Health inspection·August 1, 2025

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as was possible and received adequate supervision 2 of 9 residents (Resident's #1 and #2) reviewed for accident hazards.1. The facility failed to immediately fix a broken window in the Memory Care Unit's dayroom. Resident #1 grabbed a shard of the glass and attempted to remove it. The Surveyor intervened to get the resident to stop grabbing it.An Immediate Jeopardy (IJ) was identified on 07/17/25. The IJ template was provided to the facility on [DATE] at 4:55 PM . While the IJ was removed on 07/18/25, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal.2. The facility failed to ensure Resident #2 did not elope from the facility on 06/05/25. The resident was returned to the facility by the police on 06/05/25.An Immediate Jeopardy (IJ) was identified on 07/31/25. The IJ template was provided to the facility on [DATE] at 11:00 AM. While the IJ was removed on 08/01/25, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal.These failures could place residents at risk for injury up to and including death due to the sharp glass and elopement.Based on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as was possible and residents received adequate supervision for 2 of 9 residents (Residents #1 and #2) reviewed for accident hazards.1. The facility failed to immediately fix a broken window in the Memory Care Unit's dayroom. Resident #1 grabbed a shard of the glass and attempted to remove it. The Surveyor intervened to get the resident to stop grabbing it.An Immediate Jeopardy (IJ) was identified on 07/17/25. The IJ template was provided to the facility on [DATE] at 4:55 PM. While the IJ was removed on 07/18/25, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal.2. The facility failed to ensure Resident #2 did not elope from the facility on 06/05/25. The resident was returned to the facility by the police on 06/05/25.An Immediate Jeopardy (IJ) was identified on 07/31/25. The IJ template was provided to the facility on [DATE] at 11:00 AM. While the IJ was removed on 08/01/25, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal.These failures could place residents at risk for injury up to and including death due to the sharp glass and elopement.The findings included:1. Record review of Resident #1's quarterly MDS assessment, dated 06/17/25, revealed the resident was a [AGE] year-old male admitted on [DATE]. His BIMS score was 3 indicating his cognitive ability Page 1 of 8 675810 675810 08/01/2025 Lancaster Nursing & Rehabilitation 1515 N Elm St Lancaster, TX 75134

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few was severely impaired. His diagnoses included seizure disorder and schizophrenia (a serious mental health condition that affects how people think, feel and behave. It may result in a mix of hallucinations, delusions, and disorganized thinking and behavior.) The resident required set-up assistance for wheelchair mobility.Record review of Resident #1's Care Plan, dated 06/19/25, reflected:The resident was at risk for falls.Facility interventions included:The resident needed a safe environment with even floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, the bed in low position at night; handrails on walls, and personal items within reach.An observation and interview on 07/17/25 at 10:50 AM revealed Resident #1 was in the Memory Care Unit dayroom with 2 other residents. Resident #1 was in his wheelchair sitting next to a table close to the exit door. The window next to the exit door was broken and had a large piece of triangle shaped glass sticking straight up. There were also multiple pieces of glass sticking up and there was one large piece of glass laying in the windowsill. Pictures of the window were taken. Resident #1 said the window had been broken for 2-3 days after an unknown resident in a wheelchair hit it. The resident said he had never cut himself on the window.An interview on 07/17/25 at 10:53 AM with LVN A in the Memory Care Unit revealed she did not know the window was broken. She was walking through the day room. LVN A left the Memory Care Unit.An observation and interview on 07/17/25 at 10:55 AM revealed CNA B entered the day room. She sat in a chair at the table that was blocking the window. She said she would be staying in the day room until maintenance came to fix the window. Resident #1 was in his wheelchair next to her. She said she did not know about the broken window. The Surveyor walked around the corner to the nurse station. An interview with RN C revealed the window was broken 2-3 days ago and she did not know how it happened. She said none of the residents had cuts or injuries. The Surveyor returned to the day room, but CNA B was not there. Resident #1 was next to the broken window and grabbed the largest piece of triangle shaped glass, separate from the other pieces of glass, easily reached by the resident, and tried to remove it. The Surveyor told him to stop. The resident grabbed it again and said he needed to remove it so no one would get hurt. The Surveyor said stop and CNA B returned to the dayroom and told him to stop also. The resident stopped after he was told Maintenance was coming to fix it. The Maintenance Director entered the day room and said the window had been broken for 2 days and he thought the broken glass was removed. He said two days prior the window did not look as bad, and