Health inspection·October 3, 2024

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few 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 observation, interview and record review, the facility failed to ensure the residents environment remained as free of accident hazards as possible and ensure each resident received adequate supervision for one (Resident #1) of three residents reviewed for accidents and hazards. The facility failed to ensure Resident #1 did not elope from the front door of the facility and had adequate supervision. This failure could place residents at risk of accidents, and injuries due to a lack of supervision. The noncompliance was identified as PNC IJ. The IJ began on 08/12/2024 to 08/24/2024/ and ended on 08/24/2024. The facility had implemented actions that corrected the deficient practice prior to the beginning of the investigation. Findings included: Record review of Resident #1's Face Sheet dated, 08/18/2024, reflected an [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Resident #1 was discharged from facility on 08/13/2024. Resident #1 had diagnosis of Alzheimer's disease with late onset ( symptoms first appear in someone who is 65 or older - a brain disorder that causes the gradual loss of memory and thinking skills. Symptoms: changes in behavior, language and personality), cognitive communication deficit ( communication problems that are caused by underlying cognitive impairments, rather than speech or language deficits), difficulty in walking ( there are many reasons why someone may have difficulty with walking such as : injuries, foot problems, joint issues, nervous system disorder and brain disorders - the part of the brain that controls balance and coordination), essential hypertension (high blood pressure), and unsteadiness on feet ( when you have trouble walking in a steady, smooth manner). Record review of Resident #1's Quarterly MDS assessment, dated July 12, 2024, reflected Resident #1 had a BIMS score of 4 indicating her cognition was severely impaired. Resident #1 did not have any wandering behavior. She was independent with walking. Record review of Resident #1's Comprehensive Care Plan, dated on 07/17/2024, reflected Resident #1 was a wander risk related to confusion. Intervention: observe for any signs or symptoms of agitation, pacing, and restlessness. Resident #1 had impaired cognitive function related to dementia ( the loss of cognitive functioning, thinking, remembering, and reasoning- it interferes with a person's Page 1 of 8 676475 676475 10/03/2024 Avir at Madisonville 600 Bacon Street Madisonville, TX 77864

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few daily life and activities) Intervention: Break tasks into short segments. Assured that residents wishes were understood by being patient. Record review of Resident #1's Comprehensive Care Plan, revised on 08/12/2024, reflected Resident #1 was an elopement risk as evidence by leaving the facility unsupervised on 08/12/2024. Intervention: Distract Resident #1 from wandering by offering pleasant diversions, structured activities, food , conversation, television, and sitting with her son. Perform elopement assessment, on admission/readmission, quarterly, and with any change of condition. Provide structured activities such as :toileting, walking inside and outside supervised. Resident was to have a staff to be with Resident #1 at all times supervision until placement on a secure unit. Record review of Resident #1's Nurses Notes, dated 08/12/2024, reflected This nurse was passing meds at the end of the hall on C and received a phone call from ADON whom stated that someone had seen resident nearby the school. Immediately after, this nurse goes to nurses' station and informs nursing staff that there is a missing resident and instructed the nursing assistants to search the facility for missing resident. DON and RP ( responsible party) were notified. Shortly after, Police Department arrive to facility with resident and stated that they found resident nearby and that they would contact administrator regarding this incident. This nurse told [local] PD that the front door doesn't have a security system in place Resident is alert and confused due to dementia diagnosis and is assisted back into the facility. Upon head-to-toe assessment, no injuries are present nor does the resident complain of any pain or any signs/ symptoms of distress. Vital signs at this time are: bp 126/70, p- 66 regular, 18 respirations, temp 97.6F. Q15 min checks are in progress with a sitter present at all times. Full range of motion to all extremities. Nurse practitioner notified as well. Furthermore, resident is taken to ER for further evaluation, RP notified. At around midnight, resident is brought back to facility and no new orders at this time. This nurse also notified ADON and DON that she was last seen around 7:30 PM. Resident is awaiting transfer to a lock down unit signed by LVN A. Record review of