Health inspection·September 11, 2025

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some 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 reviews, the facility failed to ensure residents received adequate supervision and assistive devices to prevent accidents for two of five residents (Resident #1 and Resident #2) reviewed for supervision. 1.) The facility failed to ensure Resident #1 was adequately supervised in order to prevent her from eloping from the facility. Resident #1, who was known to have confusion and wandering behaviors, first exited from an exterior door of the facility on 04/01/25. The facility failed to provide adequate supervision, and Resident #1 eloped from the facility on 09/06/25. 2.) The facility failed to ensure the Wander Guard system (an electronic system that could trigger alarms and lock monitored doors to prevent a resident from leaving unattended) utilized for Resident #2 was in proper working order. An Immediate Jeopardy (IJ) was identified on 09/10/25 at 1:50PM. The IJ template was provided to the facility on [DATE] at 2:08PM. While the IJ was removed on 09/11/25, the facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm and a scope of pattern due to the facility still monitoring the effectiveness of their Plan of Removal. This failure placed residents at risk for not being adequately supervised and the potential for serious injury and/or death.Findings included: 1.) Record review of Resident #1's Face Sheet, dated 09/10/25, reflected she was an [AGE] year-old female, who was admitted to the facility on [DATE], with diagnoses including vascular dementia (a general term describing problems with reasoning, planning, judgment, memory and other thought processes caused by brain damage from impaired blood flow to your brain) and repeated falls (a personal history of falls). Resident #1 was discharged from the facility on 09/07/25. Record review of Resident #1's MDS Assessment, dated 07/09/25, reflected she had a BIMS score of 04, indicating she had severe cognitive impairment. She was not documented as utilizing a wandering/elopement alarm at the time of the assessment. Resident #1 was identified as being able to walk 150 feet independently. The MDS Assessment reflected she had not displayed any recent wandering behaviors. Record review of Resident #1's Care Plan, dated 07/09/25, reflected an identified focus area of being at-risk for wandering (initiation date 12/31/24, revision date 01/14/25). Goals included for Resident #1's safety to be maintained and for Resident #1 not to leave the facility unattended. Identified interventions included assessing Resident #1 for her risk of falls, distracting Resident #1 from wandering by offering pleasant diversions (structured activities, food, conversation, television, books), identifying a pattern for wandering, staying with Resident #1 and notifying the Charge Nurse if she was exit seeking, monitoring Resident #1 for fatigue and weight loss, and providing structured activities (toileting, walking inside and outside, reorientation strategies including signs, pictures, and memory boxes). Record review of Resident #1's Progress Notes, dated 04/01/25, reflected, .Resident disoriented but easily redirected opened door which activated the alarm. Staff immediately followed resident and walked with resident and assisted her back inside the facility. Resident stated she was searching for her car. Resident Page 1 of 7 675963 675963 09/11/2025 North Pointe Nursing and Rehabilitation 7804 Virgil Anthony Blvd Watauga, TX 76148

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some assisted back to her room. Record review of Resident #1's Elopement Risk Assessment, dated 04/01/25 (following the wandering/elopement incident), reflected she scored a 12.0, indicating she was at an increased risk for elopement. Record review of Resident #1's Elopement Risk Assessment, dated 07/02/25, reflected she scored a 20.0, indicating she was at an increased risk for elopement. Record review of an Event Report for Resident #1, dated 09/06/25, reflected, .Resident was found outside the facility after exiting through the 200 hall door. Resident was located in the front parking lot between two vehicles, on the ground. When asked, resident stated she was trying to get in her car. Assessment revealed no injuries. Resident was assisted to a standing position and ambulated back into the facility without difficulty. Record review of Resident #1's Progress Notes, dated 09/06/25 at 7:44PM, reflected, .The front and back door alarms were sounding, and staff initiated a search for residents. Resident was found outside the facility after exiting through the 200 hall door. Resident was located in the front parking lot between two vehicles, on the ground. When asked, resident stated she was trying to get in her car. Assessment revealed no injuries. Resident was assisted to a standing position and ambulated back into the facility without difficulty. Resident was redirected, and safety precautions were reinforced. Will continue to assess the resident closely for changes in condition, ensure door alarms remain functional, and notify the physician and family of the incident. Record review of Resident #1's Elopement Risk