Health inspection·October 22, 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 observations, interviews, and record review the facility failed to ensure each resident received adequate supervision to prevent accidents for 1 (Resident #1) of 5 residents reviewed for accidents and hazards. The facility failed to ensure Resident #1 did not break the window in her room, exit the window, and walk to the staff smoking area where she was found lying on a bench on 10/20/2025 at 8:10 PM, approximately 30 minutes after she was noted to be missing. The non-compliance was identified as PNC (Past Non-Compliance) on 10/22/2025 and the IJ template was provided to the facility on [DATE] at 3:21 PM. The noncompliance began on 10/20/2025 and ended 10/21/2025. The facility corrected the non-compliance before the survey began.This failure could place the residents at risk of serious harm, injury and death from wandering outside the facility in unfamiliar surroundings.Findings include:Record review of the facility reported incident, dated 10/20/2025, reflected Resident #1 broke her window and exited the building on 10/20/2025. Record review of Resident #1's Face Sheet, dated 10/22/2025, reflected the resident was an [AGE] year-old who admitted [DATE]. Resident #1 had diagnoses which included dementia (decline in cognitive function that interferes with daily life), bipolar disorder (extreme mood swings, including emotional highs and lows), and delusional disorders (false beliefs that are resistant to reasoning or contrary evidence). Record review of Resident #1's Comprehensive Care Plan, dated 10/21/2025, reflected The resident is at risk for wandering. Date initiated 07/13/2024. Interventions included to identify the pattern of wandering and intervene as appropriate; if the resident is exit seeking, stay with the resident and notify the charge nurse by calling out, sending another staff member, or using the call system; offer pleasant diversions, structured activities, food, conversation, television, or a book. Record review of Resident #1's Comprehensive Care Plan, dated 10/21/2025, reflected Actual elopement or elopement attempt. Resident left the facility unattended. Interventions included Supervise closely with increased staff monitoring x 72 hours or until further guidance. Begin with one-one-one monitoring. Dated Initiated: 10/20/2025.Determine the reason the resident is attempting to elope. Is the resident looking for something or someone Does it indicate the need for more exercise? Intervene as appropriate. Date Initiated: 10/20/2025 . Provide structured activities: toileting, walking inside and outside, reorientation strategies including signs, pictures, and memory boxes. Date initiated: 10/20/2025.Distract resident from elopement attempts by offering pleasant diversions, structured activities, food, conversation, television, books. Date Initiated 10/20/2025.Record review of Resident #1's clinical file on 10/22/2025 reflected no prior attempt to elope. Record review of Resident #1's Quarterly MDS (tool used to assess health status) Assessment, dated 09/25/2025, reflected severely impaired cognition with a BIMS (screening tool to assess cognitive status) score of 07 and indicated no behavioral symptoms. Resident #1 was ambulatory with a walker and independent with most activities of daily living. Record review of RN A's Event Nurses' Note, dated 10/20/2025, indicated Resident #1 exited through a window and was located 30 Page 1 of 4 675856 675856 10/22/2025 Whitesboro Health and Rehabilitation Center 1204 Sherman Dr Whitesboro, TX 76273

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few minutes after she was noted to be missing on the bench in the gated area of the garden. Resident #1 told staff she heard the [NAME] talking. Resident #1 was assessed, and vital signs were taken. She sustained no injury. Resident #1 was transported to the hospital for further evaluation. Record review of RN A's progress note, dated 10/20/2025, reflected Resident broke out window and crawled out. Was found on the bench in the fenced area of the garden lying on a bench with head covered with cowboy hat eyes closed. When approached and called by name opened eyes and answered all questions appropriately. Refused to sit up at that time. When asked what happened, Resident stated, ‘Matt was talking to me the ARC Angel.' Taken by ambulance to hospital for evaluation at this time.An attempt to interview RN A by telephone on 10/22/2025 was unsuccessful. During an observation and interview on 10/22/2025 at 9:42 AM, the Administrator stated at 8:30 PM on 10/20/2025, he received a phone call notifying him Resident #1 had busted her bedroom window and got out of the building. He stated the charge nurse had looked in Resident #1's room a few minutes earlier and the resident was looking through her dresser drawers. The nurse went to give medication to another resident. When the nurse returned to Resident #1's room, she was not in her room, bathroom or closet. The nurse noticed the glass window was broken and alerted the staff to search for her. The Administrator stated a CNA located her outside in the smoking area lying on a bench. He stated Resident #1 told staff [NAME] said the building was on fire and she broke the window and got out. He stated Resident #1 was assessed and she had no cuts or injury. Resident #1 refused to go back inside the building with staff. He stated emergency medical services was called, came and assessed the resident, and took her to the hospital for evaluation. The Administrator stated no other resident had eloped since this incident. The administrator showed the surveyor the window Resident #1 had