Health inspection·August 14, 2025

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few and witnesses by CNA A , in a question-and-answer format reflected, [ADM question]: were you trying to go somewhere earlier when you went out the front door. [Resident #1 answer] I went outside. [ADM question] yes, you went outside and was found right outside the front door. Were you needing anything that causes you to go outside? [Resident #1 answer] Well, no, not that I can think of. [ADM question] Are you doing ok right now do you need anything? [Resident #1 answer] I'm fine, thank you for asking. During an observation and interview with Resident #1 on 08/13/2025 at 12:15 PM revealed her walking around in the secure unit with an ink pen in her hand and asked for some paper to write on. Resident #1 was asked her name by Surveyor, and she stated her name and began to repeat yes are you here for me. Therefore, an interview with Resident # 1 was not completed. During an interview with CNA A on 08/13/25 at 1:00 pm, she stated she was leaving for work approximately at 6:30 PM and she observed Resident # 1 standing on the front porch of the facility. She stated Resident #1 was not walking and standing in one spot. She stated she asked Resident # 1 to come back in and she refused. Therefore, she opened the front entrance door to ask for help to MA B, but he could not hear her, so she ran back into the building and told the charge nurse (LVN A) Resident # 1 was outside and she would not come in. She stated LVN A came outside with her to assist, and Resident #1 had walked to unit 200 covered patio area . She stated she could not remember if Resident # 1 was sitting or standing on the patio; however, LVN A was able to get her to come back into the building. She stated Resident # 1 was assessed by LVN A. She stated Resident #1 knew how to read numbers, and it was possible she let herself out or she went out the door when a visitor left. She stated Resident #1 use to leave on the secure unit, but she was moved out because she was not showing exit seeking behaviors. An interview on 08/13/2025 at 1:30 PM with LVN A was attempted by phone; however, she did not answer, and a voicemail was left for her to return my call. During an interview with RP on 08/13/2025 at 2:00PM, she said she was okay with Resident #1 moving to the unsecure unit, but she knew the elopement was going to happen eventually. She stated she wanted to give Resident #1 a chance to prove her wrong ; however, she believed Resident #1 read the pin code instructions and let herself out the front door. She said the facility did call her the day of the incident (08/07/2025) and made her aware that Resident # 1 eloped . During an interview with ADON on 08/13/25 at 3:00pm she stated the day of Resident #1's elopement she was present and was meeting with a visiting family. She stated she last saw Resident # 1 standing by the nursing station between 5:30PM- 6:00 PM. She stated their facility team and family members had discussed moving Resident #1 to a non- secure area for some time , so they decided to move her on 07/17/2025. She stated she was moved to hall 500 and was able to recognize her name on her door and there was no exit seeking behaviors. She stated her RP wanted Resident # 1 to have free access to the vending machine at her leisure, which gave the team another reason to move her to a non-secure area. She said she completed an elopement assessment and secure care unit assessment before and after the incident on 08/07/2025 and Resident #1 moved from the secure unit on 07/21/2025. She stated on 08/07/2025, Resident #1 was assessed for injuries and was moved back to the secure unit, and her RP gave consent to move her back. An interview on 08/13/2025 at 3:15 PM with MA A was attempted by phone; however, he did not answer after two attempts. MA A voicemail was not set-up; therefore, a voice mail was not left. During an interview on 08/13/2025 at 6:20 PM with Social Worker, she stated she had observed Resident # 1 never exit seeking and she remembered they talked about her moving out of the secure unit because since her admission she has never showed any exit seeking behavior. The Social Worker looked at Resident EHR to find documents of an official IDT meeting, and stated she could not find any documents, but she knew her RP agreed with the move. She stated she could not explain why any pre-move meetings was not documented and was not sure if Resident #1's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676089 If continuation sheet Page 2 of 4 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 676089 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/14/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Winnie L Nursing & Rehabilitation 2104 N Karnes Cameron, TX 76520 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 - Few Physician agreed with her move for the secure unit. During an interview on 08/14/2025 with LVN A at 6:34 PM she stated on 08/07/2025 , CNA A was leaving work and saw Resident # 1 standing outside on the front porch . She stated Resident # 1 would not come in for CNA A; therefore, she went outside to assist. She stated Resident # 1 was not overheated and was found walking on the sidewalk to hall 200's outside covered patio sitting . She stated she was dressed in clothes appropriate for the warm weather. She stated once Resident # 1 came into the facility she completed her vitals and there were no concerns. She stated she called the ADM and informed her Resident #1 was found outside and she contacted her RP and Physician. She stated earlier on 08/07/2025 she observed Resident #1 demonstrating exit seeking behaviors by walking around the facility with some bags and a box. She stated she observed her with her belongings while walking around the nurse's station and Resident # 1 was redirected to put her things up, and she did. She stated prior to 08/07/2025, Resident # 1 did not demonstrate any exit seeking behaviors once she was moved from the secure unit. She stated the alarm to the front