Health inspection·June 26, 2023

F 0689 window hinges were observed to be broken off. Level of Harm - Immediate jeopardy to resident health or safety During an interview on [DATE] at 9:20am with LE, revealed that Resident # 1 was found near the facility on [DATE] deceased . He stated during their search of Resident # 1, that this area was searched they did not think that he was in this area at the time they were searching. He stated the judge did order that an autopsy be completed. He stated the decompensation of Resident # 1 showed that he had been deceased for more than six hours, less than three days factoring in the weather conditions the past few days. LE stated they did not suspect any foul play, stated it appeared that the resident fell and was unable to get back up. Residents Affected - Some During an interview on [DATE] at 12:30pm with, Resident # 2 revealed, Resident # 1 had recently broke the hinges off the window in their room, raised the window and put his wheelchair outside the window. He stated Resident # 1 also had put all his things in trash bag. Resident #2 stated he had moved to another to the 300 hall maybe a week ago but stated he would walk back and forth to the old room with his things in is hand. He stated Resident # 1 did not talk much so he never stated that he was leaving, but he had packed up his things like he was leaving. During an interview on [DATE] at 12:50pm with Maintenance supervisor revealed, he was not able to remember the exact date, but stated he pulled up to the facility and saw that there was a wheelchair outside Resident # 1 window. He stated he got the wheelchair and stated Resident # 1 stated he did not want the chair in his room. He stated he was not aware that the hinges were broken on the window, until shown by surveyor. He stated they were in the process of replacing all the window screens on the windows at the facility. Maintenance director stated he and the social worker went to Resident #1's room and he stated again he was not using the wheelchair and did not want the chair in his room. The Maintenace supervisor reported that one of her workers was dumping rash and he smelled an odor that wasn't coming from the trash. He stated his worker came and got him and they got the tr uck back it up in the tall brush, stood in the bed of the truck and that;s when they found Resident # 1 deceased lying in the middle of the tall brush. During an interview on [DATE] at 1:15pm with maintenance worker reported dumping trash in the back dumpster and smelled a foul odor that wasn't coming from the dumpsters. Maintenance worker stated he walked closer to the area and the odor got stronger, he stated he then went and got the maintenance director and they backed t he truck up where the bushes were and stood in the inside the bed of the truck to look and that's when they discovered Resident #1 lying on the ground and appeared to be deceased . Maintenance worker stated they alerted the DON and the ADM, and contacted the police at that time During an interview on [DATE] at 1:29pm with CNA A, revealed Resident # 1 was seen on [DATE], that morning around 10:00am when she picked up his breakfast tray. She stated she observed Resident # 1 standing by the back door looking out the door, she stated he then returned back to his room on the hall 300. During a phone interview on [DATE] at 2:24pm with MA A, revealed A few weeks prior to the incident Resident # 1 had an incident in his previous room on Hall 400. MA A stated Resident # 1 had opened his window and put his wheelchair out the window. MA A stated on the day of the incident she last saw Resident # 1 around 11:00am when she took residents out to smoke. She stated prior to that Resident # 1 did not appear to be exit seeking. During an interview on [DATE] at 2:34pm with DON, revealed Resident # 1 did have an incident where (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675438 If continuation sheet Page 2 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675438 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakeshore Village Nursing and Rehabilitation 2320 Lake Shore Dr Waco, TX 76708 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some he opened his room window on the 400 hall and put his roommate's wheelchair out the window. She stated the social worker should have documented this information in the progress notes of the incident. The DON stated she was not aware that the hinges on that window had been broken and not replaced, she stated she also was not aware that the screen had not been replaced at this time. The DON was not aware of the specific date of that incident. The DON stated a wander/elopement assessment was not completed after this incident because Resident # 1 did not show any signs of elopement or agitation. The DON stated Resident # 1 was not assessed for wander/elopement risk after he completed therapy because they do them quarterly and it was completed on [DATE]. In an interview on [DATE] at 3:00pm with ADM., revealed that he thinks he was on vacation during that time of the incident. The ADM. stated he was told about the hinge on the window this morning and maintenance is working on fixing that now. Stated they are replacing all the screens on all the windows at the facility. He stated he did think that Resident #1 was safe and able to go on an outing the building without supervision. The ADM. stated after Resident # 1 completed therapy there was no reason