exited. The surveyor observed the layout and noted the distance from Resident #1's room to the smoking area was approximately 50 feet. Resident #1 exited her window and walked to the staff smoking area in the gated courtyard. There was an opening in the courtyard where Resident #1 could have exited to the staff parking lot. From the staff parking lot, the resident would have access to the main road. Resident #1 did not reside on secure unit at time of the incident. Resident #1 had not returned from the hospital. During an interview on 10/22/2025 at 10:06 AM, the Regional Compliance Nurse stated when RN A checked on Resident #1 at about 7:10 PM, she was rearranging stuff in her dresser. The nurse continued passing medication and when she returned to give Resident #1 medication, she was not in her room. The bedroom window was broken. She stated Resident #1 never left the property. She was found lying on the bench in the courtyard. She stated the nurse ensured the resident was safe and assessed her skin and pain. She stated Resident #1 refused to go back inside the facility. She stated Resident #1 believed the arch angel told her to get out because the building was on fire. She stated she was sent to the hospital for evaluation and the emergency room documentation indicated her diagnosis was hallucinations. Resident #1 did not have any injuries. She stated it appeared Resident #1 had used a dresser drawer and her trash can to break the window, because they were on the ground outside the bedroom window. She stated all the glass was knocked out. There were no glass shards sticking out. She stated the night of the incident the window was boarded up until the glass could be replaced the following day. The facility initiated hourly monitoring of all residents' windows to ensure no windows were broken. She stated by the end of the day, all residents' windows would be equipped with an alarm to ensure if glass broke, staff would be alerted. The Regional Compliance Nurse stated the facility would continue to have elopement drills three times weekly to ensure staff knew what to do when a resident was missing. She stated the door alarms were checked daily. She stated Resident #1 would remain on 1:1 monitoring and evaluated for any changes. She stated after the incident, an elopement risk assessment was competed for all 675856 Page 2 of 4 675856 10/22/2025 Whitesboro Health and Rehabilitation Center 1204 Sherman Dr Whitesboro, TX 76273

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few other residents. She stated anyone at risk had interventions in place and included on the care plan. She stated residents that needed to be on the secure unit were already there. The Regional Compliance Nurse stated no other resident had eloped since Resident #1 exited the building. The Regional Compliance Nurse stated the hospital documentation revealed Resident #1 was admitted for a primary diagnoses of hallucinations and secondary diagnosis was hypertension (elevated blood pressure). She stated documentation revealed the resident had no physical injury. During an interview on 10/22/2025 at 11:30 AM, the Psych Nurse Practitioner was in the facility and stated she saw Resident #1 weekly. She stated she had seen her the previous week. She stated she had not seen any changes in Resident #1. She stated she was able to have logical conversations with Resident #1 and she had been very stable. She stated she could not believe the resident had gotten out of the building. She stated Resident #1 had not expressed wanting to leave the facility or reported voices telling her to leave the facility. She stated she would continue to see Resident #1. During an interview on 10/22/2025 at 1:10 PM, the DON stated the elopement risk assessment for Resident #1, dated 10/04/2025, indicated low risk with a score of 6. The risk assessment completed after the elopement indicated high risk with a score of 18. She stated Resident #1 had not exhibited any exit seeking behavior. She stated the resident was pleasant and enjoyed talking with people. She stated her family was at the facility frequently to visit and took the resident out of the facility to spend time with her. The DON stated no other resident had eloped since the incident. During a follow interview on 10/22/2025 at 1:25 PM, the Regional Compliance Nurse stated all residents had quarterly assessments for elopement risk. She stated Resident #1 was not having exit seeking behaviors and had had not attempted to get out of the building. She stated the resident's family member had a podcast focused on end time prophecy and he came in the evenings and discussed the book of Revelations with the resident. She stated staff felt that may have been a factor in Resident #1 getting out of the building, because when she was found she told staff the [NAME] told her to get out of the building because it was on fire. She stated staff discussed their concerns with the resident's family who were open to discussing other topics. An attempt to interview Resident #1's family member by telephone on 10/22/2025 at 1:50 PM was unsuccessful. During an interview on 10/22/2025 at 3:01 PM, CNA B stated she was assisting another resident and heard Resident #1 making a loud noise in her room. She stated she went to the room and Resident #1 was moving her clothes and a chair. She stated she did not think anything about it. She stated about 20 minutes later, the nurse told her the resident got out. She stated staff began searching everywhere inside the building. She stated she searched her hall and went to the exit door at the end of the hall. When she exited the building, she saw Resident #1 in the smoking area. She