segui 1219 Eastwood Dr Seguin, TX 78155

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some 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 the resident environment was as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents for 2 of 9 residents (Residents #1 and #2) reviewed for accidents and hazards. 1. The facility failed to ensure Resident #1 did not elope from the facility. Resident #1 eloped to a busy street on 12/18/23. 2. The facility failed to ensure staff were adequately trained on the elopement process, which included not training the therapy department after 12/18/23 elopement incident. 3. The facility failed to ensure interventions for elopement were updated and appropriate to prevent elopements for Resident #1 and #2. Resident #1 successfully eloped 12/18/23. An Immediate Jeopardy (IJ) situation was identified on 04/19/24 at 03:28 PM. While the IJ was removed on 04/20/2024, the facility remained out of compliance at a scope of a pattern with the potential for more than minimal harm that was an Immediate Jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk of harm, severe injury, and possible death to residents who require supervision to prevent elopement. The findings were: 1. Record review of Resident #1's admission record, dated 04/17/24, reflected an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included dementia (loss of cognitive function that interferes with daily life and activities), age relative cognitive decline, alcohol abuse and difficulty in walking. Record Review of the facility's Investigation report, dated 12/26/23, reflected On 12/18/23 at approximately 10:45 AM, [Admissions Director] noted Resident #1 was attempting to leave the premises via the front entrance. [Admissions Director] had attempted to redirect [Resident #1] back into the main portion of the building, but the resident became verbally and physically aggressive. [Admissions Director] did not have any way to flag down assistance and after numerous attempts to call for help failed and with the resident becoming more agitated, she sought help from someone in the facility to come and help her redirect the resident back into the facility. The facility social worker was the first person she was able to call for help and he was the first on the scene to attempt to redirect the resident back to the facility. The social worker was unable to determine which way the resident exited; the facility called for an immediate search from all available staff members. The staff members were able to locate the resident walking on the sidewalk approximately 100 yards from the 675380 Page 8 of 19 675380 04/21/2024 Windsor Nursing and Rehabilitation Center of Segui 1219 Eastwood Dr Seguin, TX 78155

F 0689 Level of Harm - Immediate jeopardy to resident health or safety facility grounds. The search for the resident lasted less than 5 minutes from the time the resident was unable to be redirected to the time the resident was assisted safely back inside the building. The resident was given a head-to-toe assessment, and no abnormal findings were noted. The resident's physician and family were notified and an order as well as a consent for the resident to admit to the facility unit were obtained. The resident now resides in the facility secure unit . The resident will continue to be monitored and the facility will continue to monitor the resident and make changes to the plan of care as necessary. Residents Affected - Some Record review of Resident #1's Social Services-Wandering Evaluation- V 1, dated 11/13/23, reflected Resident #1 had a moderate risk score for elopement. Record review of Resident #1's the Nurse Note, dated 09/05/23, authored by LVN B, reflected Resident with exit seeing behaviors. Trying to open exit front doors setting alarm off. Resident yelling at staff and difficult to redirect. Record review of Resident #1's Nurse Note, dated 10/25/23, authored by LVN A, reflected .Resident then self-propelled in w/c to front door of facility and repeated set off the exit alarms. Nurses x 3 attempted to stop and redirect. Not effective. Resident states that he is just going to leave facility Observation on 04/17/24 to 04/21/24 revealed a busy street less than 50 yards away from the front entrance of the facility with a speed limit of 20 mph. Attempted interview with Resident #1 on 04/17/24 at 03:11 PM denied leaving the facility. During an interview on 04/17/24 at 03:18 PM, LVN A revealed Resident #1 previously tried to elope before he was successful on 12/18/23. She revealed she told the Administrator about this incident before 12/18/23 and she was unsure if interventions were care planned for Resident #1's exit seeking behavior. LVN A further revealed she was not present at the facility on the day of Resident #1's elopement. During an interview on 04/17/24 at 04:08 PM, the Administrator revealed elopement risk was care planned on a case-by-case basis. He further revealed he would not care plan if a resident set off the exit door alarm but would care plan if the resident was pushing the doors and tried to exit the facility. During an interview on 04/17/24 at 04:59 PM, MDS Nurse C stated Resident #1 was a moderate risk for elopement on 11/13/23 and this should have been care planned. She further revealed it was care planned on 11/27/24 that Resident #1 had adjustment issues to the facility, but not that he was an elopement risk. During an interview on 04/17/24 at 05:10 PM, the Administrator could not recall if he knew of Resident #1 triggering the exit doors and vocalizing that he wanted to exit prior to the 12/18/23 incident, but this would have been mentioned in the morning meeting and care planned appropriately. During an interview on 04/18/24 at 10:53 AM, the Admissions Director revealed she was not able to redirect Resident #1 from trying to exit the front doors. She further revealed she was looking out for Resident #1's safety and did not want him to hit her and be evicted from the facility. She revealed Resident #1's safety was impacted either way because he eloped. She further revealed she should 675380 Page 9 of 19 675380 04/21/2024 Windsor Nursing and Rehabilitation Center of Segui 1219 Eastwood Dr Seguin, TX 78155

