Health inspection·October 10, 2023

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 5:30 AM to 5:45 AM he was taking the trash out for his coworker and saw a person in the grass, he approached the person and realized it was Resident #1. CNA A stated that he took Resident #1 into the facility. CNA A stated that he reported the incident to his charge nurse and the ADM and DON were immediately notified. CNA A stated that Resident #1 kept saying please don't tell my family I tried to leave, they will be so embarrassed. CNA A stated that Resident #1 did not appear hurt, and she was assessed by the charge nurse on duty. CNA A said the room that Resident #1 eloped from was right across the hall from the resident's room and the door was always shut with a sign on the door saying under construction. CNA A said that Resident #1 was agitated during the day prior to the incident and was beating on the doors between the secured unit and the main facility yelling that she wanted to go home. Interview/Observation with CNA A on 10/10/2023 at 6:05 AM revealed the area where CNA A found Resident #1. CNA A pointed to the area where he found the resident, the area was on the premises in a grassy area approximately 100 feet from the where the resident eloped. Observation on 10/10/2023 at 6:00 AM revealed that the room that the resident eloped from was directly across the hall from Resident #1's room. The door leading to the room had a doorknob that locked. Interview on 10/10/2023 at 8:10 AM, DON stated that she was called about 6:00 AM on 9/30/2023 about the incident with a resident eloping. DON stated she came immediately to the facility, and they started 15-minute watches on the resident to ensure the resident wasn't in any distress. DON stated she and ADM scheduled a Care Conference with the family on 9/30/2023. DON stated that Resident #1 had been agitated the day prior to the incident and was saying she wanted to go home. Interview on 10/10/2023 at 9:18AM, MS stated that he and his assistant were working on the empty room prior to the incident that occurred on 9/30/2023 with Resident #1. MS stated that the hole was secured with a piece of plywood and wood screws. MS stated that he didn't know how the resident eloped because the hole was secured with plywood and two small dressers were in front of the secured plywood . MS stated that the door was closed when they were not working on room. MS stated that the negative outcome for elopement would be that a resident could get hurt. MS stated that since the incident he installed a doorknob on the door with a lock and key. He and the ADM are the only two with the key. MS also stated that he has secured the hole with plywood using 3-inch cement screws. MS stated he has been in-serviced on elopement policy and procedures and the staff was given an elopement drill. Interview on 10/10/23 at 10:48 AM with Resident #1's family member revealed that the family member was contacted about Resident #1's elopement early morning on 9/30/2023. The family member said she met with the ADM and DON and decided to put Resident #1 in a behavioral hospital due to her exit seeking behaviors. Interview on 10/10/2023 at 11:38 AM, CNA B stated that she was working during the time of the incident and was working on the secured unit hall. CNA B said that she started doing her rounds at 4:00 AM on 9/30/2023. CNA B said she would always start with Resident #1's room as it was at the end of the hall. CNA B said that Resident #1 was sitting on the edge of her bed and requested water. CNA B said she got Resident #1 water and then went to check on the rest of the residents. CNA B said that she did not hear any noise relating to the incident. CNA B asked CNA A to take her trash out as she couldn't leave the secured unit. CNA A returned with Resident #1 and was assessed by her charge nurse. CNA B said the negative outcome for a resident eloping would be that a resident could get hurt. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675945 If continuation sheet Page 2 of 3 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 675945 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wellington Care Center 1506 Childress St Wellington, TX 79095 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 - Minimal harm or potential for actual harm Residents Affected - Few CNA B stated that no alarms went off as there are alarms on all doors in the facility, so she didn't know how the resident eloped. CNA B stated that she has been in-serviced on elopement policy and procedures. Interview/Observation on 10/10/2023 beginning at 1:25 PM, ADM stated she was contacted by staff about 6:00 Am on 9/30/2023 about the elopement. ADM stated that staff told her no alarms went off during the night so ADM walked through the facility looking in every room to see where the resident eloped. ADM stated she went into the empty room across from Resident #1's room and saw her wheelchair near the opening of the wall where the air conditioning unit was out of the wall. A piece of plywood was on a small dresser near the opening. Observation of the empty room revealed the hole in the wall had been secured by plywood and screws. Surveyor attempted to remove the plywood but was not able to as it was secured tightly to the wall. ADM stated that she and her Maintenance Supervisor are the only two that have a key to the room. ADM stated that she contacted her Quality Assurance and Performance Improvement(QAPI)Team. The team meets quarterly or as necessary to address any needs of care and/or quality of life. The team met relating to the incident and put in place a plan. ADM also so said she in-serviced her employees on elopement prevention and policy. ADM stated that she had an elopement drill and conducted Champion rounds to ensure that the door to the empty room stayed secured. Record Review of SecureCare Environment admission Criteria and Process policy revealed the following: The goal of the SecureCare Environment is to meet the individual needs of residents with dementia related illness. The SecureCare Environment will provide a safe environment. Record Review revealed the ADM conducted two In-services for entire staff on 9/30/2023. In-service for Rooms that are under construction/doors/alarms or window issues and and In-service on Secure Units. Record Review revealed the ADM conducted two In-services for entire staff on 10/02/2023. In-service for Elopement policy and procedures and an In-service for Elopement prevention. Record Review revealed the documentation of Champion rounds that were being done daily to check on the room's lock status. Record Review revealed that the ADM conducted an Elopement Drill with her staff on 10/02/2023. Record Review orevealed that the ADM had an Off-Cycle Quality Assurance and Performance Improvement(QAPI) meeting on 9/30/2023. The meeting identified a system failure with the room under construction that was left unlocked and allowed a resident to enter and attempt to elope. The goal for the plan is to have all rooms that are under construction locked and secure to prevent any resident from going inside. The plan included doing champion rounds for 4 weeks ensuring the room under construction stayed locked and re-educating staff on secured units. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675945 If continuation sheet Page 3 of 3