to complete wander/elopement assessment because he had not shown any signs of elopement and wander /elopements assessments are completed quarterly. During an interview on [DATE] at 6:06pm with Director of Rehabilitation, revealed Resident # 1 had completed OT (Occupational therapy) and PT (physical therapy) on [DATE]. She stated Resident # 1 was independent with ADL's (activities of daily living), Resident # 1 was ambulatory. Director of Rehabilitation was asked if an elopement assessment was completed at this time for Resident # 1since he was now independent she stated she was not aware that one had been completed. During a phone interview on [DATE] at 11:05am with PNP, revealed that she could not recall specifically what was said in the conversation, but she recalled that the facility called her regarding Resident #1 being agitated and that he had placed his wheelchair out the window. She stated that the specifics would be in her notes that she uploads to PCC. She stated that she did not have any concerns or complaints about resident care or about the facility. During an interview on [DATE] at 12:40pm with SOWK, revealed on [DATE] the Maintenance Director came and told her about the wheelchair sitting outside of a window. We went down to talk to Resident #1. The SOWK reported that when they got to the room Resident #1 was lying across the bed watching TV. She stated that she saw the window screen between the wall and the head of the bed, and the window was closed. She reported that she noticed the resident's clothing all bagged up and she asked him about it, and he told her it was how he wanted to keep them, and that he did not like using the drawers. She stated that the resident asked them to leave so he could watch mutherfucking [NAME]. She stated that she did ask him if there was any particular staff that he felt comfortable talking to if he had any issues or concerns and Resident #1 told her that he preferred to talk to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675438 If continuation sheet Page 3 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675438 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakeshore Village Nursing and Rehabilitation 2320 Lake Shore Dr Waco, TX 76708 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 the Level of Harm - Immediate jeopardy to resident health or safety blond lady up by the office The social worked determined this to be staff from laundry. She stated that Residents Affected - Some ordinary for the resident and that he did walk around the facility with his personal items in hand at the resident denied thoughts or plans to elope. The SOWK stated that this behavior was not out of the times. She stated that this incident with the wheelchair was reported to the Psychiatric nurse practitioner. She stated that after he completed therapy his cognition and physical state had improved from when he was first admitted . She stated that she had received in-service this past week on abuse, neglect, elopement. Reporting broken item, missing screen etc. to maintenance and heart injury. During an interview on [DATE] at 1:45pm with house-keeping, revealed she had been at the facility for about 2 1/5 months. She stated that she knew Resident #1 from before he entered the facility. She reported that the resident would stay in the area where she lived on the streets and everyone in the neighborhood knew him. She reported that when he came into the facility, they helped find him some clothes and personal care items because he did not have anything. She stated that when he went missing, she thought he might have gone back to the neighborhood, so she drove around looking for him after work. She stated that Resident #1 had never talked about leaving and had never tried to leave that she knew of. She reported that he would walk around with his clothes, and she thought this was because of his history of being homeless. During an interview on [DATE] at 11:27am with SOWK, revealed Resident # 1 had an incident earlier in the month as could not remember the exact date where Resident # 1 opened his room window on the 400 hall and put his wheelchair out the window. She stated she and the maintenance supervisor went down to the resident's room and stated she observed Resident # 1 had his things packed in a clear bag, his window was open, but he was sitting on the bed when they arrived. SOWK stated Resident # 1 stated the wheelchair was in his way, she stated when she asked about his clothing being in the bag stated Resident # 1 responded by stating he liked them in the bag. SOWK stated she reported this information to the nursing staff and in the morning meeting about Resident # 1 behavior. She stated it was discussed and that's when the decision was made to move Resident # 1 to the 300 hall. SOWK was asked if Resident # 1 was moved due to him opening his window, packing his things, and placing his wheelchair outside the window, she stated no. SOWK stated Resident # 1 was moved to hall 300 because he and his roommate were not getting along. SOWK was asked if an elopement assessment was completed at the time of this incident she stated no. Weather website reviewed: https://weather.com/weather/monthly/l/dab66db432c15c4b458fc6dfaa6c73a5703d4aaa8bc36cb83356ed6c80af938cc2be9 Reflected, the weather temperature for Waco on [DATE] was 99 degrees, [DATE] 101 degrees, [DATE] 101 degrees, and [DATE] 96 degrees (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675438 