Inspection·January 8, 2024

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few and meet needs, assist with word finding as needed/appropriate and ensure/provide a safe environment. Resident #1 was an elopement risk/wanderer related to disorientation to place and impaired safety awareness and interventions included document wandering behavior and monitor Wander Guard placement. Record review of Resident #1's physician's order dated 07/05/23 indicated an order to monitor placement and function of Wander Guard every shift; (+) = in place and function correctly, (-) = not working and replaced. Record review of Resident #1's Elopement/Wandering Evaluation dated 07/06/2023 at 08:25 a.m. indicated he had dementia and was disoriented. Resident #1 was at significant risk of getting to a potentially dangerous place (stairs, outside the facility). Resident #1 had a score of 11 indicating he was a high risk for elopement (Score ranges: Low risk: 0-9, High Risk:10-55). Record review of nursing note dated 07/07/23 at 10:03 a.m. indicated Resident #1 went to the front door and attempted to open it. When the alarm sounded he turned around and went back to his room. Record review of behavior note dated 07/29/23 at 09:26 a.m. indicated Resident #1 was pushing a resident in a wheelchair. They attempted to exit through the front door and the wander guard alarm alerted staff to the attempted elopement. Both residents were redirected, continue to wander throughout the facility and at risk for further elopement incidents. Record review of nursing note dated 08/13/23 at 6:44 p.m. indicated Resident #1 attempted to elope through the front door and was redirected back to his room. Record review of nursing note dated 09/18/23 at 8:58 p.m. by LVN C indicated she received a call from the police. Resident #1 walked to the store. A private citizen put him in their car and drove to a church where the police were sitting. The police brought him back to the facility. An elopement incident report dated 09/18/23 at 8:26 p.m. by LVN C indicated she received a call from the police who stated they had Resident #1. Resident #1 had walked to the store by a highway and a citizen brought him to them at a church. The police were sitting in the parking lot. Resident #1 was unable to give a description. Record review of facility Provider Investigation Report dated 09/23/2023 indicated on 09/18/23 at 6:01 p.m. Resident #1 was standing at the main entrance and a visitor let him out. Resident #1 walked to a store near the facility where an unknown individual drove him to a church parking lot where the police were at. The brought him back to the facility. An undated written interview statement by LVN D regarding Resident #1 elopement indicated she responded to the wander guard alarm then turned the alarm off after she looked and did not see anyone. LVN D assumed someone brought a wander guard resident into the building and they did not know the code because it happens so often. LVN D did not ask the nurses if anyone was missing because some employees do not know the wander guard code and set the alarm off when they bring residents in and out of the building. The facility determined a visitor let Resident #1 out and confirmed the findings. Record review of the facility's timeline for Resident #1's elopement indicated on 09/18/23 at 6:01 p.m. Resident #1 left the facility through the front door when a family member entered the door code and entered the facility. Resident #1 was seen on camera footage walking on the sidewalk in the front of the building at 6:14 p.m. and walking in the parking lot by the back door at 6:27 p.m The DON (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676193 If continuation sheet Page 2 of 7 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 676193 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Waterton Healthcare & Rehabilitation 2875 Shiloh Road Tyler, TX 75703 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 received a call from LVN D at 8:17 p.m. and was informed Resident #1 eloped. Level of Harm - Immediate jeopardy to resident health or safety Record review of Resident #1's MAR for the month of July 2023, August 2023, and September 2023 revealed there was no documentation indicating his Wander Guard was in place and functioning or not working and replaced. Residents Affected - Few Record review of www.timeanddate.com/sun for [NAME], Texas on 09/18/23 indicated sunset was 7:23 p.m. Record Review of CNA A's personnel file indicated she was hired on 10/18/23 and completed a web-based training for Wandering and Elopement on 10/20/23. There was no documented training for Wander System Monitoring Program. Record Review of NA B's personnel file indicated he was hired on 10/18/23 and completed a web-based training for Wandering and Elopement on 10/20/23. There was no documented training for Wander System Monitoring Program. During an interview on 01/04/24 at 12:55 p.m., NA B said residents at the facility who are at risk for elopement wore a wander guard bracelet which will alert staff by setting of the door alarm if they attempt leave. NA B said he did not know the residents that had a wander guard device on or what he needed to do if the wander guard alarm sounded but would ask the charge nurse or another CNA. NA B said he had worked at the facility almost 2 months and was not in-serviced on the facility's Elopement Policy or Wander System Monitoring Policy. NA B said this was his first shift back since the end of December 2023. During an interview on 01/04/24 at 1:01 p.m., CNA A said residents at the facility at risk for elopement wore a wander guard bracelet which will alert staff by setting of the door alarm if they attempt leave. CNA A said she did not know which residents had a wander guard device on. CNA A said she had worked at the facility for 2 months and was not in-serviced on the facility's Elopement Policy or Wander System Monitoring Policy. NA B said this was his first shift back since the end of December 2023. During an interview on 01/04/24 at 2:27 p.m., the DON said elopement trainings are conducted through a web-based company for new hires and annually after hire along with in-services at the facility when needed. The DON said the elopement training on web-based company was generalized and not specific to the facility's elopement policy. The DON