F 0689 have stayed with Resident #1 as he was eloping. She further revealed there were no other staff around and she had to run to get another staff member for help. Level of Harm - Immediate jeopardy to resident health or safety During an interview on 04/18/24 at 12:20 PM, the Social Worker revealed Resident #1 should have had interventions in his care plan to prevent his elopement on 12/18/23. Residents Affected - Some Attempted interview with LVN B on 04/18/24 at 1:49 PM was unsuccessful. A voicemail was left for LVN B . 2. During an interview on 04/18/24 at 09:23 AM, CNA D revealed he was trained on elopement last month. He revealed he was not aware of what to do when a resident left the facility or when a resident was heading to the exit door. During an interview on 04/18/24 at 10:15 AM, the Administrator revealed if the in-service sign in sheets were missing signatures, it may have been the therapy department because the facility did not train the therapy department. During an interview on 04/18/24 at 10:18 AM, the Director of Rehab revealed she did not specifically train her staff on elopement, but it was the facility that would come to her department and train her staff members. She further revealed if her staff were trained, they would have signed the in-service sign in sheet. During an interview on 04/18/24 at 11:35 AM, the Maintenance Director revealed he was not sure if he needed to accompany the residents when they were in the process of eloping, but he would let a nurse know and get some help. During an interview on 04/18/24 at 02:13 PM, the Director of Rehab provided documentation of the therapy department receiving training for elopement, but they did not have any documentation for training for the facility policy for elopement. Observation on 04/18/24 revealed the therapy department was located to left side of the front entrance before walking out of the facility. Record review of the facility's, undated, In-Service training Report for Elopement reflected all departments were trained, however, no one in the therapy department singed the in-service sign in sheet. 3. Record review of Resident #2's admission record reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #2 had diagnoses which included Alzheimer's (degenerative brain disorder causing problems with memory, thinking, and behavior), difficulty in walking, and cerebral infarction (condition that results in the death of brain tissue due to lack of blood and oxygen supply). Record review of Resident #2's care plan reflected problem [Resident #2] scored 6 or above on wandering assessment is at risk for elopement., dated 12/19/23 with interventions complete wandering risk tool and fall risk assessment. Record review of Resident #2's quarterly MDS assessment, dated 03/01/24, reflected the resident was not a wanderer. Resident #2 had a BIMS score of 03/15, which indicated severe cognitive impairment. 675380 Page 10 of 19 675380 04/21/2024 Windsor Nursing and Rehabilitation Center of Segui 1219 Eastwood Dr Seguin, TX 78155