Resident #1's Nurses Notes, dated 08/13/2024, reflected CP ( Care Plan) meeting was held today. SW discussed the recent elopement, and explained that for her safety, she would need to be moved to a secure unit. Guardian was ok with this and thankful. SW sent guardian the contact info for the new facility. Record review of Resident #1's Nurses Notes, Dated 08/13/2024 at 14:24, Resident #1 was discharged to a sister facility with all personal belongings and medications via facility transport van in stable condition. Signed by LVN B. Record review of Resident #1's Facility Investigation dated, 08/18/2024, reflected the incident date occurred on 08/12/2024 at 7:30 PM. Her ambulation was independent. She was interview able , however unable to make informed decisions. Resident #1 did not have a history of similar allegations. Resident #2 was a witness. Resident #1 went on an unsupervised outing. Resident #1 did not have any injury. Resident #1 was transferred to the ER on [DATE] and returned to the facility on [DATE]. In the facility investigation record reflected the incident was not reported to the police. There was a head count of all facility residents completed with no others identified missing. Immediate notification of guardian and attending physician. Resident#1 was placed on 1:1 when she re-entered the facility. All resident's elopement assessments were updated Investigations Findings were confirmed. On 08/13/2024 resident was transferred to another facility to reside on secure unit. Resident #1 had continuous staff supervision until such date. Signed by [NAME] President of Clinical Operations. Record review of Resident #1's incident report , dated 08/12/2024, reflected Resident #1 returned 676475 Page 2 of 8 676475 10/03/2024 Avir at Madisonville 600 Bacon Street Madisonville, TX 77864

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few to facility escorted by the police. Resident #1 was located by a school approximately 1 mile from the facility. Resident #1 was last seen at 7:30 PM by Resident #2. Resident #1 stated she was going for a walk to Resident #2. Immediate action taken: Resident #1was placed on 1:1 supervision. Skin assessment completed and revealed no area of concern. Vitals signs within normal limits. Resident #1 was able to speak in clear sentences. Resident #1 was not taken to hospital. Resident #1 did not have any injuries at time of incident ( elopement). Resident #1 was able to recall some information. Her BIMS score was a 4 ( her cognition was severely impaired). Resident #1 was not in any pain. The incident location was outside. [NAME] President of Clinical Operations prepared the incident report. Record review of Resident #1's hospital report, dated 08/12/2024, reflected Resident #1 skin was warm, dry, and normal in color. Her mucous membranes pink, moist. Resident #1 was well-groomed. She denied any pain. 1. Neuro: GCS - Resident #1's eyes opening: spontaneous, verbal: confused , Motor: obeys commands, Upper extremity strength strong and lower extremity strength strong, no associated dizziness present. No associated nausea. 2. Respiratory/Chest: respiratory assessment findings include respiratory effort easy, respirations regular, conversing normally, neck and chest exam findings include chest expansion equal and chest movement symmetrical. 3. Cardiovascular: Assessment findings include heart rate normal. 4. Abdomen: abdomen soft, non-tender, no associated nausea or vomiting. 5. Left and Right Upper and Lower Extremity: findings include capillary refill (a physical exam technique that measures how long it takes for color to return after pressure applied) less than two seconds, skin color, muscle tone, skin temperature to hand was normal. Distal sensation intact and muscle tone normal. 6. Psych/ Social: psychiatric/ social assessment findings include affect normal. 7. Notes: Emotional support needed and given. Physical Exam: 1. Vital signs reviewed, Resident #1 was afebrile ( free from fever), and pulse , blood pressure, hypertensive, respiratory rate- all normal. Resident #1 was non-toxic and pain- free. She was oriented to person. 2. Head: head exam included findings of head atraumatic ( not causing injury or trauma) and normocephalic ( a person's head and major organs are normal without significant abnormalities) 3. Eyes, Neck, respiratory chest, cardiovascular, abdomen, back upper and lower extremity was all normal. Discharge Notes: 1. Resident #1 was in no distress; she was resting quietly. She would be discharged back to the 676475 Page 3 of 8 676475 10/03/2024 Avir at Madisonville 600 Bacon Street Madisonville, TX 77864