If continuation sheet Page 4 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675438 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakeshore Village Nursing and Rehabilitation 2320 Lake Shore Dr Waco, TX 76708 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 outside. Level of Harm - Immediate jeopardy to resident health or safety Review of Resident # 1 Risk elopement/wander assessments dated [DATE] that was provided later in the investigation had written, indicating Resident # 1 was low risk for elopement, [DATE] assessment, identified Resident # 1 as low risk for wandering /elopement. No assessment was completed after Resident # 1 incident and no assessment after completion of therapy services. Residents Affected - Some Record review of progress notes dated from [DATE] - [DATE] reflected, reflected no exiting behaviors. The progress notes do not reflect the incident where Resident # 1 opened his window and put his wheelchair outside his window or that he had his things packed in a bag. Review of facility Elopement policy dated [DATE] reflected the following: 1. Upon admission and re-admission residents will be assessed for elopement risk in conjunction with the nursing admission data collection. 7. Following admission, residents are evaluated for elopement risk quarterly, annually, and with significant change of condition. Review of facility Abuse/Neglect policy dated [DATE]reflected: Residents have the right to be free from abuse and neglect. The (IJ) Immediate Jeopardy template was delivered to the ADM on [DATE] at 5:00pm. While the (IJ) Immediate Jeopardy was removed on [DATE] at 2:00pm, the facility remained out of compliance at a level of actual harm with potential for more than minimal harm that is Immediate Jeopardy because all staff have not been trained on Abuse/Neglect, documentation, care plans, elopements and the effectiveness of systems. Plan of removal submitted on 6/232023 and accepted on [DATE] at 8:49am. The Plan of Removal is as follows: LETTER OF PLAN FOR REMOVAL OF IMMEDIATE JEOPARDY [DATE] On [DATE], a survey was initiated at facility, At approximately 5:00pm on [DATE], a surveyor provided verbal notification that Texas Health and Human Services had determined the conditions at the facility constitute immediate jeopardy to resident health and safety. The Immediate Jeopardy findings were identified in the following areas:

F689: The facility failed to ensure that the resident received adequate supervision and assistive devices to prevent accidents and hazards. 1 resident was affected by this deficient practice. All residents could be affected by this deficient practice. Immediate Corrections Implemented for Removal of Immediate Jeopardy. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675438 If continuation sheet Page 5 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675438 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakeshore Village Nursing and Rehabilitation 2320 Lake Shore Dr Waco, TX 76708 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 On [DATE]nd, 2023, at approximately 6:00pm the following actions were taken: Level of Harm - Immediate jeopardy to resident health or safety Action: Administrator and Director of Nursing received education on elopement policy and education for all direct care and ancillary staff (including housekeeping and dietary) given by Director of Clinical Operations. Start Date: [DATE] Residents Affected - Some Completion Date: [DATE] Responsible: Director of Clinical Operations. Action: Education given by Infection preventionist and ADONs to all direct care (including agency) and ancillary staff (including housekeeping and dietary) on Elopement risk, Abuse/Neglect/Exploitation, Signs to watch for with residents exhibiting potential for elopement, including, packing items, statements of plans to leave, moving assistive devices to locations of exits. Education will be maintained at, agency shift worked, new hire orientation and annual refresher in-services. Start Date: [DATE] Completion Date: [DATE] Responsible: Director of Nursing/designee Action: Maintenance Director and Administrator checked windows on the 400 and 300 halls validated to be fully functional, screens replaced and secured. The screen on the 400 hall was replaced on [DATE]. No repairs were necessary to any latches on either window. All windows are in working order. Start Date: [DATE] Completion Date: [DATE] Responsible: Administrator Action: Maintenance Director and Maintenance Tech secured all resident room windows to open no greater than 6 inches to prevent the potential of residents exiting via window Start Date: [DATE] Completion Date: [DATE] Responsible: Administrator/Designee IDENTIFICATION OF OTHER AFFECTED: Action: Maintenance Director and Maintenance Tech completed sweep of all facility resident room windows, to validate windows are in functional repair and screens are in place to all resident room windows. 12 screens were replaced on [DATE]. No repairs were necessary to any latches on any window. All windows are in working order. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675438 If continuation sheet Page 6 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675438 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakeshore Village Nursing and Rehabilitation 2320 Lake Shore Dr Waco, TX 76708 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Start Date: [DATE] Level of Harm - Immediate jeopardy to resident health or safety Completion Date: [DATE] Residents Affected - Some Action: ADONs and MDS Coordinators completed Elopement Risk Assessment on all residents and validated all residents at high risk of elopement, score of 11 or greater, have appropriate interventions and plan of care in place per risk assessment. After IDT interventions/care plan, those deemed to be high risk residents will have information placed in the elopement risk binder at the reception desk. Elopement Risk assessment is part of the Admission/Baseline care plan Summary completed on all new admissions by the charge nurse. This assessment is reviewed by DON/designee for completeness within 48 hrs of admission. Responsible: Administrator Start Date: [DATE] Completion Date: [DATE] Responsible: Director of nursing/designee Action: MDS Coordinators and Social Services completed sweep of all residents for history of homelessness, interviews completed and education on risks of homelessness, validation completed for any potential plans of exiting facility. Care plans updated to reflect IDT interventions for risks identified. Start Date: [DATE] Completion Date: [DATE] Responsible: Director of nursing/designee SYSTEMIC CHANGES AND/OR MEASURES: Action: ADONs and Infection Preventionist in-service and education was provided to all direct care (including agency) and ancillary staff (including housekeeping and dietary) and residents regarding the process for safe discharge as well as risks associated with heat exhaustion including signs and symptoms to watch for. Education will be maintained at agency shift worked, new hire orientation and annual refresher in-services. New residents will be educated on admissions by the admissions coordinator. Start Date: [DATE] Completion Date: [DATE] and ongoing until all staff have received education prior to their next scheduled shift. Responsible Party: Director of Nursing/Designee Action: Education to the Maintenance Director on the requirement to validate that windows are functioning properly and that screens are in place and in good repair. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675438 If continuation sheet Page 7 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675438 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakeshore Village Nursing and Rehabilitation 2320 Lake Shore Dr Waco, TX 76708 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Start Date: [DATE] Level of Harm - Immediate jeopardy to resident health or safety Completion Date: [DATE] Residents Affected - Some Action: Education provided by Infection preventionist and ADONs to all direct care and ancillary staff (including housekeeping and dietary) on Elopement policy, Abuse/Neglect/Exploitation and reporting missing or broken windows and/or screens to their supervisor and/or maintenance staff. This will be reported immediately. Maintenance orders are placed in the TELs system that is linked to Point click care and point of care electronic medical record system. Responsible: Administrator Start Date: [DATE] Completion Date: [DATE] and Ongoing until staff have received training prior to the start of their next shift. Responsible Party: Director of Nursing/Designee Action: Education was provided by Infection preventionist and ADONs to all direct care (including agency) and ancillary staff (including housekeeping and dietary) regarding new behaviors that must be reported to nursing which could indicate an increased risk or likelihood of imminent elopement attempt including but not limited to increased wandering, packing of belongings, verbalization of intent to leave, tampering with windows or doors and exit seeking. Additional education was provided to nursing staff on the expectation that these behaviors will be monitored/documented each shift as they occur by the charge nurse through the electronic medical record system in point click care. The elopement risk assessment and care plan will be updated within 24hrs by DON/designee. Education will be maintained at agency shift worked, new hire orientation and annual refresher in-services. Start Date: [DATE] Completion Date: [DATE] and Ongoing until staff have received training prior to the start of their next shift. Responsible Party: Director of Nursing Action: Ad hoc QAPI meeting held with IDT team and MD to review policy on Elopement, Abuse and neglect, and Plan of removal/response to Immediate Jeopardy Citation on [DATE] Start Date: [DATE] Completion Date: [DATE] Responsible: Administrator/Designee Tracking and Monitoring Director of Nursing/Designee will review residents with High Risk for wandering or elopement identified or newly admitted with history of homelessness, to assure appropriate interventions and plan of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675438 If continuation sheet Page 8 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675438 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakeshore Village Nursing and Rehabilitation 2320 Lake Shore Dr Waco, TX 76708 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 care are in place 5 times per week beginning [DATE] for 4 weeks. Level of Harm - Immediate jeopardy to resident health or safety Administrator/Designee will monitor windows for appropriate functioning, security, screens in place 5x/week beginning [DATE] for 4 weeks. Residents Affected - Some Administrator/designee will complete random audit every shift for 7 days, beginning [DATE], for appropriate staff response to wandering or potentially exit seeking residents, immediate education will be provided, if necessary, then will monitor random shifts, 5 times a week for 4 weeks. Any trends or concerns were/will be addressed with Quality Assurance Performance Committee meeting monthly and continue until a lessor frequency deemed appropriate through QAPI review. The administrator and/or designee will be responsible for reporting any identified trends. Monitoring of Plan or Removal on [DATE] is as follows: Observation on [DATE] at 11:10am, observed facility window and screens are on all windows. Observation on [DATE] at 11:20am, observed windows in rooms on the 400 and 300 halls. Windows are fully functional, screens replaced, and secured. During an interview on [DATE] at 11:30am with Activity Assistant revealed, she has been in-serviced on abuse, neglect, exploitation, safe discharge, risk associated with heat exhaustion, signs, and symptoms to watch for heat exhaustion, and reporting all windows, doors and alarm that are not properly functioning/any missing screens from windows to appropriate designated staff, charge nurse, or maintenance staff in a timely manner. Activity Assistant stated if a resident is exit seeking, packing belonging or verbalizing intent to leave then you need to notify charge nurse, DON, and Administrator. If the resident insisted on leaving have discuss the benefits of staying and the risk of leaving. The resident will need to sign the against medical advice form located in the elopement risk binder at the front desk. Activity Assistant stated staff are to discuss the risk of heat exhaustion as well as monitor the signs of heat exhaustion. Activity Assistant stated the staff were in-serviced on notifying charge nurse and maintenance if they see a window, door, or alarm not working properly or any missing screens from windows. During an interview on [DATE] at 11:45am with LVN A, revealed she had been in-serviced on abuse, neglect, exploitation, safe discharge, risk associated with heat exhaustion, signs, and symptoms to watch for heat exhaustion, and reporting all windows, doors and alarm that are not properly functioning/any missing screens from windows to appropriate designated staff, charge nurse, or maintenance staff in a timely manner. LVN A stated if a resident is exit seeking, packing belonging or verbalizing intent to leave then you need to notify charge nurse, DON, and Administrator. If the resident insist on leaving have discuss the benefits of staying and the risk of leaving. The resident will need to sign the against medical advice form located in the elopement risk binder at the front desk. LVN A stated staff are to discuss the risk of heat exhaustion as well as monitor the signs of heat exhaustion. LVN A stated the staff were in-serviced on notifying charge nurse and maintenance if they see a window, door, or alarm not working properly or any missing screens from windows. During an interview on [DATE] at 12:12pm with RN revealed, she had been in-serviced on abuse, neglect, exploitation, safe discharge, risk associated with heat exhaustion, signs, and symptoms to watch for heat exhaustion, and reporting all windows, doors and alarm that are not properly functioning/any missing screens from windows to appropriate designated staff, charge nurse, or maintenance staff (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675438 If continuation sheet Page 9 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675438 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakeshore Village Nursing and Rehabilitation 2320 Lake Shore Dr Waco, TX 76708 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some in a timely manner. The RN stated if a resident is exit seeking, packing belonging or verbalizing intent to leave then you need to notify charge nurse, DON, and Administrator. If the resident insist on leaving have discuss the benefits of staying and the risk of leaving. The resident will need to sign the against medical advice form located in the elopement risk binder at the front desk. The RN stated staff are to discuss the risk of heat exhaustion as well as monitor the signs of heat exhaustion. The RN stated the staff were in-serviced on notifying charge nurse and maintenance if they see a window, door, or alarm not working properly or any missing screens from windows. During an interview on [DATE] at 12:30pm with SOWK, revealed she had been in-serviced on abuse, neglect, exploitation, safe discharge, risk associated with heat exhaustion, signs, and symptoms to watch for heat exhaustion, and reporting all windows, doors and alarm that are not properly functioning/any missing screens from windows to appropriate designated staff, charge nurse, or maintenance staff in a timely manner. The SOWK stated if a resident is exit seeking, packing belonging or verbalizing intent to leave then you need to notify charge nurse, DON, and Administrator. The resident insist on leaving have discuss the benefits of staying and the risk of leaving. The resident will need to sign the against medical advice form located in the elopement risk binder at the front desk. The SOWK stated staff are to discuss the risk of heat exhaustion as well as monitor the signs of heat exhaustion. The SOWK stated the staff were in-serviced on notifying charge nurse and maintenance if they see a window, door, or alarm not working properly or any missing screens