said they do not train staff upon hire or annually on the facility's wander system policy. The DON said they had an in-service at the facility on the elopement policy and conducted elopement drills when Resident #1 eloped from the facility. The DON said LVN D responded to the wander guard alarm and turned it off when Resident #1 eloped on 09/18/23. The DON said LVN D should have accounted for the residents wearing wander guard bracelets and searched the facility grounds. LVN D did not follow the facility's elopement policy. The DON said Resident #1 would not have eloped if LVN D followed the elopement policy. The DON said she expected all staff to respond to the wander guard alarm, account for the residents and conduct a search inside the facility and outside on the grounds if a resident was unaccounted for. The DON said they had 5 residents wearing a wander guard bracelet. During an interview on 01/04/24 at 2:36 p.m., the ADON said elopement trainings are conducted through a web-based company for new hires and annually after hire along with in-services at the facility when needed. The ADON said the elopement training on the web-based company was generalized and not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676193 If continuation sheet Page 3 of 7 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 676193 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Waterton Healthcare & Rehabilitation 2875 Shiloh Road Tyler, TX 75703 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 specific to the facility's elopement policy. The ADON said she was responsible to ensure all new hire trainings were completed. The ADON said they do not train staff upon hire or annually on the facility's wander system policy. During an observation and interview on 01/04/24 at 3:36 p.m., LVN C said she was the charge nurse and worked the 2 p.m.-10 p.m. shift on 09/18/23 when Resident #1 eloped. LVN C said at 8:15 p.m. the police called and informed her a private citizen found Resident #1 at a store then dropped him off to them at a church parking lot. LVN C said she had last seen Resident #1 at the facility around 5:30 p.m. during dinner and then at 8:26 p.m. when the police brought him back to the facility. LVN C said she did not know Resident #1 had eloped and was missing over 2 hours. LVN C said she never heard the wander guard system alarm go off during the time Resident #1 was missing. LVN C said she was in-serviced on the facility's Elopement Policy after Resident #1 had eloped. LVN C said she had not been in-serviced on the facility's Wander System Monitoring Policy. LVN C said she was responsible for monitoring a resident's wander guard bracelet for placement and function and documenting it on the resident MAR during her shift. LVN C said a plus (+) sign documented on the MAR indicates the wander guard was working during the shift and a negative (-) sign indicates it was not. LVN C was provided a copy of Resident #1's MARs for the month of July 2023, August 2023, and September 2023 and reviewed them. LVN C said Resident #1's MARs did not have a plus (+) or minus (-) sign documented on them. LVN C said there was no documentation Resident #1's wander guard was functioning properly. Record review of the facility's Elopement/Unsafe Wandering policy revised 06/2018 indicated, . It is the policy of this facility to provide a safe environment for all residents through appropriate assessment and interventions to prevent accidents related to unsafe wandering or elopement .Elopement is when a resident leaves the facility premises or a safe area without authorization .4. If a resident is missing it is a facility-wide emergency. The missing resident procedures will be initiated: .B. if the resident was not authorized to leave, institute a search of the premises. C. IF the resident is unaccounted for after a thorough search of the building and grounds, immediately notify: Administrator, Director of Nursing Services .D. Provide search teams with resident identification information and begin extensive search of the surrounding territory .12. Staff will be educated on proper identification, assessment, and treatment of residents with elopement risks. Education will be provided on orientation and annually thereafter. Record review of the facility's Wander System Monitoring Program policy revised 09/2007 indicated, It is the policy of this facility that all new residents will be evaluated with initial assessment process as to whether he or she presents a wandering risk .All residents identified to be at risk for wandering will have a wander-monitoring bracelet. A monitoring notebook will be kept at each nurse's station identifying all residents currently using the wander monitoring system. Anytime an alarm sounds all staff is to respond and all wanderers will be accounted for. Procedures: .8. All staff is responsible to respond to alarm. 9. All new staff will be in-serviced regarding the Wander System during initial orientation. 10. All staff will be [NAME]-serviced annually .Basic Rules for Wanderer Management .6. Monitor each wanderer's wristband device each shift and record placement in the med sheet or other designated location .9. Check for that all wanderers are accounted for whenever an alarm sounds. Always assume that a second wanderer has left the facility at the same time. The Administrator was notified on 01/05/24 at 1:29 p.m. that an Immediate Jeopardy situation was identified due to the above failures. The Administrator was provided the Immediate Jeopardy template on 01/05/24 at 1:38 p.m The facility's Plan of Removal was accepted on 01/06/24 at 9:00 a.m. and included: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676193 If continuation sheet Page 4 of 7 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 676193 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Waterton Healthcare & Rehabilitation 2875 Shiloh Road Tyler, TX 75703 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 Per the information provided in the IJ Template given on 01/05/24 at 13:38. The facility failed to follow the elopement policy and the facility failed to ensure adequate supervision for Resident #1 who was at risk for elopement. Resident #1 was found off the facility grounds in a parking lot. Facility failed to ensure the function of Resident #1 wander monitoring bracelet was documented each shift. Facility failed to ensure staff were trained on the facility's wander system/policy procedure and elopement policy/procedure. The identified resident was assessed by a licensed nurse on 9-18-2023 at 8:27 PM and found to have no injuries. The identified resident was placed on one-to-one monitoring on 9-18-2023 upon his return to the facility, until alternate placement was found at a facility with a secure unit on 9-20-2023 1. The Medical Director was notified of IJ on 01/05/24 at 1405. 