F 0689 facility. Level of Harm - Immediate jeopardy to resident health or safety 2. Doctor notes; Resident #1 had dementia. She did not have any complaints of pain. Resident #1 had no outward signs of trauma. She did not require further exam. Resident #1 was sent back to the nursing facility where she would be monitored. Residents Affected - Few Record review of Resident #1's Assessment reflected Resident #1 did not require an Elopement Assessment prior to 08/12/2024. Record review of Resident #1's SBAR ( situation, background, assessment, and recommendation), dated 08/12/2024, reflected the change of condition , symptoms, or signs was elopement from nursing facility. Started on 08/12/2024. Resident #1 was evaluated such as : vital signs, B/P, pulse, and or apical heart rate, temperature, respiratory rate, oximetry, and finger stick glucose, if indicated. Things that make the condition worse : wandering. Things that make the condition or symptom better: redirection. Blood Pressure 132/72, Pulse 82, Respiration 18.0, Temperature: 98.9, O2 SATS 96.0 percent room air. Assessment / nurse narrative progression of Alzheimer's Disease. Family member and Physician notified on 08/12/2024. Signed by LVN A. Record review of Resident #1 Elopement Nurses' Note Assessment record , dated 08/12/2024 , reflected this was Resident #1's initial elopement assessment. Resident #1 was unaware of situation due to dementia diagnosis. 1. Initial episode- elopement from the facility. 2. She exited the facility from the front door. 3. Follow- up- no further elopement attempt and Resident #1 was calm. 4. New orders : Resident #1 did not have any new orders. 5. Physician and Family was notified. 6. Interventions: Resident #1 was placed on 1:1 monitoring. Signed by LVN A Record review of Resident #2's Quarterly MDS Assessment, dated 09/20/2024, reflected Resident #2 had a BIMS score of 15 indicating his cognition was intact. Record review of elopement in-service / elopement drill on 08/13/2024 reflected the staff received in-service on elopement and an elopement drill was completed with the staff. Record review of elopement in-service and elopement drill on 08/26/2024 reflected the staff received in-service on elopement and an elopement drill was completed with staff. There were 36 employees signed the in-service. 676475 Page 4 of 8 676475 10/03/2024 Avir at Madisonville 600 Bacon Street Madisonville, TX 77864

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Record review on 10/03/2024 reflected the elopement binder located at the nurse's station revealed the residents at risk for elopement, each resident's information, and a picture in the binder. Record review of Resident #1's 1:1 supervision log reflected Resident #1 received 1:1 supervision began on 08/12/2024 at 8:45 PM until 08/13/2024 at 1:00 PM. Resident #1 was discharged from the facility on 08/13/2024 at 1:00 PM to a sister facility approximately 45 minutes away to a secure unit. Residents Affected - Few Observation on 10/03/2024 throughout the day revealed the front door alarms and other door alarms was working. In an interview on 10/03/2024 at 8:45 AM, the Social Worker stated she was not involved with the investigation of the elopement of Resident #1. She stated she was involved with the discharge planning and discharge of Resident #1 to a secure unit at a sister facility. Social Worker stated Resident #1's Guardian was explained the incident with the elopement. She stated Resident #1's Guardian was aware of the elopement and was notified on 08/12/2024. Social Worker stated she spoke with Resident #1's Guardian on 08/13/2024. She stated Resident #1's Guardian was concerned of Resident #1's safety. Resident #1's elopement and agreed transferring Resident #1 to a secure unit. Social Worker stated the Guardian believed she would benefit being on a unit with other residents with Alzheimer's. She stated she emailed the guardian the contact information for the new facility. She stated she was in-serviced on elopement and participated in elopement drills in September 2024. Social Worker stated she learned an elopement was when a resident left the facility and wandering was when a resident did not have a goal; they wandered in the facility without a specific place they were wanting to go. In an interview on 10/03/2024 at 10:10 AM, CNA B stated she was working the night of 08/12/2024. She stated she was not assigned to Resident #1 on 08/12/2024 when the resident eloped from the facility. She stated Resident #1 did not exit seek or attempt to leave the facility prior to 08/12/2024. CNA B stated she would walk inside the facility and visit other residents but never attempted to leave the facility unsupervised. CNA B stated she saw Resident #1 around 7:15 PM walking toward the nurse's station. CNA B stated she ( CNA B) was walking down C Hall to continue her rounds on the residents she was giving care to on 08/12/2024. CNA B stated she did not notice anything unusual about Resident #1. She stated Resident #1 was placed on 1:1 supervision when she returned to the facility and after she returned from the hospital. CNA B stated she was in-serviced on elopement and how to use the alarm on the front door . She stated she participated in elopement drills. CNA B stated the facility had several elopement drills and