Assessment, dated 09/06/25 (following the wandering/elopement incident), reflected she scored a 26.0, indicating she was at an increased risk for elopement. Observation of the path from the exterior door on the 200 Hall to the front of the building in which Resident #1 was located (the path in which it was determined by the facility that Resident #1 walked, after she eloped from the building on 09/06/25) on 09/11/25 at 8:40AM revealed the path was approximately 150 feet in length. During an interview with the ADON on 09/10/25 at 11:22AM, she stated Resident #1 had a history of confusion, and it was not uncommon for her to sundown (a phenomenon where people with dementia or other cognitive impairments experience increased confusion, agitation, and other behavioral changes in the late afternoon and evening hours). The ADON stated Resident #1 had previously gone toward exterior doors before and had even opened an exterior door in the past, but she was always easily redirected. The ADON stated when Resident #1 previously opened an exterior door (04/01/25), a staff member had line-of-sight supervision of her and was able to redirect her back inside. The ADON stated on 09/06/25 at approximately 7:00PM, the front door alarm and the alarm from the exterior door on the 200 Hall were both sounding at the same time. She stated facility staff immediately responded to the alarms. The ADON stated she went outside via the exterior door on the 200 Hall and LVN A went outside via the front door; staff remaining inside were conducting a head count of residents. The ADON stated she did not immediately see anyone when she went outside, so she started to walk around the exterior of the building. When she arrived at the front of the building, she noted LVN A waving her hands and calling her (the ADON) over toward her. The ADON stated when she arrived to where LVN A was standing, she saw Resident #1 sitting between two cars, on the concrete ground. Resident #1 denied being injured and stated she was looking for her car. She was easily redirected and taken back inside of the facility. A head-to-toe assessment revealed no noted injuries. The Administrator was notified of the incident, and Resident #1 was placed on 1:1 supervision/monitoring until alternate placement could be located at a secured facility the following day. The ADON stated in total, it was about 2-3 minutes from the time the alarms went off until the time Resident #1 was located outside. Through the facility's investigation, it was determined that the front door alarm was sounding because the door had not adequately latched when a visitor had exited the building (a company came out and repaired the latch following the incident). Resident #1 exited through the exterior 675963 Page 2 of 7 675963 09/11/2025 North Pointe Nursing and Rehabilitation 7804 Virgil Anthony Blvd Watauga, TX 76148

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some door of the 200 Hall, which was the reason for that alarm sounding. Following the incident, facility staff were in-serviced on abuse/neglect and elopement prevention/response. The ADON stated the risk of a resident eloping from the facility included the potential for injury. During an interview with LVN A on 09/10/25 at 11:36AM, she stated on 09/06/25 at approximately 7:00PM, the front door alarm started sounding. When staff attempted to immediately disarm the alarm, it was noted that the alarm from the exterior door on the 200 Hall was also sounding. LVN A stated the sound from the front door alarm was overpowering the sound of the alarm from the exterior door on the 200 Hall. Upon realizing that the exterior door on the 200 Hall was also sounding, LVN A said she immediately questioned to available staff, Where is [Resident #1]? LVN A stated this was her first thought because she knew Resident #1 had a history of sundowning, packing up her belongings, and attempting to exit from the exterior door on the 200 Hall. LVN A stated she went to Resident #1's room and noticed the top drawer of her dresser was out (as though she was potentially packing up her belongings), and she was not in the restroom. LVN A stated she immediately went outside and started searching for Resident #1. She found Resident #1 in the front of the building, sitting between two parked cars. Resident #1 was confused; she stated she had found her car and was trying to get in it. LVN A stated she waved facility staff over toward her and Resident #1 was assisted back inside the building. She was clearly confused but had no signs of injury. She was placed on 1:1 supervision/monitoring until alternate placement could be located the following day. LVN A stated facility staff were in-serviced on abuse/neglect and elopement prevention/response. She also stated the facility had the alarm system repaired, so the front door alarm no longer overpowered the other exterior door alarms. LVN A stated the risk of a resident eloping from the facility included the potential for injury. During an interview with the Administrator in Training on 09/10/25 at 11:44AM, she stated Resident #1 had a history of wandering and sundowning; she had also previously exited from an exterior door (04/01/25). The Administrator in Training stated the facility's