Health inspection·May 23, 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 review, 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 not later than 2 hours to the State agency for 2 of 9 residents (Residents #1 and #5) reviewed for failure to report. 1. The facility did not report an allegation of misappropriation of property for Resident #1 to the State Agency. 2. The facility did not report an allegation of misappropriation of property for Resident #5 to the State Agency. This failure could place residents at risk of abuse, neglect, or misappropriation of resident property. Findings included: 1. Record review of the admission Record for Resident #1 revealed she was a [AGE] year-old female who was originally admitted to the facility on [DATE] with diagnoses which included: schizoaffective disorder (a chronic mental illness involving symptoms of schizophrenia and characterized by symptoms such as delusions and hallucinations), and multiple fractures of the pelvis. Record review of Resident #1's Quarterly MDS, dated [DATE], revealed the resident had a BIMS score of 14, indicating no cognitive impairment. Record review of a facility complaint/grievance report form, dated 03/29/2024, stated the nature of the complaint was, Resident #1 stated someone stole her cellular device from her room. Documentation of the facility follow-up on the report form dated 03/29/2024, listed the facility Social Worker as the person who was notified, and the Social Worker wrote, Social Services informed Resident #1 she will ask staff and look around the facility for her device. Resolution of the concern/grievance dated 04/01/2024 and completed by the facility Social Worker read, Social Services informed Resident #1 that she was not able to find/locate her phone. Social Services will contact phone company to see if phone can be replaced through Social Security. Update: Social Services verified that all residents are only allowed one phone per year. Further review revealed the report form was signed by the facility Social Worker and by the facility Administrator on 04/10/2024. During an interview with Resident #1 on 05/22/2024 at 10:40 a.m., the resident stated she believed Page 1 of 6 675409 675409 05/23/2024 Windsor Mission Oaks 3030 S Roosevelt Ave San Antonio, TX 78214

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few someone stole her phone. Resident #1 stated she had received the phone from the facility Social Worker a few days prior to it going missing. The resident stated she had received the phone through a special program and showed the investigator a cellular phone box that included a phone number to the device. The resident stated she had the phone plugged in to the charger on her nightstand to charge it overnight and when she woke up in the morning, the phone was missing. Resident #1 stated she reported the missing phone directly to the facility Social Worker, and the Social Worker looked around her room, and told her she was only allowed one phone per year. During an interview with the Social Worker on 05/22/2024 at 11:30 a.m., the Social Worker stated she was responsible for completing grievance forms when items were reported missing. The Social Worker stated she filled out the form and then gave them to the Administrator to review and sign. When asked how missing items were investigated, the Social Worker stated she looks for the items and asks the staff if they have seen the items in question. When asked about Resident #1's grievance form, dated 03/29/2024, regarding the missing phone, the Social Worker stated she gave Resident #1 the new phone on Monday, 03/25/2024. The Social Worker further stated Resident #1 reported the phone as stolen to her on 03/29/2024. The Social Worker stated Resident #1 had reported the phone was charging on her nightstand overnight and was gone on the morning of 03/29/2024. The Social Worker stated she looked for Resident #1's phone and talked to staff about it. The Social Worker stated she notified the Administrator about Resident #1's missing phone and stated he was the Abuse Prevention Coordinator. The Social Worker further stated the Administrator should have reported the resident's missing phone and was not sure if it was reported by the Administrator to the state agency or the local police department. During an interview with the Administrator on 05/23/2024 at 2:20 p.m., the Administrator stated he was the Abuse Prevention Coordinator, and he was responsible for reporting allegations of abuse, neglect, and misappropriation of residents' property to the state agency. The Administrator stated he was not aware Resident #1's cellular phone had gone missing, and he did not remember being told about the missing phone. When asked if an allegation of a stolen phone should have been reported to the local police department and the state agency the Administrator stated, yes, if it meets the criteria of misappropriation, it should have been investigated and reported. The Administrator was shown a copy of the complaint/grievance reported dated 3/29/2024 regarding Resident's #1 reporting her phone as stolen and he responded, yes, that is my signature on the bottom and yes it should have been reported. When asked why it was important for allegations of abuse and misappropriation to be reported the Administrator stated, it's like the cry wolf theory, how do you know what happened if you do not investigate it. People don't get to pick and choose what is reportable. When asked what harm could happen to a resident if an allegation is not reported the Administrator responded, psychological harm could occur if it is not investigated and reported and they are missing their items. 2. Record review of the admission Record for Resident #5 revealed she was a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included: hypertension (heart problems caused by high blood pressure), and mild neurocognitive disorder (a type of progressive disease associated with abnormal deposits of protein called Lewy bodies in the brain which that leads to decline in thinking, reasoning, and independent function). Record review of Resident #5's Quarterly MDS, dated [DATE], revealed the resident had a BIMS score of 13, indicating no cognitive impairment. Record review of a facility complaint/grievance report form, dated 03/27/2024, stated the nature of the complaint was, Resident #5 stated someone stole her cellular device out of her room and she 675409 Page 2 of 6 675409 05/23/2024 Windsor Mission Oaks 3030 S Roosevelt Ave San Antonio, TX 78214