he said it looked like someone hit the window again. The Maintenance Director removed the glass pieces and said he would cover it with a piece of cardboard. He left the room. CNA B had also left the room. The window had a gaping hole with sharp edges. The Surveyor stayed with the window and Resident #1 to make sure he did not touch the window again. The 2 other residents in the day room were still in their same spot.An observation and interview on 07/17/25 at 11:03 AM revealed the Maintenance Director returned. He said there were no cameras in the dayroom. The Maintenance director said he was told that there was just a crack in the window, and he did not know the hole had gotten so big. He placed cardboard over the window and said he had called the window company 2 days ago to fix it, but they had not arrived yet.An interview on 07/17/25 at 11:12 AM with the DON revealed she did not know about the broken window in the dayroom prior to 07/17/25. She said she did not know how it happened. She said the nurse was assessing the residents in Memory Care for cuts and injuries. She said it was everyone's responsibility to check windows and environment issues and report them to be fixed. She said a broken window put residents at risk for harm.An interview on 07/17/25at 12:42 PM with the Administrator revealed he did not know about the broken window and would contact the Maintenance Director. He said staff were supposed to notify him about the broken window.Review of the facility policy, Preventive Maintenance not dated, reflected:The facility will ensure 675810 Page 2 of 8 675810 08/01/2025 Lancaster Nursing & Rehabilitation 1515 N Elm St Lancaster, TX 75134

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few that a comprehensive preventive maintenance program is in place for essential operating equipment. Preventive maintenance will be completed routinely and according to protocol by the Maintenance Supervisor or qualified designee. The facility will maintain documentation of all preventive maintenance.Review of the facility policy, Facility Assessment dated 08/08/24, reflected: The facility assessment addresses the following.A facility-based and community-based risk assessment, utilizing an all- hazards approach.This was determined to be an IJ on 07/17/25. The Administrator and the DON were notified. The Administrator was provided with the IJ template on 07/17/25 at 4:55 PM. The Plan of Removal was accepted at 8:35 AM on 07/18/25 and reflected the following:Interventions:The window referenced on the secure unit was repaired on 07/17/25 by the maintenance director.All windows in the facility and secure unit were inspected by the maintenance director. No additional windows needed repair. Completed 07/17/25.All residents in the secure unit were assessed for injuries by the DON and ADON on 07/17/25. No new injuries were noted.New Process: If there is a window or any area in the in facility that needs repair and presents as an accident/hazard, staff will ensure that someone remains at the site to protect residents from harm. The administrator, maintenance director, or ADON will be notified immediately. If repairs cannot be completed immediately, the administrator will contact the Area Director of Operations for guidance. The process will begin 07/17/25 and ongoing.The Maintenance Director, Administrator, or designee will inspect all windows in the facility weekly to ensure all windows are intact and functioning. Windows that need repair will be addressed immediately. Start date will be 07/17/25 and ongoing.The Administrator, DON, Maintenance Director and ADON were in-serviced 1:1 by the Regional Compliance Nurse and completed as of 07/17/25 on the following:New Process: If there is a window or any area in the in facility that needs repair and presents as an accident/hazard, the staff will ensure that someone remains at the site to protect residents from harm. The administrator, maintenance director, or ADON will be notified immediately. If repairs cannot be completed immediately, the administrator will contact the Area Director of Operations for further guidance in ensuring the safety of the residents.Abuse and Neglect failure to repair a broken window immediately could be considered neglect and be a potential hazard to staff and residents.The Medical Director was notified of the immediate jeopardy citation on 07/17/25 by the DON.An ADHOC QAPI meeting was conducted as of 07/17/25 to review the immediate jeopardy citations and subsequent plan of removal.In-services:The Regional Compliance Nurse, Administrator, DON, and ADON will in-service all staff on the following topics below. All staff not present for the in-services will not be allowed to work their next shift until the in-services are completed. All new hires will be in-serviced during orientation prior to working their shift. All agency staff will be in-serviced prior to assuming scheduled shift. In-servicing began that needs repair and presents as an accident/hazard, staff will ensure that someone remains at the site to protect residents from harm. The administrator, maintenance director, or ADON will be notified immediately. If repairs cannot be completed immediately, the administrator will contact the Area Director of Operations for guidance in ensuring the safety of the residents.Abuse and Neglect failure to repair a broken window immediately could be considered neglect and be a potential hazard to staff and residents.Monitoring of the facility's Plan of Removal included the following:Record reviews of the facility Plan of Removal In-services reflected:25 staff were in-serviced on: In Service Training Attendance Roster, dated May 2025, reflected: Service Training Topic:New Process: If there is a window or any area in the in facility that needs repair and presents as an accident/hazard, staff will ensure that someone remains at the site to protect residents from harm. The administrator, maintenance director, or DON will be notified immediately. If repairs 675810 Page 3 of 8 675810 08/01/2025 Lancaster Nursing & Rehabilitation 1515 N Elm St Lancaster, TX 75134