policy was to find alternate, secured placement for residents who began showing signs of exit-seeking behavior. She stated she was not sure why Resident #1 was allowed to stay at the facility following the incident in April of 2025; she believed it must have been because she was always easily redirected. The Administrator in Training stated she responded to the most recent incident involving Resident #1's elopement (09/06/25), as the Administrator was on leave at that time. The Administrator in Training stated she came to the facility following the incident, after she had been notified by the ADON that Resident #1 eloped. The Administrator in Training stated it was her understanding that Resident #1 eloped from the exterior door on the 200 Hall. She was found within just a few minutes by facility staff and was easily redirected and brought back inside the building. She denied the presence of pain and did not sustain any injuries. Her family and physician were notified of the incident. Resident #1 was placed on 1:1 supervision/monitoring until alternate placement could be located the following day. The Administrator in Training stated Resident #1 did not have a Wander Guard bracelet (an electronic device that could trigger alarms and lock monitored doors to prevent a resident from leaving unattended) at the time of the incident. The Administrator in Training stated there was one resident at the facility (Resident #2) who utilized a Wander Guard bracelet, but aside from that, the facility stopped ordering them. Following the incident, the Administrator in Training stated facility staff were in-serviced on abuse/neglect and elopement prevention/response. She also stated the facility had the alarm system repaired, so the front door alarm no longer overpowered the other exterior door alarms. During an interview with the Administrator on 09/10/25 at 12:05PM, she stated she was on leave when the incident involving Resident #1's elopement occurred (09/06/25). She stated the Administrator in Training responded to the incident. The 675963 Page 3 of 7 675963 09/11/2025 North Pointe Nursing and Rehabilitation 7804 Virgil Anthony Blvd Watauga, TX 76148

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Administrator stated Resident #1 initially admitted to the facility in December of 2024; she was very ambulatory, so she was placed on 1:1 supervision/monitoring to ensure she would adjust appropriately to the facility. She did not display any exit-seeking behaviors, so 1:1 supervision/monitoring was discontinued. She continued to reside at the facility without incident until 04/01/25, when she opened the exterior door on the 200 Hall. A staff member saw her open the door, walked with her and redirected her back inside. A staff member was with her at all times during that incident. The Administrator stated the incident was discussed amongst facility staff and they did not think Resident #1 was actually trying to elope from the building, so she was allowed to stay at the facility. She stated if a resident was truly trying to elope from the building, then that resident would be moved to a sister facility with a secured unit. The Administrator stated the facility was trying to get away from the use of Wander Guard bracelets, which was why Resident #1 did not have one at the time of the incident on 09/06/25. The Administrator stated the risk of a resident eloping from the facility included the potential for harm and/or death. 2.) Record review of Resident #2's Face Sheet, dated 09/10/25, reflected she was a [AGE] year-old female, who was admitted to the facility on [DATE], with diagnoses including dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), vascular dementia (a general term describing problems with reasoning, planning, judgment, memory and other thought processes caused by brain damage from impaired blood flow to your brain), and anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities). Record review of Resident #2's MDS Assessment, dated 06/13/25, reflected she had a BIMS score of 03, indicating she had severe cognitive impairment. She was not documented as utilizing a wandering/elopement alarm at the time of the assessment. Resident #2 was identified as being able to walk 10 feet with partial/moderate assistance from staff. The MDS Assessment reflected she had not displayed any recent wandering behaviors. Record review of Resident #2's Care Plan, dated 07/01/25, reflected an identified focus area of being at-risk for injuries/elopement due to wandering behaviors and wandering with poor safety awareness. This focus area also identified Resident #2 as wearing a Wander Guard bracelet (initiation date 11/21/22, revision date 01/21/25). Goals included for Resident #2 to have no elopements/injuries due to wandering behaviors. Identified interventions included assessing Resident #2 for her risk of falls, distracting Resident #2 from wandering by offering pleasant diversions (structured activities, food, conversation, television), identifying a pattern for wandering, staying with Resident #2 and notifying the Charge Nurse if she was exit seeking, monitoring the placement of the Wander Guard bracelet each shift, and providing structured activities (toileting, walking