stated the following day when she returned to work, the facility had an elopement drill. She stated the facility called a code orange if a resident was missing. CNA B stated she had never seen Resident #1 try to get out of the building.During a follow up interview on 10/22/2025 at 4:06 PM, the Administrator stated risk assessments were completed for all residents and elopement drills were initiated. He stated administrative staff began logging hourly window checks and the facility had a work order for window alarms to be installed on all residents' windows. The Administrator stated it was important to have elopement prevention measure in place for the safety of the residents to prevent residents from getting out of the building and being harmed. He stated facility policies and elopement drills were in place to prevent elopement and ensure staff responded properly to help residents stay safe.During a follow up interview on 10/22/2025 at 4:14 PM, the DON stated Nurse A told her Resident #1 got out of her bedroom window and was found lying on the bench in the garden area. The DON stated patient safety was the number one priority. She stated it was important to provide in-services so staff knew what to 675856 Page 3 of 4 675856 10/22/2025 Whitesboro Health and Rehabilitation Center 1204 Sherman Dr Whitesboro, TX 76273

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few do in an emergency such as elopement or potential elopement. She stated it was important to follow protocol to find the resident as soon as possible and ensure the resident was safe. The DON stated staff did what they were supposed to do and did it well. She stated it was something they did not do often and that was a different situation. The DON stated the resident was found within the 30 minutes of staff noticing she was missing. The DON stated Resident #1 told staff the [NAME] told her to get out of the building and when staff located her, she refused to go back into the building. She stated the nurse assessment revealed no physical injury. The DON stated the emergency medical services took Resident #1 to the hospital for evaluation. The DON printed Resident #1's hospital record which showed she was admitted for hallucinations and hypertension. The DON stated the resident would return on 1:1 monitoring.Interviews on 10/22/2025 between 1:42 PM and 5:40 PM were conducted with multiple staff members which included the Administrator, DON, Regional Compliance Nurse, ADON, Social Worker, RN A, CNA B, MDS Coordinator, Business Office Manager, Housekeeping Supervisor, LVN C, LVN D, CNA E, CNA F, CNA G, LVN I, Housekeeping Staff and CNA K. Interviews revealed staff members received elopement in-service training and participated in elopement drills. Staff were reminded to be alert to signs of exit seeking and to notify the charge nurse or DON to assess the resident as needed. Staff members were educated on their role when a code orange (elopement) was called in the facility. The elopement drills included the designation by the charge nurse of staff members to an assigned search area which included searching every room in the facility to ensure the resident was in the building and safe. If a resident was not located inside or outside the building, police, family, and the physician must be notified. No lack of knowledge or procedure was identified. The facility initiated the following interventions prior to the state surveyor entry on 10/21/2025:Record review of Resident #1's clinical file on 10/22/2025 at 10:15 AM reflected the following:-Resident #1's risk assessment on 10/04/2025 reflected the resident was not a high risk for elopement. The elopement risk assessment completed on 10/20/2025 indicated the resident was at high risk.-Resident #1's Comprehensive Care Plan was updated with interventions on 10/20/2025 after the resident exited the building.-Elopement risk assessments and care plans were updated on all residents in the building on 10/20/2025. -The Medical Doctor, Psychiatrist, Director of Nursing, Administrator, and Resident #1's family member were notified of the elopement on 10/20/2025. -Documentation of education of all staff on resident rights, abuse, neglect, and exploitation beginning with night shift staff on 10/20/2025. -Documentation of education of all staff on elopement prevention and response, exit seeking, and door protocols beginning with night shift on 10/20/2025.-Documentation of elopement drills initiated on 10/21/2025 and to continue three times weekly following the elopement.- Documentation of an hourly monitoring log initiated on 10/20/2025 to ensure all residents' windows were intact until window alarms installed- Documentation of a facility work order, dated 10/21/2025, for alarms to be installed on all residents' windows - Documentation of door alarm or lock function monitoring 5 times weekly for each exit door was initiated on 10/20/2025.Administrative staff were observed conducting window checks in the residents' rooms on 10/22/2025 at 10:00 AM, 11:00 AM, 12:00 PM, and 1:00 PM. The work order was completed and the residents' windows equipped with window alarms prior to the surveyor's exit. Record review of the facility's policy Elopement Prevention, undated, reflected Every effort will be made to prevent elopement episodes while maintaining the last restrictive environment for residents who are at risk for elopement. Record review of the facility's policy Elopement Response, undated, reflected Nursing personnel must report and investigate all reports of missing residents. When an elopement has occurred or is suspected, our elopement response plan will be immediately implemented. 675856 Page 4 of 4