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Record review of Resident #2's Social Services-Wandering Evaluation- V 1, dated 03/01/24, reflected Resident #2 had a moderate risk score for elopement. Resident #2 had not had any elopements in the facility. Record review of Resident #2's Psychiatric Services note, dated 02/09/24, reflected Resident #2 had a diagnosis of Dementia . with other behavioral disturbance [unsafe wandering, exit-seeking] .Resident frequently says she needs to go home . poor safety awareness. During an interview on 04/18/24 at 12:20 PM, the Social Worker revealed Resident #2 had interventions to be distracted to not elope, but this was not care planned and should be care planned. During an interview on 04/19/24 at 09:38 AM, LVN F revealed if a resident was exit seeking, she would have to look at that specific resident's care plan for interventions. During an interview on 04/19/24 at 10:13 AM, Resident #2's RP did not have any concerns with Resident #2 trying to leave the facility, but every time the RP left, she made sure to tell the nurses what to do in order to prevent Resident #2 from trying to exit the facility, which included re-direct her and don't let her go past the nurse's desk. She further revealed she expected the nurses to prevent Resident #2 from trying to head to the exit doors. During an interview on 04/19/24 at 11:05 AM, ADON E revealed there was no policy or procedure to follow for when residents were transitioned from the secure unit to other hallways in the facility. She further revealed there was no documentation other than signing a consent form for transitioning out of the secure unit. She confirmed there were no specific interventions for Resident #2 to prevent her from eloping and there should be specific interventions for any resident transitioning out of the secure unit. She was able to verbalize what interventions she does do for Resident #2 even though they were not documented on Resident #2's care plan. During an interview on 04/19/24 at 12:55 PM, the DON revealed she was not aware if there were any policies for residents who moved from the secure unit to other hallways in the facility. She further revealed she knew they did a trial run for residents who moved out of the secure unit and the family was involved. During an interview on 04/19/24 at 12:45 PM, ADON G revealed when a resident came off the secure unit, the nursing staff would communicate through nurse's report and verbally but was not aware of any policies to follow for this transition. During an interview and record review on 04/19/24 at 01:30 PM, the ADON E revealed there were no progress notes documented when Resident #2 transitioned from the secure unit to the 400-hallway. She further revealed Resident #2 moved to 400-hallway from the secure unit 04/01/2023. Record review of nursing notes from 02/2023 to 05/2023 reflected no nursing note of the resident transitioning from the secure unit to 400 hallways. During an interview on 04/19/24 at 02:15 PM, the Administrator revealed he did not have a policy to take residents out of the secure unit to put them in the other hallways in the facility. He revealed there was discussion with the IDT when a resident left the secure unit, in order to reside in another hallway in the facility. He revealed his expectation was for documentation at least once a day for resident's adjustment and it's the nurse's standard of practice to check on residents frequently. He revealed care plans should be as person-centered as possible. 675380 Page 11 of 19 675380 04/21/2024 Windsor Nursing and Rehabilitation Center of Segui 1219 Eastwood Dr Seguin, TX 78155

F 0689 Level of Harm - Immediate jeopardy to resident health or safety During an interview on 04/18/24 at 03:24 PM, ADON E revealed the interventions listed for Resident #2's problem of being at risk for elopement (completing tool and doing fall risk assessment) would not be an appropriate intervention to prevent Resident #2 from eloping. She further revealed appropriate interventions were needed so the CNA and nurses knew about resident care and how to keep the resident safe. She knew some interventions for Resident #2 could be re-direction and distracting her with activities. She further revealed Resident #2 packed her bags and stated she was leaving the facility frequently. Residents Affected - Some During an interview on 04/18/24 at 03:49 PM, MDS nurse C revealed she reviewed residents' care plans and there could be a more personalized intervention to prevent elopement. During an interview and observation on 04/18/24 at 04:13 PM, Resident #2's roommate revealed Resident #2's clothing were stacked on her bed because Resident #2 frequently stated she was going to go home. She further revealed Resident #2 had not attempted to exit facility yet. During an interview on 04/20/24 at 06:41 PM, NP Y (on call NP for the facility) revealed if resident was exit-seeking, the expectation was for the facility to protect the resident and keep them safe. She revealed the residents of the facility could run into the car because of the street in front of the facility. She further revealed the interventions in the care plan, for those at risk for elopement, should be to prevent elopements. She suggested some interventions could include psychiatric evaluation, redirect resident, or keep them busy with activities. When looking at Resident #2's interventions due to being at risk for elopement, she revealed fall risk assessment was not an intervention for elopement and any assessment was not enough to stop an elopement from happening. She further revealed care plan interventions should be individualized because every resident was different. Record review of the facility's policy Elopements and Wandering Residents, dated 11/21/22, reflected the following: The facility shall establish and utilize systemic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary . 4. Monitoring and Managing Residents at Risk for Elopement or Unsafe Wandering a. Residents will be assessed for risk of elopement and unsafe wandering upon admission and throughout their stay by the interdisciplinary care plan team. b. The interdisciplinary team will evaluate the unique factors contributing to risk in order to develop a person-centered care plan. c. Interventions to increase staff awareness of the resident's risk, modify the resident's behavior, or to minimize risks associated with hazards will be added to the resident's care plan and 675380 Page 12 of 19 675380 04/21/2024 Windsor Nursing and Rehabilitation Center of Segui 1219 Eastwood Dr Seguin, TX 78155