inside and outside, reorientation strategies including signs, pictures, and memory boxes). Record review of Resident #2's Physician's Orders, dated 09/10/25, reflected, .Monitor Wander Guard to right lower leg for placement, function, and skin integrity every shift. The start date for this order was 10/18/24 and there was no set end date. Record review of Resident #2's September 2025 Medication Administration Record/Treatment Administration Record, dated 09/10/25, reflected facility staff documented confirming the placement, function, and skin integrity for Resident #2's Wander Guard bracelet every shift. Record review of Resident #2's Elopement Risk Assessment, dated 07/21/25, reflected she scored a 12.0, indicating she was at an increased risk for elopement. Record review of Resident #2's Elopement Risk Assessment, dated 09/06/25, reflected she scored an 11.0, indicating she was at an increased risk for elopement. Observation of Resident #2 on 09/10/25 at 11:55AM revealed she was wearing a Wander Guard bracelet on her ankle. Observation revealed the front door of the facility (the door which was equipped with a Wander Guard alarm system; all other 675963 Page 4 of 7 675963 09/11/2025 North Pointe Nursing and Rehabilitation 7804 Virgil Anthony Blvd Watauga, TX 76148

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some exterior doors were fire alarm doors with controlled egress locks) did not automatically lock, as it should have, when Resident #2 was within one foot of the door. This occurred on two out of three attempts of verification of the functionality of the Wander Guard alarm system. The Administrator and the Administrator in Training both verified this observation. During an interview with the Administrator of 09/10/25 at 12:05PM, she stated she would ensure the Wander Guard alarm system was fixed today. She stated Resident #2 had been placed on 1:1 supervision/monitoring until it could be fixed. The Administrator stated she herself had verified the Wander Guard alarm system was working multiple times within the past few days, as a result of the investigation following Resident #1's elopement. Record review of the facility's Elopement Prevention Policy, dated 01/2023, reflected, .Every effort will be made to prevent elopement episodes while maintaining the least restrictive environment for residents who are at risk for elopement. and .All facility exits that residents have access to will have a device in place to alert staff of possible elopement attempts. Examples of these devices included Wander Guard systems (locking or alarming), keypad exit magnetic locks, keyed alarms, secured units, and/or a combination of these interventions. Record review of the facility's Elopement Response Policy, dated 01/2023, 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 implemented immediately. and .A resident is determined to be missing when he/she leaves the facility without the staff's knowledge. An Immediate Jeopardy (IJ) was identified on 09/10/25 at 1:50PM. The IJ template was provided to the facility on [DATE] at 2:08PM and signed by the Administrator. A Plan of Removal was requested at that time. The facility's Plan of Removal was accepted on 09/11/25 at 5:51AM and reflected the following: .Interventions: Resident #1 no longer resides in the facility as of 9-10-25. Resident #2 was placed on 1:1 supervision by DON/designee on 9-10-25 until the wander guard system on the door is fixed by Fire Protection. Line of sight monitoring for the front door initiated by Admin/designee on 9-10-25 until the wander guard system on the door is fixed by Fire Protection. An audit was completed on all residents in the facility to determine if they are at risk for elopement by Regional Compliance Nurse on 9.10.25. Resident #2 was the only resident identified as an elopement risk as of 9-10-25. IDT will review elopement risk scores on admission and quarterly. A Secure Care Consult while [sic] be requested by the DON/Designee to assist with ensuring appropriate placement and interventions if a resident is at risk. Administrator contacted Fire Protection vendor to inspect the doors and alarms on 9-8-25. Fire Protection vendor ensured the annunciator panel at the nurse's station was functioning and alarming properly. This was completed on 9-9-25. Administrator contacted Fire Protection vendor to inspect the front door to ensure proper functioning of the Wander Guard system. The front door will now be locked 24 hrs per day and 7 days per week and the latch was fixed. Completed on 9-10-25. The medical director was notified by the Administrator of the immediate jeopardy on 9-10-25. An Ad Hoc QAPI meeting to include the medical director was conducted on 9-10-25 to review the immediate jeopardy citation and subsequent plan of removal. In-services: The Administrator, DON, and ADON were in-serviced 1:1 by the Regional Compliance Nurse and completed as of 9-10-25 on the following: Abuse/Neglect Policy Proper functioning of the Wander Guard systemElopement Prevention and Response In-services: All staff will be in-serviced on 9.10.25 by the Admin/designee regarding the following and all staff not in-serviced by 9.10.25 will not be allowed to work their assigned position until completion of these in-services. All new hires, PRN, and agency staff will be in-services prior to the start of their assignment: This will be ongoing. Admin and ADON were in-serviced by Compliance Nurse. Abuse and NeglectProper functioning of the Wander Guard system Elopement Prevention and Response. The facility's implementation of the Plan of Removal was 675963 Page 5 of 7 675963 09/11/2025 North Pointe Nursing and Rehabilitation 7804 Virgil Anthony Blvd Watauga, TX 76148