2. Education initiated with all staff on elopement risk, elopement / unsafe wandering policy and procedure, wander guard system monitoring program policy and procedure. This education will be provided by the Clinical Resources, DON, ADON and cluster DON's. This training will be initiated on 01/05/24 and completed by 01/06/24. 3. All residents will be assessed for elopement risk 01/05/24 and all residents with wander guards will be assessed to assure that system is functioning and appropriate interventions and orders in place completed by DON and Clinical Resource on 01/05/24 by 1900. 4. Elopement drills will be completed with each shift starting on 01/05/24, and will continue with each shift by the clinical resources, DON, ADON, administrator and cluster DON's, cluster administrators until all staff have participated in an elopement drill to be completed by 01/08/23. Elopement drills will continue to be completed weekly x 4 weeks by the DON/ADON/Administrator or clinical resources. 5. All staff will complete a knowledge check on wander guard system and elopement policy procedure started on 01/05/24. This training will include the facility policy on elopement and use of the wander guard system to include monitoring, risk assessment and facility response. This training will be completed by 01/06/23 6. This training, elopement drill and knowledge check will be completed in-person with all staff prior to the start of their next shift. A member of management will be at the facility at each change of shift to ensure all staff complete training prior to going to work on the floor. Staff will not be allowed to work unless they have completed the training and competency checks. This training will also be included in the new hire orientation and will be included for any PRN staff prior to starting (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676193 If continuation sheet Page 5 of 7 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 676193 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Waterton Healthcare & Rehabilitation 2875 Shiloh Road Tyler, TX 75703 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 work on the floor. These staff will not be allowed to work unless they have received their training and knowledge check. Level of Harm - Immediate jeopardy to resident health or safety 7. Residents Affected - Few An ad hoc QA meeting regarding items in the IJ template was completed on 01/05/24 at 1630. Attendees included the Clinical Resource, Administrator, DON, ADON, and will include the plan of removal items and interventions. 8. Wanderguard elopement knowledge checks will be included in the orientation packet for new hires. 9. Wander guard system/doors will be checked daily by maintenance director, administrator, or weekend supervisor to assure proper functioning. On 01/06/24 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Verifying the Medical Director had been informed of the Immediate Jeopardy from a printed copy of a text message communication on 01/05/24 between the Administrator and the Medical Director. Interviews with 5 Licensed Nurses, 5 CNAs, 1 MA, 1 Dietary Staff, 1 Laundry Staff (on all shifts 8 a.m.- 5 p.m., 6 a.m.- 2 p.m., 2 p.m.-10 p.m., 10 p.m.- 6 a.m. and Weekend Double) were performed on 01/06/24. All staff were able to correctly identify, elopement risks, elopement/unsafe wandering policy and procedures, and wander guard system monitoring program policy and procedures. All staff said they completed a knowledge check on the elopement/unsafe wandering policy and procedures, and wander guard system monitoring program policy and procedures. During an interview on 01/06/24 at 10:39 a.m., the DON said she in-serviced the facility staff on elopement risks, elopement/unsafe wandering policy and procedures, and wander guard system monitoring program policy and procedures. The DON said staff completed a knowledge check on the elopement/unsafe wandering policy and procedures, and wander guard system monitoring program policy and procedures and will be included in the orientation packet for new hires. The DON said elopement drills were conducted and completed on each shift and will continue for each shift over the next 4 weeks. Record reviews on five resident charts wearing wander guard bracelets were completed on 01/06/24 to ensure wander guard function was documented each shift. There were no issues identified. Record review of in-services revealed staff were educated on elopement risks, elopement/unsafe wandering policy and procedures, and wander guard system monitoring program policy and procedures. There were no issues identified. Record review of knowledge checks revealed staff completed the elopement/unsafe wandering policy and procedures, and wander guard system monitoring program policy and procedures checks. There were no issues identified. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676193 If continuation sheet Page 6 of 7 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 676193 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Waterton Healthcare & Rehabilitation 2875 Shiloh Road Tyler, TX 75703 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 Record review of Elopement Drills conducted revealed drills were completed on 01/05/24 during the 2 p.m.-10 p.m. and 10 p.m.-6 a.m. shifts and the 6 a.m.-10 p.m. weekend double shift. There were no issues identified. Record review of the daily wander guard system/door log revealed checks were completed on 01/05/24 and 01/06/24. Residents Affected - Few On 01/06/24 at 2:10 p.m., the Administrator was informed the IJ was removed; However, the facility remained out of compliance at a scope of isolated and severity level with a potential for more than minimal harm that is not immediate jeopardy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676193 If continuation sheet Page 7 of 7