F 0689 communicated to appropriate staff Level of Harm - Immediate jeopardy to resident health or safety 6. Procedure Post-Elopement Residents Affected - Some This was determined to be an Immediate Jeopardy (IJ) on 04/19/24 at 3:28 PM. The facility Administrator and the DON were notified. The Administrator was provided with the IJ template on 4/19/24 at 3:28 PM. e. Staff may be educated on the reasons for elopement and possible strategies for avoiding such behavior. The following Plan of Removal submitted by the facility was accepted on 04/19/24 at 7:43 AM: Windsor Nursing and Rehabilitation Center of [NAME] Issue:

F689 Free of Accident Hazards/ Supervision/ Devices For Residents Involved: Resident #1: 4/19/24, wandering/ elopement risk evaluation completed by Social Services Director 4/19/24, care plan for wandering evaluation was reviewed and revised 4/19/24, exit seeking behavior added to the Medication Administration Record to track every shift behavior 12/18/23, wandering evaluation completed by Social Services Director 12/18/23, Resident #1 was transferred to the secure unit. M.D. and RP notified 12/18/23 12/18/23, Resident #1's care plan was completed for wandering behavior and placement on secure unit. Resident #2: 4/19/24, wandering evaluation completed by Social Services Director 4/19/24, care plan for wandering evaluation was reviewed and revised 4/19/24, exit seeking behavior added to the Medication Administration Record to track every shift behavior To Identify Any Other Residents to Have the Potential: The Director of Nursing and/ or designee is reviewing that all current residents have a current 675380 Page 13 of 19 675380 04/21/2024 Windsor Nursing and Rehabilitation Center of Segui 1219 Eastwood Dr Seguin, TX 78155

F 0689 wandering/elopement risk evaluation. 4/19/24 Level of Harm - Immediate jeopardy to resident health or safety The Director of Nursing and/ or designee will review those with moderate risk or above are being reviewed for care plan interventions 4/19/24 Residents Affected - Some The Director of Nursing and/ or designee will ensure those with exit seeking behavior have that on the Medication Administration Record for every shift documentation. 4/19/24 The Director of Nursing and/ or designee will review residents admitted in the last 30 days to ensure that wandering evaluations are complete and if have wandering risk will have care plans reviewed to ensure interventions are care planned. 4/19/24 Education/ System Change: All staff including Therapy will be reeducated by the Director of Nursing and/ or designee on the following topics: 4/19/24 Abuse and Neglect Wandering/ Elopement Policy to include what to do if a resident displays exit seeking behavior Adding exit seeking behavior to the Medication Administration Record to track behavior each shift for number of times Care plan development and interventions to prevent wandering behavior/ exit seeking To complete Interdisciplinary Team documentation as to evaluation to remove a resident from the secure unit To update care plan when removing a resident from secure unit Re-education will continue for all staff until 100% of staff have completed the education. Those that are PRN, Agency and/ or out on FMLA/ LOA will have the education completed prior to accepting assignment for their next scheduled shift. Employee roster will be used to validate completion. Monitoring: The Director of Nursing or designee will review the 24- hour report in the morning clinical meeting to ensure that changes of condition such as those with wandering/ exit seeking behavior that are documented in the clinical record are identified and care planned interventions are in place. The Director of Nursing or designee will ensure new admissions have wandering evaluations completed and that interventions are care planned if exit seeking. The Director of Nursing or designee will monitor compliance each weekly morning. Results of findings will be discussed in the monthly QAPI meeting for three months and the plan will be continues as needed. The Administrator will attend the morning clinical meeting to ensure the Director of Nursing or 675380 Page 14 of 19 675380 04/21/2024 Windsor Nursing and Rehabilitation Center of Segui 1219 Eastwood Dr Seguin, TX 78155

