Inspection·April 10, 2024

F 0689 Clozapine 100MG tablet in the morning Level of Harm - Immediate jeopardy to resident health or safety Haloperidol 5mg at night Residents Affected - Few Donepezil HCL 10MG daily Haloperidol 5mg at noon Trazadone 25MG at night Simvastatin 5MG every night Gemfimbrozil 600MG twice a day Metoprolol Tartrate 37.5MG Twice a day Record review on 04/03/24 of Resident #1's MAR for the month of April revealed that on 04/01/24 all his medications scheduled for 9:00PM, were administered by CNA D. Record review of facility's incident report to HHSC dated 04/02/24 reflected, on 04/02/24 at 7:30AM staff noticed Resident #1 was missing and not on the property. CC camera review showed Resident #1 eloped from facility through a secured exit gate on 04/01/24 at 8:08PM. Record review on 04/03/24 of Facility's Monitoring Sheet Every Two Hours' dated 04/01/24, documented by LVN B, reflected resident was at the facility at 5PM,7PM,9PM,11PM,1AM,3AM and 5AM and Monitoring Sheet Every Two Hours' dated 04/02/24 reflected Resident #1 was absent at the facility since 7AM. Observation on 04/03/24 at 11.45AM of the CC camera footage revealed Resident #1 exited through one of the facility's three locked fence gates around the facility on 04/01/24 at 8:08PM by opening forcefully. Observation of Resident #1's room on 04/03/24 at 11:00AM revealed he was sharing the room with another resident. Resident #1's bed was towards the window, away from the door. His privacy curtain was fully drawn so that his bed was not visible from the door. During an interview on 04/03/24 at 11:30 AM, LVN A stated she knew Resident #1 very well since his admission a few years ago. She said on 04/01/24 she did overtime and left the facility at about 7:30PM. LVN A stated Resident #1 was in the facility at around 7:00PM and she marked his presence on the two hour's monitoring sheet. LVN A stated she came to know Resident #1's elopement on 04/02/24 at about 8:00AM when she arrived for work and observed staff and police were on the lookout for Resident #1. During an interview on 04/03/24 at 2:30PM CNA D stated he is a Med Aide and works the afternoon shifts. He stated he had administered Resident #1's evening medications at 8:00PM on 04/01/24. CNA D said Resident #1 did not voice any concerns at that time and was appeared in his usual presentation. During a telephone interview on 04/03/24 at 6:00PM, LVN B stated she was the night nurse at the facility. She said she started her shift at 8:00PM on 04/01/24 and finished at 7:00AM on 04/02/24. LVN B stated she had the task of checking on residents every two hours and marked Resident #1 on the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676291 If continuation sheet Page 2 of 6 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 676291 B. Wing (X3) DATE SURVEY COMPLETED A. Building 04/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oakcrest Nursing and Rehabilitation Center 9808 Crofford LN Austin, TX 78724 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 'Two Hour's Monitoring Sheet' as present at the facility in the whole night, without physically seeing him. LVN B said she assumed Resident #1 would be at the facility since he was one of the residents with very low elopement risk, over the years. She stated to ensure the residents were present at the facility, she should have observed all of them physically at every two hours instead of assuming. During an interview on 04/04/24 at 7:00AM, LVN C stated she was the night nurse at the facility. She stated she worked on 04/01/24 in the East Hall where Resident #1 was not living. LVN C stated, in the nights she physically checked all the residents every two hours by entering in their rooms unlike, as observed, LVN B who used flashlight from the door for observation, without entering their rooms. During a telephone interview on 04/03/24 at 3:00PM the NP at the facility stated since Resident #1 had eloped, there was risk of relapsing his mental illness due to the lack of medication. She stated this would make him more vulnerable in the community and could be a threat to the safety of his and/or of the community. NP stated Resident #1 has long history of mental illness and even if he returned to the facility after few days, it would take some time to build up a therapeutic level of medications in the blood to make him mentally stable. During a telephone interview on 04/08/24 at 10:35AM the LEO stated Resident #1 was still missing. He stated the department was on a [NAME] to trace him down and the facility also was making efforts to find him. LEO stated he was one of the three officers who responded to the 911 call from the facility on 04/02/24 at about 7:30AM. He said the observation of the CC camera footage revealed the resident exited the facility by breaking open the gate forcefully. LEO stated, while he could not find any remarkable noncompliance of the facility, the Two Hour's Check Sheet did not make any senses as Resident #1 was marked in it as present at the facility throughout the night on 04/01/24. He said, it was clear from the CC camera footage that he exited the facility at about 8:00PM. LEO stated the earlier the search for a missing person the higher the chances of success in finding them. During an interview on 04/03/24 at 5:00PM the DON stated, he came to know about the elopement of the resident from a phone call by the staff on 04/02/24 at about 8:00AM, on his way to work. He stated Resident #1 was on low risk of elopement and on 2 hours observation whereas a resident with high risk of elopement were on 30minutes check. The DON stated staff who do the checks should make sure that they physically observed the resident before signing off the monitoring sheet in order to eliminate issues like elopement. The DON stated there was no system at the facility in place to check the accuracy of these observations. During an interview on 04/03/24 at 5:30PM the ADM stated the facility had no right to stop Resident #1 from leaving the facility as he was the responsible party for himself. When the investigator asked ADM if Resident #1 discussed with him or staff about leaving the facility and signed or refused to sign any documents like AMA, ADM stated Resident #1 did not do so any time before eloping. the ADM also stated Resident #1 had not taken any medication with him as well, as all his medications were stored and managed by the facility. Review of facility policy 2 hr Resident Monitoring dated 09/10/2016 reflected: Policy: Resident who score 0-8 on the Elopement /Wandering Risk Assessment will be checked physically present Q2 hours. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676291 If continuation sheet Page 3 of 6 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 676291 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oakcrest Nursing and Rehabilitation Center 9808 Crofford LN Austin, TX 78724 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 1.Nursing staff will conduct rounds Q 2 hours on their assigned residents. Level of Harm - Immediate jeopardy to resident health or safety 2.Nursing staff will use assigned 2 hrs monitoring checklist to document their checks. Residents Affected - Few 4.Nursing staff must report any resident that is not accounted for during their checks immediately to their supervisor in order to initiate a possible elopement protocol. 3.Nursing staff must confirm time checked and initial checklist. 5.If an elopement protocol is initiated, the nurse supervisor must contact the Administrator and DON immediately for assistance. Indicate that a plan of removal was requested; when it was received and accepted. The notification of Immediate Jeopardy states as follows: The facility failed to ensure all the residents were present in the facility by doing routine checks accurately, resulted in the elopement of Resident #1 unnoticed Action: All residents were re-assessed for elopement risk with no new residents identified on 4/02/2024. All Nursing Staff Inservice to include PRN and New Hires on doing routine checks accurately to ensure residents are in facility and accounted for as per our 2-hour monitoring checklist. (No Agency in Use). Per checklist, Residents who score 0-8 on the Elopement/Wandering risk Assessment must be checked physically present by setting eyes on resident to ensure present Q 2 hours. Inservice of all nursing staff to ensure the 2 hr monitoring checks are being completed and that staff must set eyes on resident to ensure they are physically present, as per updated policy. All new admissions will continue to be assessed for elopement risk per policy. Start Date: 4/02/2024. Completion Date: 4/04/2024 Responsible: DON Action: The charge nurse for the given shift will be the primary monitor and will ensure staff are completing checks by monitoring and signing-off on the checklist for their assigned shift. The DON will monitor the 2-hour checks for compliance through QAPI checks weekly. Administrator will be secondary QAPI monitor as needed. The DON is responsible for the training of staff. The DON has been inserviced by Regional Nurse Consultant on 4/03/2024. Administrator has been trained by DON 4/04/2024. Start Date: 4/03/2024. Completion Date: Ongoing checks per policy 2 hour resident monitoring policy. QAPI will monitor for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676291 If continuation sheet Page 4 of 6 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 676291 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oakcrest Nursing and Rehabilitation Center 9808 Crofford LN Austin, TX 78724 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 3 months or as necessary thereafter. Level of Harm - Immediate jeopardy to resident health or safety Responsible: DON Residents Affected - Few Inservices for all nursing staff will include on explaining the difference between a resident elopement and resident right to leave. Action: Start Date: 4/04/2024 Completion Date: 4/04/2024 Responsible: DON Action: Adhoc QAPI to discuss the plan and monitoring for effectiveness. Monitoring for effectiveness will be done weekly and reported to QAPI for review. DON or designee will review checklist being used and do random checks, follow up with staff, and educate as needed. Progress or concerns reported to QAPI. Start Date: 4/03/2024 Completion Date: QAPI will monitor for 3 months or as necessary thereafter to ensure compliance. Responsible: Administrator/DON Action: The exit gates have been reinforced for safety and security immediately following the incident. Hinges were reinforced by adding an additional bolt to secure hinge mechanisms in place. Maintenance Supervisor will be responsible and will monitor and log compliance weekly. Administrator will ensure ongoing compliance weekly. Start Date: 4/03/2024. Completion Date: Ongoing weekly Responsible: Maintenance Supervisor The surveyor confirmed the facility implemented their plan of removal sufficiently from 04/03/24 through 04/05/24 to remove the IJ by: 1. New Elopement risk assessment for all residents were reviewed. No additional residents with risks were noticed. There are 9 high risk residents at the facility. Risk management plan is in place and implementation is continuing without any issues at this time. 2. The updated policy 2hr Resident Monitoring reviewed. The sentence by setting eye on resident to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676291 If continuation sheet Page 5 of 6 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 676291 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oakcrest Nursing and Rehabilitation Center 9808 Crofford LN Austin, TX 78724 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 ensure present' is added to the existing policy. Level of Harm - Immediate jeopardy to resident health or safety 3. Inservice records reviewed. All staff members were in serviced. This includes DON and ADM. The following staffs were interviewed, and they were able to explain the new policy and procedure with the importance of ensuring that the residents are physically present. Residents Affected - Few LVN C (Night Shift) LVN A (Morning shift), CNA E (Afternoon shift) , AD ( day shift) and DON(Day shift). 4. During an interview on 04/05/24 at 11:00AM, the DON explained the facility plan to reduce the risk of elopement by close and efficient observation. The ADM elaborated his role of supervision was to ensure the plan was executed correctly and consistently. 5. Record review revealed the QAPI meeting conducted on 04/03/24. During an interview on 04/05/24 at 12:00PM, the ADM stated QAPI meeting conducted and as per plan the facility will monitor for 3 months or as necessary thereafter to ensure compliance. 6. The exit gates observed and confirmed that the reinforcement done to make it more secure. MS during the interview on 04/05/24 at 11:25am stated she tried to open the gate with the paddle lock in place like how Resident #1 did and it was difficult to open initially however with a powerful push the gate opened. She stated, she added additional nut and bolt on the existing lock to secure the system with good effect. She said her current plan is to do a daily check on fence, gates, and locks. She stated she maintains a work logbook and review of the log book revealed documentation of her daily inspection. An IJ was identified on 04/03/24 at 5:00PM. The IJ template was provided to the facility on [DATE] at 6:00PM. While the IJ was removed on 04/05/24 at 9:12AM, the facility remained out of compliance at a scope of isolated and a severity level of no actual ham but potential for harm as the resident was missing as on 04/10/24. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676291 If continuation sheet Page 6 of 6