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few cannot find her device. Documentation of the facility follow-up on the report form, dated 03/27/2024, listed the person notified as the facility Social Worker and read, Social Services informed Resident #5 that she would look around the facility and ask staff for device (if they noticed where the device could be). The resolution of the concern/grievance, dated 04/01/2024, read, Social Services informed Resident #5 that she will continue looking for the device. Although she is only allowed 1 phone per year through Social Security. Resident #5 stated that she understood. Further review revealed the report form was signed by the Social Worker and by the Administrator on 04/10/2024. During an interview with the Social Worker on 05/22/2024 at 11:22 a.m., the Social Worker stated she had provided Resident #5 with a new cellular phone on 03/25/2024. The Social Worker stated Resident #5 reported to her on 03/27/2024 that her phone was stolen from her room. The Social Worker stated Resident #5 had told her the phone was on her nightstand when it went missing. The Social Worker stated she had no idea what happened to Resident #5's missing phone, and further stated the Administrator was notified of the allegation and signed the concern/grievance form. During an interview with Resident #5 on 05/22/2024 at 1:50 p.m., the resident stated she was provided a cellular phone by the Social Worker and had received the phone only a few days before it went missing. Resident #5 stated she left her phone on her nightstand while she went to lunch in the dining room, and when she returned to her room the phone was gone. The resident stated she reported the missing phone to the Social Worker, and the Social Worker told her, Nothing could be done about it. During an interview with the Administrator on 05/23/2024 at 2:20 p.m., the Administrator stated he did not remember being told Resident #5 reported her cellular phone as stolen. The Administrator did acknowledge signing the complaint/grievance report, dated 03/27/2024, regarding Resident #5's allegation of a stole cellular phone and stated it should have been reported to the local police and the state agency. The Administrator stated he was the Abuse Prevention Coordinator. When asked what harm could happen to a resident if an allegation is not reported the Administrator responded, psychological harm could occur if it is not investigated and reported and they are missing their items. Record review of the facility's policy titled, Abuse, Neglect, and Exploitation, dated 08/15/2022, revealed, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. The facility will have written procedures that include: Reporting of all alleged violations to the Administrator, state agency, adult protective services, and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: 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, or b). Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. 675409 Page 3 of 6 675409 05/23/2024 Windsor Mission Oaks 3030 S Roosevelt Ave San Antonio, TX 78214

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to thoroughly investigate allegations of misappropriation of resident property for 2 of 9 residents (Residents #1 and #5) reviewed for the investigation of allegations. Residents Affected - Few 1) The facility did not investigate when Residents #1 reported an allegation of misappropriation of property. 2) The facility did not investigate when Residents #5 reported an allegation of misappropriation of property. Findings included: 1. Record review of the admission Record for Resident #1 revealed she was a [AGE] year-old female who was originally admitted to the facility on [DATE] with diagnoses which included: schizoaffective disorder (a chronic mental illness involving symptoms of schizophrenia and characterized by symptoms such as delusions and hallucinations), and multiple fractures of the pelvis. Record review of Resident #1's quarterly MDS, dated [DATE], revealed the resident has a a BIMS score of 14, indicating no cognitive impairment. Record review of a facility complaint/grievance report form, dated 03/29/2024, stated the nature of the complaint was Resident #1 stated someone stole her cellular device from her room. Documentation of facility follow up on the report form dated 03/29/2024, listed the facility Social Worker as the person who was notified, and the Social Worker wrote, Social Services informed Resident #1 she will ask staff and look around the facility for her device. Resolution of the concern/grievance dated 04/01/2024 and completed by the facility Social Worker stated Social Services informed Resident #1 that she was not able to find/locate her phone. Social Services will contact phone company to see if phone can be replaced through Social Security. Update: Social Services verified that all residents are only allowed one phone per year. The report form is signed by the facility Social Worker and by the facility Administrator on 04/10/2024. During an interview with Resident #1 on 05/22/2024 at 10:40am, she stated that she believed someone stole her phone. Resident #1 said she had received the phone from the facility Social Worker a few days prior to it going missing. The resident stated said she had received the phone through a special program and showed the investigator a cellular phone box that included a phone number to the device. The resident stated she had the phone plugged in to the charger on her nightstand to charge it overnight and when she woke up in the morning, the phone was missing. Resident #1 stated she reported the missing phone directly to the facility Social Worker. and the Social Worker looked around her room and told her she was only allowed one phone per year. During an interview with the facility Social Worker on 05/22/2024 at 11:30am, the Social Worker stated she is responsible for completing grievance forms when items are reported missing. The Social Worker stated she fills out the form and then takes it to the Administrator to review and sign. When asked how missing items are investigated, the Social Worker stated she looks for the items and asks the staff if they have seen the items in question. When asked about Resident #1's grievance form, dated 03/29/2024, regarding the missing phone she stated she gave Resident #1 the new phone on Monday, 675409 Page 4 of 6 675409 05/23/2024 Windsor Mission Oaks 3030 S Roosevelt Ave San Antonio, TX 78214