F 0689 designee is reviewing the admissions and the 24-hour report in the morning clinical meeting. Level of Harm - Immediate jeopardy to resident health or safety An AdHoc QAPI was conducted on April 19, 2024, by the Administrator, with the Medical Director, Director of Nursing, and the Regional Clinical Specialist to discuss the immediate jeopardy concerning F 689 and to develop the above-mentioned plan of care. Residents Affected - Some We respectfully submit this action plan for removal of Immediate Jeopardy. Monitoring of the POR was as follows: Observation on 4/20/2024 at 12:29 PM in the facility's locked unit, Resident #1 was in the dining area eating lunch. Record review of Resident #1 Wandering Evaluation, dated 4/19/2024, reflected he scored a 10- moderate risk signed by the Social Worker (4.) SW stated on Wandering Evaluation [Resident #1] was reassessed today, he scored severely impaired cognitively. He has a dx of dementia, disoriented to year and day of the week. He continues to benefit from residing in the the facility's locked unit. Record review of Resident #1's care plan, dated updated on 4/19/2024, reflected Resident #1 scored a 6 or above on his wandering assessment r/t disoriented x 2, independent no assist, taking antidepressant and antianxiety, known wanderer/history of wandering, is an elopement risk/wanderer r/t dementia, currently resides in Generations Unit for structured environment. Interventions-Asses for fall risk, becomes easily agitated when he is hungry, will be easily redirected with snacks and drinks, Complete wandering evaluation tool, Monitor for fatigue and weight loss Resident #1 placed in Generations Secure unit, Provide structured activities: toileting, walking inside and outside, reorientation strategies including signs, pictures and memory boxes, Staff to redirect Resident #1 as needed/Engage Resident #1 in social activities, provide alternate task/Admit to generations unit for exit seeking behaviors. Record review of Resident #'s 1 consolidated orders reflected Resident #1 was admitted to the facility's secure unit on 12/18/2023 for a structured environment. An order, dated 4/19/2024, document the number of times Resident #1 was exit seeking on current shift. Record review of Resident #1's consent for the Generations Unit placement, dated 12/18/2024, reflected via phone by family. Record review of Resident #1's MAR was reflected document the number of times Resident #1 was exit seeking on current shift. No times xd as exit seeking. Record review of Resident #1's progress notes, dated 12/18/2023, reflected 11:30 a.m. Informed resident's RP of exit seeking behavior with verbal consent given via telephone for placement in Generation's Unit for Structured Environment. Care ongoing. Record review of Resident #1's care plan dated 2/22/2024 revealed Resident #1- is an elopement risk/wanderer r/t dementia, currently resides in the Generations Unit for structured environment, scored 6 or above on wandering assessment. Interventions were Assess for fall, risk, Complete wandering evaluation too, Monitor for fatigue and weight loss, Provide structured activities: toileting, walking inside and outside, reorientation strategies including signs, pictures and memory boxes, Resident placed in Generations Secure Unit and Staff to redirect resident as needed/Engage resident in social 675380 Page 15 of 19 675380 04/21/2024 Windsor Nursing and Rehabilitation Center of Segui 1219 Eastwood Dr Seguin, TX 78155