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some verified through the following: Record review of the facility's Resident Roster, dated 09/11/25, reflected Resident #1 was not listed as a current resident. Observations of Resident #2 on 09/10/25 at 2:17PM and on 09/11/25 at 8:27AM revealed she was being provided with 1:1 supervision/monitoring by facility staff. Observation of the facility's front door on 09/11/25 at 9:23AM revealed the door was securely locked. Upon opening the door and allowing it to close, the latch secured properly and the door automatically locked. Resident #2, who was wearing her ordered Wander Guard bracelet on her ankle, was brought within one foot of the door, and the door remained locked. Observation of the annunciation panel (a panel that provides both visible and audible indications to alert caregivers about the status of alarmed doors) for the door alarm system on 09/11/25 at 9:28AM revealed when multiple alarms were sounding, the front door alarm did not overpower other alarms. All alarms sounding were able to be heard. Record review of Resident #1's Face Sheet, dated 09/10/25, reflected Resident #1 was discharged from the facility on 09/07/25. Record review of a 1:1 Supervision/Monitoring Log for Resident #2, dated 09/10/25, reflected Resident #2 had been provided with 1:1 supervision/monitoring by facility staff on 09/10/25 starting at 12:00PM through 09/11/25. Record review of a Line of Sight Door Monitoring Log, dated 09/10/25, reflected there was line of sight monitoring of the front door at the facility by facility staff on 09/10/25 starting at 12:00PM through 09/11/25. Record review of an Elopement Risk Assessment History audit, dated 09/10/25, reflected Resident #2 was the only resident present at the facility who was identified as being at-risk for elopement. Record review of in-service logs, dated 09/10/25, reflected facility staff members had been in-serviced on areas including abuse/neglect, elopement/wandering prevention and response, and proper functioning of the Wander Guard system. During interviews with multiple staff members who represented all departments and all assigned shifts (MDS Coordinator, Social Worker, Business Office Manager, Dietary Manager, Maintenance Director, Housekeeping Supervisor, LVN A, LVN B, LVN C, LVN D, LVN E, LVN F, RN G, CNA H, CNA I, CNA J, CNA K, CNA L, and MA M) on 09/11/25 between 5:38AM 9:15AM, they each reported being in-serviced on topics including abuse/neglect, elopement/wandering prevention and response, and proper functioning of the Wander Guard system. These staff members were able to verbalize the facility's policies and procedures related to the aforementioned areas, as well as how they would respond to resident changes of condition, residents who were wandering, missing residents, etc. These staff members appeared knowledgeable on the facility's policies and procedures. They each verbalized being aware that the facility had one resident with a Wander Guard system in place (Resident #2). These staff members reported that there had been no previous attempts of elopement by Resident #2, but the Wander Guard was in place as a prevention method due to her increased risk of elopement. These interviews were conducted without incident or concern regarding the trainings provided. During interviews with the Administrator, the Administrator in Training, and the ADON on 09/11/25 between 7:45AM and 9:05AM, they reported being in-serviced on topics including abuse/neglect, elopement/wandering prevention and response, and proper functioning of the Wander Guard system. These staff members appeared knowledgeable on the facility's policies and procedures. It was reported that the facility's Interdisciplinary Team (IDT) would review elopement risk scores on admission and quarterly; if a resident was identified as being at-risk for elopement, a Secure Care Consult would be requested to assist in ensuring appropriate placement and interventions. It was also reported that a QAA/QAPI meeting was held on 09/10/25 to review the Immediate Jeopardy citation and discuss the plan of removal. The Administrator stated she would be responsible for overseeing the plan and would notify the Regional Compliance Nurse of any negative findings. The Administrator was notified the IJ was removed on 09/11/25 at 9:35AM, however the facility remained out of compliance at a severity level of no actual harm with the 675963 Page 6 of 7 675963 09/11/2025 North Pointe Nursing and Rehabilitation 7804 Virgil Anthony Blvd Watauga, TX 76148

F 0689 potential for more than minimal harm and a scope of pattern due to the facility still monitoring the effectiveness of their Plan of Removal. Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some 675963 Page 7 of 7