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 03/25/2024. The Social Worker further stated Resident #1 reported the phone as stolen to her on 03/29/2024 and said Resident #1 reported the phone was charging on her nightstand overnight and was gone on the morning of 03/29/2024. She stated she looked for Resident #1's phone in her room and laundry and talked to staff about it. She said she did not remember how many people she asked about it. When asked if she had documentation of an investigation and interviews, she said no. The Social Worker stated she notified the Administrator about it and stated he was the Abuse Prevention Coordinator. The Social Worker stated, he signed the grievance form and said the Administrator should have investigated it and was not sure if it was investigated by the Administrator. During an interview with the Administrator on 05/23/2024 at 2:20pm, the Administrator stated he was the Abuse Prevention Coordinator, and he was responsible for investing and reporting allegations of abuse, neglect, and misappropriation of resident property. He stated he was not aware that Resident #1's cellular phone had gone missing and stated he did not remember being told about the missing phone. When asked if an allegation of a stolen phone should have been investigated, he said yes, if it meets the criteria of misappropriation, it should have been investigated. The Administrator was shown a copy of the complaint/grievance reported dated 3/29/2024 regarding Resident's #1 reporting her phone as stolen and he responded yes, that is my signature on the bottom and yes it should have been investigated. When asked why it is important for allegations of abuse and misappropriation to be reported he stated it's like the cry wolf theory, how do you know what happened if you do not investigate it. People don't get to pick and choose what is reportable. When asked what harm could happen to a resident if an allegation is not reported the Administrator responded, psychological harm could occur if it is not investigated and reported and they are missing their items. 2. Record review of the admission Record for Resident #5 revealed she was a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included: hypertension (heart problems caused by high blood pressure), and mild neurocognitive disorder (a type of progressive disease associated with abnormal deposits of protein called Lewy bodies in the brain which that leads to decline in thinking, reasoning, and independent function). Record review of Resident #5's Quarterly MDS, dated [DATE], revealed the resident had a BIMS score of 13, indicating no cognitive impairment. Record review of a facility complaint/grievance report form, dated 03/27/2024, stated the nature of the complaint was, Resident #5 stated someone stole her cellular device out of her room and she cannot find her device. Documentation of facility follow-up on the report form, dated 03/27/2024, listed the person notified as the facility Social Worker and read, Social Services informed Resident #5 that she would look around the facility and ask staff for device (if they noticed where the device could be). The resolution of the concern/grievance, dated 04/01/2024, read, Social Services informed Resident #5 that she will continue looking for the device. Although she is only allowed 1 phone per year through Social Security. Resident #5 stated that she understood. Further review revealed the report form was signed by the Social Worker and by the Administrator on 04/10/2024. During an interview with the Social Worker on 05/22/2024 at 11:22 a.m., the Social Worker state she had provided Resident #5 with a new cellular phone on 03/25/2024. The Social Worker stated Resident #5 reported to her on 03/27/2024 that her phone was stolen from her room. The Social Worker stated Resident #5 had told her the phone was on her nightstand when it went missing. The Social Worker stated she had no idea what happened to Resident #5's missing phone, and further stated the Administrator was notified of the allegation and signed the concern/grievance form. 675409 Page 5 of 6 675409 05/23/2024 Windsor Mission Oaks 3030 S Roosevelt Ave San Antonio, TX 78214

F 0610 Level of Harm - Minimal harm or potential for actual harm During an interview with Resident #5 on 05/22/2024 at 1:50 p.m., the resident stated she was provided a cellular phone by the Social Worker and had received the phone only a few days before it went missing. Resident #5 stated she left her phone on her nightstand while she went to lunch in the dining room, and when she returned to her room the phone was gone. The resident stated she reported the missing phone to the Social Worker, and the Social Worker told her, Nothing could be done about it. Residents Affected - Few During an interview with the Administrator on 05/23/2024 at 2:20 p.m., the Administrator stated he did not remember being told Resident #5 reported her cellular phone as stolen. The Administrator did acknowledge signing the complaint/grievance report, dated 03/27/2024, regarding Resident #5's allegation of a stole cellular phone and stated it should have been investigated. The Administrator stated he was the Abuse Prevention Coordinator. Record review of the facility Abuse, Neglect and Exploitation policy dated 08/15/2022 stated as the policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. The policy further stated The facility will have written procedures that include: Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: 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, or b). Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. 675409 Page 6 of 6