F 0689 activities, provide alternate task/Admit to generations unit for exit seeking behaviors. Level of Harm - Immediate jeopardy to resident health or safety Observation on 4/20/2024 at 12:33 PM in the main dining room, Resident #2 was sitting in wheelchair with family. Residents Affected - Some Record review of Resident #2 Wandering Evaluation, dated 4/19/2024, reflected the resident scored a 9, which meant Moderate risk. This was signed by the Social Worker. The Social Worker documented Resident #2 was apt to wander within the facility. She did pack her personal belongings and made statements of wanting to go home. Her family members do not believe she would attempt to leave the facility. She was redirected by reminding her that she was staying at the facility and her family members knew. She could call her family members at any time if verbal redirection did not work or if she just wanted to talk to them. She is not exhibiting exit seeking behaviors. Record review of Resident #2's care plan, updated on 4/19/2024, reflected Resident #2 had scored 6 or above on the wandering assessment r/t disoriented x 3, forgetfulness, short attention span, independent with aide, Alzheimer's disease, taking antidepressant medication. Has a history of wandering. She was not exhibiting any exit seeking behaviors. Interventions were Complete wandering assessment quarterly and as needed. Resident #2 was easily redirected by calling her family members at any time of the day or night. Staff to let Resident #2 pack personal items as desired and staff would help unpack items at her discretion. Resident #2 stayed in bed once staff assisted her into bed. When Resident #2 made statements about going home, she was easily redirected with reminding her that she lived in the facility and her family members were aware she was there. Record review of Resident #2's consolidated orders reflected an order to document the number of times resident was exit seeking on current shift (ordered on 4/19/2024). Record review of Resident #2's MAR reflected document the number of times Resident #2 was exit seeking on current shift. No times xd as exit seeking. Interview and record review on 04/20/24 at 07:14 PM, Regional Clinical Specialist X and the DON revealed: 1. 107 out of 107 residents had a wandering/elopement risk evaluation done 4/19/24. 61 out of 107 residents scored moderate to high risk of wandering/elopement. 2. Sample of 10 out of 61 residents reflected care plan interventions. 3. Every calendar day the charge nurse will Document the number of times resident is exit seeking on current shift. Every shift. The DON or designee will mark every calendar day that they reviewed each resident's MAR that is exit seeking. 4. 675380 Page 16 of 19 675380 04/21/2024 Windsor Nursing and Rehabilitation Center of Segui 1219 Eastwood Dr Seguin, TX 78155

F 0689 Level of Harm - Immediate jeopardy to resident health or safety 107 out of 107 residents had a wandering/elopement risk evaluation done 4/19/24, including residents admitted in the last 30 days. Observation on 04/20/24 at 06:15 PM revealed a sign on the front door of the facility which stated ATTENTION VISITORS. Please check with a facility team member before assisting a patient/resident outdoors. Residents Affected - Some Interview on 04/20/24 at 7:14 PM, Regional Clinical Specialist X and the DON revealed all departments were trained on ANE and Wandering/Elopement Policy. Staff who were not interviewed would be interviewed before they worked the floor. Record review of all staff were trained on 04/19/24 on topic Elopement Prevention with summary including, Preventing, identifying, and reporting abuse and neglect; Wandering/Elopement Policy; Identifying and responding to behaviors/triggers to prevent elopement; Evaluation and identifying exit seeking/wandering risk for all new admissions/readmissions/quarterly/change in condition. Interviews with the following staff included: 3 out of 6 MAs 6 out of 28 CNAs 1 out of 10 Dietary Department 3 out of 10 Therapy Department 1 out of 5 Housekeepers 3 out of 13 LVNs 1 out of 5 RNs Shift breakdown was as follows: 6 AM- 2 PM: 11 out of 39 2 PM- 10 PM: 12 out of 20 10 PM- 6 AM: 4 out 16 8 AM- 5 PM: 7 out of 21 The interviews below were separated into shifts: All shifts (6 AM-2 PM, 2 PM-10 PM, 10 PM-6 AM) Interview on 04/20/224 at 01:05 PM with CNA J revealed CNA worked for 1 year and worked all shifts. She revealed she attended in-services on Elopement and ANE. 675380 Page 17 of 19 675380 04/21/2024 Windsor Nursing and Rehabilitation Center of Segui 1219 Eastwood Dr Seguin, TX 78155