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few cannot be completed immediately, the administrator will contact the Area Director of Operations for guidance in ensuring the safety of the residents.Abuse and Neglect failure to repair a broken window immediately could be considered neglect and be a potential hazard to staff and residents.Observations on 07/18/25 from 9:30 AM to 1:00 PM of the facility, including the Memory Care Unit revealed no broken windows or safety hazards. The broken window in the Memory Care Unit was fixed. Residents in the Memory Care Unit did not have visible cuts or scrapes.Interviews with staff from 07/18/25 at 10:00 AM to 07/18/25 at 1:00 PM were completed. 11 staff were interviewed in person/on the phone who worked all shifts at the facility. The interviewed staff were RN C, LVN A, Activity Director, Housekeeper D, LVN E, CNA F, CNA G, Maintenance Director, LVN H, DON, and the Administrator. The staff were able to verbalize they were in-serviced on the new process. If there was a window or any area in the facility that needed repair and presented as an accident/hazard, staff would ensure that someone remained at the site to protect residents from harm. The administrator, maintenance director, or DON would be notified immediately. Also, they were able to verbalize that failure to repair a broken window immediately could be considered neglect and be a potential hazard to staff and residents.An interview with the Maintenance Director on 07/18/25 at 12:46 PM revealed he was in-serviced regarding the POR for the broken window. The Maintenance Director said he inspected all windows on 07/17/25 and no additional windows needed repair. He said he was supposed to report to the Administrator and Supervisor and get it fixed ASAP if he found a broken window. He said he or staff had to stay with the resident until the window was fixed. He said he had to look everyday to make sure no windows were broken and failure to repair the window could be neglect and present a potential hazard to the residents.An interview with the DON on 07/18/25 at 12:25 pm revealed her role in the Plan of Removal was to ensure staff were in-serviced and assist with in-services. She said if a broken window was found, she would direct staff to stay with the residents until the window was fixed. She said if staff found a broken window, they were to stay with the residents and call the Administrator, DON, and Maintenance Director. She said staff were supposed to check daily for broken windows. The DON said failure to fix a broken window and stay with the resident posed a potential hazard and neglect.An interview on 07/18/25 at 12:10 PM with the Administrator revealed his role in the Plan of Removal was to supervise and make sure the facility stayed in compliance. The Administrator said he would contact the Area Director of Operations if a window was found broken and could not be fixed. He said he would monitor to ensure the Maintenance Director was checking for broken windows and fixing them immediately. The Administrator said if staff found a broken window, they were supposed to stay with the resident and notify the Maintenance Director, DON, and Administrator about the broken window. He said failure to stay with the resident and fix the broken window was a potential accident hazard and neglect. The Administrator said the issue was also discussed at the QAPI meeting held with facility administration.The Administrator and DON were informed the Immediate Jeopardy was removed on 07/18/25 at 2:15 PM. On 07/17/25 at 4:55 PM, an IJ was identified. While the IJ was removed on 07/18/25, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal.2. Record review of Resident #2's admission MDS assessment, dated 06/16/25, revealed the resident was a [AGE] year-old male admitted on [DATE]. His BIMS score was 3 indicating his cognitive ability was severely impaired. His diagnoses included metabolic encephalopathy (brain dysfunction caused by underlying metabolic disturbances, leading to symptoms like confusion, memory loss, and altered consciousness) and delirium (a serious change in mental abilities. It results in confused thinking and a lack of awareness of someone's surroundings). The resident 675810 Page 4 of 8 675810 08/01/2025 Lancaster Nursing & Rehabilitation 1515 N Elm St Lancaster, TX 75134