she did not recall the exact date of the first elopement drill. She stated she thought it was the next day after the elopement of Resident #1. She stated she learned the difference between elopement and wandering. She stated elopement was when a resident left the facility without anyone with them and wandering was when they walked in the facility and did not have somewhere they wanted to go. In an interview on 10/03/2024 at 10:25AM, CNA C stated she never witnessed or heard of Resident #1 eloping from the facility except in August 2024. She stated she did not recall the exact date and she was not in the facility when Resident #1 eloped. CNA C stated Resident #1 never attempted to leave the facility or exit seek. She stated she was surprised when she heard Resident #1 eloped due to never attempting to elope in the past. CNA C stated she had been in- serviced on elopement and she had participated in elopement drills. She stated after Resident #1 eloped an alarm was placed on the front door. There were alarms already in place on the other doors. and the other doors already had alarms. She stated she was in-service on how to use the alarm on the front door. She stated she learned when an alarm sounded to immediately go to the location of the alarm and to make sure a resident had not left the facility. CNA C stated the staff immediately began to count the residents and make 676475 Page 5 of 8 676475 10/03/2024 Avir at Madisonville 600 Bacon Street Madisonville, TX 77864

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few sure all residents were in the facility. She also stated they were to take directions from the supervisor to prevent all staff going on the same hall. The staff needed to be divided to search entire facility. In an interview on 10/03/2024 at 10:49 AM, LVN D stated Resident #1 did not have a history of exit seeking and never eloped from the facility until the elopement in August 2024. She stated she did not recall the exact date. LVN D stated Resident #1 enjoyed walking in the facility sometimes during the day, but she never exits sought or attempted to leave the facility. LVN D stated she was in-service on elopement, neglect, and abuse. She stated she participated in elopement drills and new alarm was placed on the front door. She stated she was in-service on how to use the alarm. In an interview on 10/03/2024 at 11: 15 AM, the ADON stated she was at home and heard on the police scanner an elderly lady was found at the high school. She stated she immediately called the facility and alerted LVN A to check the residents. She stated she did not come to the facility or go to the high school. ADON stated she was not involved in the investigation; the Corporate Nurse Consultant was notified and she came to the facility and did the investigation for the facility. ADON stated a front door alarm was installed, and Resident #1 was placed on supervision. In a phone interview on 10/03/2024 at 11:45 AM, [NAME] President of Clinical Operations stated she came to the facility when she was called ( did not remember who called her about Resident #1), and had been working at the facility and was in town when the incident with Resident #1 occurred on 08/12/2024. She stated she immediately came to the facility and spoke with Resident #1. She stated Resident #1 pointed to the right of the road when asked the direction she walked to the school. [NAME] President of Clinical Operations stated she went to the right and then she took another right and went to the first school. She stated she knew she went to the first school because that was the nearest school to the facility. [NAME] President of Clinical Operations stated she completed skin assessment. She stated Resident #1 did not have any injuries, bruising, or skin tears. She stated she wanted Resident #1 to be transferred to the ER for evaluation to ensure Resident #1 did not have any injuries. The [NAME] President of Clinical Operations stated the last person who saw her was Resident #2. She stated Resident #2 stated he saw her around 7:30 AM, and she was wanting to go for a walk. She stated Resident #1 was immediately placed on 1:1 supervision when she returned to the facility by the police from the emergency room. [NAME] President of Clinical Operations stated the time frame of Resident #1's unsupervised outing was between 7:30 AM and she returned to the facility approximately 8:30 PM. She stated it was not dark; it was still daylight and it had began getting dark around 8:30 PM. She stated the meaning of unsupervised outing was a resident leaving the facility unsupervised such as elopement. She stated a CNA did see Resident #1 between 7:00 PM and 7:20 PM, but she did not recall the CNA's name. She stated in-services and elopement drills immediately began September after Resident #1 eloped. The [NAME] President of Clinical Operations stated Resident #1 was on 1:1 supervision until she was discharged to a sister facility on a secure unit. In an