from windows. During an interview on [DATE] at 1:30pm with the DON, revealed she had been in-serviced on abuse, neglect, exploitation, safe discharge, risk associated with heat exhaustion, signs, and symptoms to watch for heat exhaustion, and reporting all windows, doors and alarm that are not properly functioning/any missing screens from windows to appropriate designated staff, charge nurse, or maintenance staff in a timely manner. She gave example of abuse, neglect, and exploitation. The DON stated if a resident is exit seeking, packing belonging or verbalizing intent to leave then you need to notify charge nurse, DON, and ADM. If the resident insist on leaving have discuss the benefits of staying and the risk of leaving. The resident will need to sign the against medical advice form located in the elopement risk binder at the front desk. The DON stated staff are to discuss the risk of heat exhaustion as well as monitor the signs of heat exhaustion. The DON stated the staff were in-serviced on notifying charge nurse and maintenance if they see a window, door, or alarm not working properly or any missing screens from windows. The DON stated that the facility identified 19 residents that are high risk for elopement. 18 of the residents are on the secured unit. The DON stated the elopement risk binder is kept at the front desk, if there is a questionable situation about their care refer to the binder or if a resident is missing a photo of every resident is located in the elopement risk binder. There was also a missing resident form in the binder for staff to complete if a resident was missing. During an interview on [DATE] at 2:15pm with CNA B, revealed she worked the day Resident # 1 opened his window and put his wheelchair outside the window. She stated they were informed right after the morning meeting by Resident # 1's roommate stated, Resident # 1 was very upset and wanted to leave the facility. CNA B stated that's when she, the SOWK and the maintenance supervisor went to Resident # 1's room. She stated the SOWK was able to calm Resident # 1 down and stop him from leaving that day. CNA B stated the Admin. was aware that Resident # 1 wanted to leave but nothing was done about, she stated she felt something could have been done about it, if the first incident had been documented. During an interview on [DATE] at 11:20am with ADM., he stated that management staff were present this weekend working on POR and staff education. He reported that the Regional Care Coordinator had (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675438 If continuation sheet Page 10 of 11 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675438 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakeshore Village Nursing and Rehabilitation 2320 Lake Shore Dr Waco, TX 76708 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some worked with him and the DON and has completed their education on Elopement. The ADM. stated that Resident #1 had requested to stay in the facility long term and helped them complete the MEDICAID application. Observation completed on [DATE] at 11:45am, of windows observed in room on the 300 hall which is the room that Resident #1 was assigned to when he left the facility through the window. There was only one window in the room. The window was intact there is no damage around the casing to the wall. There was a cooling/heating unit in the wall just below the window. The locking mechanism was intact, the window was functional. There were screws placed internally to prevent the window from being raised greater than six inches. The screen is intake. The window opened to a small grassy area that meets the facility's rear parking lot. During an interview on [DATE] at 11:50am with the Maintenance Director, revealed he and his crew had checked all windows and screens this past week. He reported that the facility had ordered new solar screens and they would be replacing all screens with those when they arrive. He reported that he had not encountered any broken or damaged windows or window locks. There had been some screens with some small holes they had replaced. The Maintenance Director reported that he had in- serviced staff this week on putting in maintenance orders in the event they find something broken or that needed attention. He stated they could either text, call, come find him or put the work order into the TELS system which is connected to their electronic medical record (PCC). He stated they had performed test reports to demonstrate to staff how the order came across their phones. He stated that he had been serviced in the past and this week on elopement, abuse, and neglect. He also stated that they were in-serviced on heat-related injury. During an interview on [DATE] at 1:15pm with laundry aide, revealed she had been employed with the facility for 34 years. She stated that she had been in serviced on elopement, abuse and neglect, heat stroke and when to report broken things to maintenance this week. She stated that they are always doing some type of in-service. She denied any concerns or complaints regarding the facility or resident care or supervision. During an interview on [DATE] at 2:20pm with CNA C, revealed she had worked at the facility in her current position for about 4 years. She reported that they had been in serviced this week on [NAME][TRUNCATED] FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675438 If continuation sheet Page 11 of 11