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few required set-up assistance for ambulating. Record review of Resident #2's Care Plan, not dated, reflected:The resident was at risk for wanderingFacility interventions included:If the resident is exit seeking, stay with the resident and notify the charge nurse by calling out, sending another staff member, call system, etc.Record review of Resident #2's elopement assessment, dated 06/06/25, reflected the resident was severely impaired and verbalized the desire to leave the facility after his elopement on 06/05/25. The resident ambulated independently and was a new admission to the facility. Record review of Resident #2's incident report, dated 06/05/25, and completed by the DON, reflected:Resident removed plexi-glass next to exit door at the back of the unit and left facility. Police saw the resident walk down the street near the facility and brought him back. The police said they spoke to the resident and assumed that he had psychiatric issues. The police returned him to the facility. The resident was unharmed and was immediately placed on 1:1 monitoring.Record review of Resident #2's Provider Investigation Report, dated 06/05/25, reflected: Resident left facility by pushing out a window next to the exit at the back of the building. Last seen in hallway at about 8:30 PM by charge nurse. Returned to facility at 9:45 PM.Skin, trauma, pain and elopement assessments were completed. Assessments were normal. No signs or symptoms of mental or physical distress.Resident put on 1:1 observation. Maintenance repaired window and put up braces so that window could not be pushed out again. Safe surveys obtained. Residents' family, Medical Director, Compliance Nurse, DON, and Administrator contacted.Safe surveys obtained. In-services on elopement, abuse and neglect, resident rights, trauma informed care, and behavior management were given to staff.An observation on 07/17/25 at 10:30 AM revealed Resident #2 was not at the facility. The memory care unit exit doors were locked and there were no windows visible next to the exit doors.An interview on 07/17/25 at 3:15 PM with RN I revealed he had worked at the facility for a year. He said the cameras in the memory Care Unit did not work. He said Resident #2 was admitted on [DATE] between 6:30 PM -7:00 PM. RN I said that he supervised the residents in the memory Care Unit and he saw the resident at about 8:30 PM wandering up and down the halls of the Memory Care Unit. RN I said at 9:15 PM the police arrived with Resident #2. RN I said he was not aware that the resident had eloped from the facility. He said the police told him Resident #2 was found wandering around the neighborhood. RN I said he did not realize that Resident #2 was going to elope. He said when the resident returned, RN I searched the Memory Care Unit to see how the resident eloped. He said he noticed the plexi-glass window next to the back exit door was pushed out. RN I said when the resident returned, they placed him on 1:1 monitoring and did a head count and followed the facility elopement policy. RN I said the resident discharged from the facility on 06/24/25 and was on 1:1 until he discharged . He said Resident #2 did not have any further elopements and no other residents had eloped. RN I said the facility covered the windows next to the exit door with walls.An interview on 07/31/25 at 1:55 PM with CNA K revealed Resident #2 was in the Memory Care Unit when she arrived to work at 6:00 PM on 06/05/25. She said she saw him walking around the unit at 9:15 PM and the police brought him back between 9:45 PM - 10:00 PM. She said the police asked if they were missing anyone. CNA K said she did a head count and realized Resident #2 was not in his room. CNA K stated RN I described him to the police and the police brought him back into the unit. CNA K said they started searching the unit to see how he got out. CNA K said she was checking everything to see how he got past her, and she saw the window next to the back exit door was pushed out. The window was not broken or anything. He just slid out through the opening. She said Resident #2 was being supervised by her and RN I and he was constantly walking around and looking out the windows. He was placed on 1:1 monitoring when he returned to the Memory Care Unit.An interview on 07/17/25 at 2:15 PM with the DON revealed there were no other elopements after Resident #2 on 06/05/25. 675810 Page 5 of 8 675810 08/01/2025 Lancaster Nursing & Rehabilitation 1515 N Elm St Lancaster, TX 75134

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few She said at the time he eloped, he pushed out the plexi-glass window that was next to the exit door, but the staff did not realize he had eloped until the police brought him back. She said RN I saw the resident last at around 8:30 PM.Record Review of Resident #2's 1:1 monitoring from date of elopement to date of discharge revealed he remained on 1:1 observation.Record Review of Resident #2's updated care plan, not dated, reflected:At risk for elopement or has had an actual elopement due to metabolic encephalopathy, and delirium.Resident pushed out plexi-glass on wall and stepped through it.Facility interventions: Resident to remain on 1:1 services until further notice, or until resident discharges from the facility. Window was immediately repaired so others were not at risk for leaving.Review of the facility policy, Elopement Prevention not dated, reflected: Policy StatementEvery effort will be made to prevent elopement episodes while maintaining the least restrictive environment for residents who are at risk for elopement.The Elopement Risk Assessment will be completed upon admission. The assessment should be completed by reviewing the resident's medical