doors work and was never broken, and if Resident #1 had pushed the door the alarm would have sounded . She stated it was very likely for Resident # 1 read the code and let herself out the front door because she could read. She stated she did not know if the IDT had met prior to Resident # 1's move but the facility did provide in-services on self- report / missing resident or elopement protocol elopement drills and ANE. Record Review of Elopement nurse's note-12hr dated 08/07/2025 at 6:54 PM by LVN A reflected, 3. Follow-Up: Resident walked out front door was seen by a CNA when they were leaving the building after their shift, CNA attempted to redirect resident back to the building, redirection unsuccessful, this nurse followed CNA to resident and assisted back inside. New order from Physician: Resident to reside on secure unit due to history of elopement with active exit seeking behaviors. Review of Secure care Environment Screening Tool dated 05/8/2025 for Resident # 1 reflected, diagnosis of Alzheimer's disease or related dementia disorders, resident continue to exhibit exit seeking behavior. Record review of elopement risk assessment dated [DATE] reflected Resident #1 had no history of attempts to leave facility. Her current behaviors: restlessness. [Resident #] 1 can state her name and recognizes stop lights and signs; however, she did not know her current residence, or recognize her physical needs. Record Review of Elopement Assessments dated 08/8/2025, reflected all current residents who were located in the secure unit and non-secure unit were re-assessed for elopement risk. No new residents were identified to be at high risk who resided in non- secure unit. During an interview on 08/14/2025 at 2:00 PM with ADM she stated she, the DON and ADON were in-serviced by their [NAME] President of clinical services on Pre and Post tools because they did not follow the facility protocol to ensure Resident #1's move was documented, and she was monitored after her move. She stated all staff was in-serviced on ANE, missing resident / elopement monitoring which included checking locking mechanism or alarm function properly on all exit doors, and elopement drills which would be conducted monthly on different shifts at random time. She stated other in-services was a Post elopement drill all staff and QAPI evaluation checklist for administrative staff . She stated without proper pre and post move transfer meeting and monitoring from a secure unit to non-secure being done a negative outcome could be Resident elopement , injury or even death of they are lost and have health issues. Record review of facility's policy on elopement/wandering unknown date, reflected , Every effort will be made to prevent elopement episodes while maintaining the least restrictive environment for residents who are at risk for elopement.1. The Elopement Risk Assessment will be completed upon admission. The assessment should becompleted by reviewing the resident's medical history and social history. Informationmay be obtained by reviewing current medical records, if available, interview withresident/family, or conference with the interdisciplinary team member. The (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676089 If continuation sheet Page 3 of 4 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 676089 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/14/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Winnie L Nursing & Rehabilitation 2104 N Karnes Cameron, TX 76520 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 - Few FORM CMS-2567 (02/99) Previous Versions Obsolete assessmenttool should be completed, and interventions implemented as indicated. The ElopementRisk Assessment is to be completed at least quarterly and upon change of condition.2. All residents who are at risk for harm because of wandering (elopement) will be assessed by theinterdisciplinary care planning team.Interventions into elopement episodes will be entered onto the resident's care plan and medical.6. 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 ofNursing Services should be notified of elopement.7. If a resident is discovered to be missing, a search shall begin immediately. On 08/13/2025 at 6:50 PM, the ADM was informed of an IJ. The non-compliance was identified as past non-compliance. The IJ began on 08/07/2025 and ended on 08/08/2025 at 2:20PM The facility had corrected the noncompliance before the investigation began. The interventions and plan of correction included: Review of Resident #1 EMR revealed Resident #1 was moved to the secure unit for her safety immediately.Review of Resident # 1 EMR revealed she was seen by her MD on 08/08/2025. It was recommended by MD for Resident #1 to remain in secure unit. No other concerns noted.Review of facility in-services dated 08/07/2025-08/8/2025 revealed all staff were educated regarding elopements, securing doors and activating alarms, abuse and neglect and supervision of residents. Staff were instructed to notify DON, Admin regarding any attempts of elopement or resident who may have increased confusion and attempt to exit. Review of Elopement drills dated 08/08/2025 revealed a drill was completed on all shifts. Review of Elopement Assessments dated 08/07/2025 revealed current residents were assessed for elopement/wandering risk. No new residents were identified to be at high risk.Review of Ad Hoc QAPI meeting held on 08/08/2025 revealed an QAPI meeting was held to discuss the elopement of Resident #1. Record review of elopement follow- up interviews conducted by DON to all staff on 08/08/2025.Observations at facility on 08/13/2025 - 08/14/2025 and did not reveal observations of exit seeking or wandering residents. Interviews with facility staff on 8/13/2025-8/14/205 revealed they were educated on elopements, securing doors and alarms, supervision of residents, abuse and neglect, monitoring and documenting procedures during pre and post move from secure unit to a non- secure unit. Event ID: Facility ID: 676089 If continuation sheet Page 4 of 4