interview on 10/03/2024 at 12:20 PM, Resident #2 stated he remembered a female resident saying she wanted to go for a walk. He said he remembered he had to answer questions when he saw her. Resident #2 stated it was about 7:30 PM when she said that and he stated he learned she left the facility and went on a walk to a school. In an interview on 10/03/2024 at 12:45 PM, the Administrator stated she began working at the facility on 08/23/2024. She stated she continued with in servicing and elopement drills after she began working at the facility. The Administrator stated she was in-service on elopement by the [NAME] President of Clinical Operations during orientation. She stated she was not an employee at the facility 676475 Page 6 of 8 676475 10/03/2024 Avir at Madisonville 600 Bacon Street Madisonville, TX 77864

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few when Resident #1 eloped. She stated she was responsible for updating the elopement binder whenever there was a new admit. The Administrator stated any new staff including agency would not be allowed to begin working with the residents until the elopement in-service was completed. She stated there was not any new staff or new residents since 08/12/2024. The Administrator stated since she has been an administrator, the alarms were being monitored at least 5 times a week by the Maintenance Supervisor . She stated she developed the elopement binder. The Administrator stated elopement drills would be ongoing on both shifts and she would continue in-services on elopement. She stated she could not respond to question of what occurred on 08/12/2024 when Resident #1 eloped from the facility. She stated she read the investigation. In an interview on 10/03/2024 at 12:45 PM, The Director of Nurses stated she was not an employee at this facility when Resident #1 eloped on 08/12/2024. She stated her first day of work at this facility was on 09/23/2024. The Director of Nurses stated she would be involved with the elopement in-services and drills. She stated she would ensure all residents' elopement profiles would be updated in the elopement binder as needed. The Director of Nurses stated she did receive an in-service on elopement when she began working at the facility. In an interview on 10/03/2024 at 1:15 PM, Policewoman stated a citizen ( did not know the name of the citizen) called the police station about a concern of a female at the high school near the football field. The Policewoman stated she was with another policewoman ( did not give this person's name) and they arrived at the high school approximately 8:05 PM. She stated Resident #1 did not know her name or where she lived. The Policewoman stated she had to look in her purse to identify Resident #1. She stated Resident #1 was afraid, did not know where she was, and disoriented. She stated it was not dark at the time Resident #1 was found. The Policewoman stated when Resident #1 was transported by her to the facility, it began getting dark, they arrived at the facility at 8:30 PM. She stated Resident #1 did not have any visible injuries or bruises. She stated a nurse came to outside and assisted the resident into the facility. In an interview on 10/03/2024 at 1:40 PM, the Maintenance Supervisor stated he checked the alarms to ensure they were working and he installed the alarm on the front door as part of the plan to ensure another resident did not elope after the elopement of Resident #1. He stated it was installed within few days of 08/12/2024. In an attempt to contact Resident #1's Guardian on 10/03/2024 at 4: 40 PM was unsuccessful. Record review of the facility's policy on Elopement and Wandering Residents, not dated, reflected This facility ensures that residents who exhibit wandering behavior and/ or at risk for elopement receive adequate supervision to prevent, accidents, and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. Definitions: Wandering is random or repetitive locomotion that may be goal-directed (e.g., the person appears to be searching for something such as an exit) or non-goal directed or aimless. Elopement occurs when a resident leaves the premises or a safe area without authorization (i.e., an order for discharge or leave of absence) and/ or any necessary supervision to do so. Policy Explanation and Compliance Guidelines: 676475 Page 7 of 8 676475 10/03/2024 Avir at Madisonville 600 Bacon Street Madisonville, TX 77864

F 0689 1. The facility is equipped with door locks/alarms to help avoid elopements. Level of Harm - Immediate jeopardy to resident health or safety 2. Alarms are not a replacement for necessary supervision. Staff are to be vigilant in responding to alarms in a timely manner. Residents Affected - Few The noncompliance was identified as PNC IJ. The IJ began on 08/12/2024 to 08/24/2024 and ended on 08/24/2024. The facility had implemented actions that corrected the deficient practice prior to the beginning of the investigation. 676475 Page 8 of 8