history and social history. Information may be obtained by reviewing current medical records, if available, interview with resident/family, or conference with the interdisciplinary team member. The assessment tool should be completed, and interventions implemented as indicated. The Elopement Risk Assessment is to be completed at least quarterly and upon change of condition.All residents who are at risk for harm because of wandering (elopement) will be assessed by the interdisciplinary care planning team.The resident's current chart and assessments will be reviewed to determine what changes have occurred that would trigger elopement episodes.The resident's care plan will be modified to indicate the resident is at risk for elopement episodes.Interventions into elopement episodes will be entered onto the resident's care plan and medical record.Should an elopement episode occur, the contributing factors, as well as the interventions tried, will be documented on the nurses' notes. Director of Risk Management and\or Director of Nursing Services should be notified of elopement.If a resident is discovered to be missing, a search shall begin immediately. (See policy entitled Elopement Response.)Identify the cause of wanderingWandering may reflect the need to use the bathroom, relieve hunger, thirst, physical discomfort, or desire for exercise.Wandering may be an indication of worsening of confusion secondary to dehydration, infection, congestive heart failure, or medication side effects.Wandering may be in response to uncomfortable temperature, excess stimulation, sensory deprivation, or uncomfortable clothing.The wanderer may be seeking a fulfillment of unmet psychological needs by acting out a habitual routine.The wanderer may be a person who handles stress by being physically active.The wanderer may be simply unable to find his/her room or the bathroom.Intervention StrategiesReduce physical discomfort (e.g., analgesia to reduce pain, more comfortable seating, and scheduled toileting).Use personal items, family photos, or familiar objects to label resident's room clearly.Maintain familiar routines as much as possible.Schedule regular ambulation program or opportunity for exercise.Reduce excess sensory stimulation (sensory overload), decrease noise level and confusion.Use simple, clear language. Tell the resident what you want him/her to do, not what you don't want them to do. (e.g., come with me instead of don't go outside)Approach the resident in non-threatening manner.Do not confront or argue with the resident. Acknowledge the resident's concerns and gently redirect the resident.Follow the resident to see where he/she goes. If the destination is safe, consider use of volunteer companion or family member as a suitable escort.Give resident something to do that makes him/her feel useful (e.g., winding yarn or folding towels).Allow verbalization of feelings.Obtain information from family on pattern of physical activity, daily home routine, style of coping with stress, etc.Environmental ModificationAllow the resident to wander in a safe and secure setting (e.g., closed courtyard or hallway free from obstacles or stairs).Use large signs or pictures to help residents 675810 Page 6 of 8 675810 08/01/2025 Lancaster Nursing & Rehabilitation 1515 N Elm St Lancaster, TX 75134

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few identify his/her room or bathroom.Use full-length mirrors, black doormats, or black tape grid pattern on floor to discourage demented residents from approaching doors.Use signs with large letter stating No/No Entry/Sorry, Door Closed.Use door locks that are out of reach/sight to prevent wanderers from opening doors.Use door alarms or monitoring devices to notify staff when residents try to leave the facility.Consider putting wandering residents on the same unit with a single exit near the nursing station.If applicable, consider the resident for a secured unitStress During AdmissionIdentify barriers to effective communication (e.g., hearing loss, aphasia, language barrier, dysarthria , etc.).Make sure the resident has all prescribed assistive devices (e.g., glasses, hearing aid, dentures, walking aids, etc.).Obtain information from family and friends on the resident's prior behavior, personal preferences, and routines.Determine the resident's need for assistance in mobility (transfers, gait, or wheelchair mobility) and the ability to follow and remember instructions.Consider teaming the new resident with another resident who is comfortable and oriented in the facility (i.e., the buddy system).Interventions to Reduce StressWhenever possible, maintain the resident's familiar routine.Adjust bedroom and bathroom to resident's functional capacity.Use personal items, photographs and familiar objects from home, to make the new environment less strange.Encourage visits by the family members and friends.Orient the resident to the daily routine.Allow the resident to participate as much as possible in daily decision making.Allow time for new information to be absorbed.Acclimate resident to the new environment.Provide reassurance and support. Physical PlantAll facility exits that residents have access to will have a device in place to alert staff of possible elopement attempts. Examples of these devices:Wanderguard System (locking or alarming)Placement of the residents' device to alarm the system will be verified each shift and