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Interview on 04/20/24 at 01:25 PM with LVN L revealed LVN has worked at the facility for 14 years and worked all shifts. She further revealed she was in-serviced on ANE, elopement process, and change of condition. Interview on 04/20/24 at 03:24 PM with CMA/CNA/Medical record P revealed she worked for 14 years and worked all shifts. She revealed she was in-serviced on elopement, change of condition and ANE. Residents Affected - Some Shifts 6 AM-2 PM and 2 PM-10 PM Interview on 4/20/2024 at 12:47 PM with MA H revealed she worked at the facility for 35 years and worked the 6 AM-2 PM and 2 PM-10 PM. She further revealed she was in-serviced on Abuse and Elopement. She further revealed if she saw possible abuse, she would try to separate resident and perpetrator, keep resident safe, notify nurse, and report to Administrator. She further revealed in elopement training, she learned she would stay with resident and re-direct resident as needed. Interview on 4/20/2024 at 01:18 PM, Laundry Aid K stated she worked for 1.5 years. and worked 2 PM-10PM, then 6 AM -2 PM. She revealed she was in-serviced on elopement and ANE. She learned if resident left the building, she needed to follow the resident and not leave them alone. She would call someone for help and she notified the Administrator. Interview on 4/20/2024 at 01:38 PM with CNA M revealed she worked for 41 yrs. and worked the 6 AM-2 PM, 2 PM-10 PM. She revealed she was in-serviced on ANE and Elopement. Interview on 4/20/2024 at 03:18 PM with CNA/Central Supply staff member O worked for 16 years. She revealed she was in-serviced Elopement, notifications of changes and ANE. She learned if sees any abuse, she would notify the administrator. Interview on at 01:57 PM with LVN A revealed she worked for 4 years for the 6 AM-2 PM, 2 PM-10 PM shifts. She revealed she was in-serviced on ANE and Elopement and change of condition. She further revealed if a resident had a change of condition, she would notify MD, SBAR, ADON/DON and family. Interview on 4/20/2024 at 3:55 PM with CNA S revealed she worked for 5 months for 6 AM-2 PM and 2 PM-10 PM shift. She further revealed she was in-serviced on ANE and elopement. She revealed she would call the Administrator if she observed ANE with a resident. Shift: 6 AM-2 PM Interview on 04/20/24 at 12:56 PM, HSK I stated she worked for 8-9 years and 6 AM-2 PM shift. She revealed she was in-serviced on Elopement and ANE. She identified examples of abuse and revealed reporting ANE and the elopement process. Interview on 04/20/24 at 01:46 PM, RN N revealed she worked for 1 year. She further revealed she was in-serviced on Elopement and ANE reporting. She reviewed ANE reporting and the elopement process. Shift: 8 AM- 5 PM Interview on 04/20/24 at 01:11 PM, the Maintenance Director worked for 2 years and worked 7:30 AM -4 PM shift. He further revealed he was in-serviced on the elopement process including staying He further revealed he was trained on ANE including reporting to the administrator as soon as possible. 675380 Page 18 of 19 675380 04/21/2024 Windsor Nursing and Rehabilitation Center of Segui 1219 Eastwood Dr Seguin, TX 78155

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Interview on 04/20/24 at 04:10 PM with Food Service Supervisor reveal she worked for 2 years and worked the 8 AM-5 PM shift. She further revealed she was in-serviced on the Elopement and ANE process. She revealed different examples of ANE and the elopement process. Interview on 04/20/24 at 04:44 PM with PTA V revealed they worked for 10 years. They were in-serviced on the elopement process and ANE. They gave examples of ANE and would report to Administrator as soon as possible. They revealed the elopeme[TRUNCATED] 675380 Page 19 of 19