documented on a treatment or other flow record.Function of the resident's device will be verified at least daily and documented on a treatment of other flow record.Function of the alarm system will be verified each week and documented in a maintenance log. Keypad exit magnetic locksKeyed AlarmsSecured UnitOr a combination of the aboveAll other exits not considered fire exits will be locked when not occupied by staff members.All exit devices will be maintained by the manufacturer's recommendations and function of each door device will be verified weekly and a log maintained.Staff TrainingStaff will receive training during their orientation process and then annually regarding: Elopement prevention Operation of all exit devices Actions to take if elopement occursThis was determined to be an IJ on 07/31/25. The Administrator and the DON were notified. The Administrator was provided with the IJ template on 07/31/25 at 11:55 AM.The Plan of Removal was accepted at 10:28 AM on 08/01/25 and reflected the following:Plan of RemovalProblem: Elopement InterventionsResident #2 was immediately assessed and placed on 1:1 supervision until discharged from the facility on 6/24/25.All windows on the secured unit were inspected and repaired by the maintenance director. Completed on 7/17/25All exit doors in the facility were checked by the Maintenance Director and Administrator for proper alarming and functioning. No issues were identified. Completed on 6/5/25.Elopement risk assessments for all residents in the facility were completed and reviewed by the DON/ADON/Regional Compliance Nurse on 6/6/25. Completed on 6/6/25.All residents that were determined high risk for elopement based on the assessments had their care plans reviewed and updated by DON, Regional Compliance Nurse and ADON for appropriate interventions to prevent elopement. Care plans will be reviewed and updated upon admission, quarterly, and as needed by the DON, ADON or MDS Nurse. Completed on 6/6/25.The Charge Nurse on shift will be responsible for completing elopement risk assessments on all residents upon admission, quarterly, and residents who demonstrate exit seeking behavior or verbally express the desire to elope from the facility. The resident will be placed on 1:1 supervision as delegated by the charge nurse. The charge nurse or designee will notify 675810 Page 7 of 8 675810 08/01/2025 Lancaster Nursing & Rehabilitation 1515 N Elm St Lancaster, TX 75134

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few the administrator or DON immediately for further guidance on appropriate interventions to ensure the safety of the residents. The resident's care plan will be reviewed and updated with the appropriate interventions. Completed on 6/6/2025 and will continue indefinitely.Elopement Risk Assessments for all new admissions, quarterly assessments, and residents who demonstrate exit seeking behavior or verbally express the desire to elope from the facility will be reviewed by the Interdisciplinary Team daily during the morning clinical meeting to ensure that appropriate supervision and interventions were implemented. The administrator and DON will be responsible for ensuring that any late and/or incomplete assessments are completed immediately after the meeting. Completed on 6/6/2025 and will continue indefinitely.New Process: If there is a window or any area in the facility that needs repair and presents as an accident/hazard, staff will ensure that someone remains at the site to protect residents from harm. The administrator, maintenance director, DON or ADON will be notified immediately by the charge nurse or designee. If repairs cannot be completed immediately by the maintenance director, interventions specific to the hazard will be implemented to ensure the safety of the residents. The administrator will contact the Area Director of Operations to assist in hiring any third-party contractors to complete repairs immediately or as soon as possible. Completed on 7/17/25 and will continue indefinitelyThe Regional Compliance Nurse in-serviced the DON and Administrator 1:1 on the following policies below. Completed on 7/17/25.Abuse and Neglect: failure to repair a broken window immediately could result in a missing resident, neglect, and be a potential safety hazard to staff and residents.Elopement Prevention and Response Policies: to include properly functioning windows and doors to prevent residents from eloping or harm.Behavior Management Policy: a resident who is exit seeking or expressing a desire to elope will remain on 1:1 supervision until the Administrator or DON is notified to give further guidance to ensure the safety of the resident.New Process: If there is a window or any area in the facility that needs repair and presents as an accident/hazard, staff will ensure that someone remains at the site to protect residents from harm. The administrator, maintenance director, DON or ADON will be notified immediately by the charge nurse or designee. If repairs cannot be completed immediately by the maintenance director, interventions specific to the hazard will be implemented to ensure the safety of the residents. The administrator will contact the Area Director of Operations to assist in hiring any third-party contractors to complete repairs immediately or as soon as possible.The Medical Director was notified of the immediate jeopardy citation on 7/31/25 by 675810 Page 8 of 8