Eastland Nursing & Rehabilitation

F-F600 POR/POC signed by RDO on 04/01/2025.

Record review on 04/02/2025 at 07:15 AM of in-service provided to the staff on 04/01/2025, that drive the facility's van. The in-service included the facility van is not to be used for wheelchair transports until further notice.

Record review on 04/02/2025 at 07:20 AM of the facility's in-service conducted on 03/31/2025 included the van driver's competency with emergency procedures and a completed post-test by MM and Transport Aide B.

During an interview 04/02/2025 at 08:10 AM, Transport aide B stated she/he had in-service on neglect on 04/01/2025 by DON. Transport aide B stated had been re-trained on use of seatbelts in van, in-serviced on new van orientation for calling 911 and notifying ADM if a resident slid out of wheelchair or got any injury

during transport. Transport Aide B stated she was observed driving the van and parking the van, following speed limit, and parking the van, and securing resident in wheelchair in van with seat belt secured. Transport Aide B stated she had watched a YouTube video on van transportation and securing a wheelchair in van. Transport Aide B stated completed a competency for seat belts and safety in the van on 04/01/2025.

During a record review on 04/01/2025 at 08:20 AM record review of facility's Ad-Hoc QAPI held on 03/31/2025 with Medical Director, ADM, DON, ADON, Regional Nurse Consultant that reviewed the alleged deficiency, policy and procedures and transport injury.

Record review of Van Driver Orientation List for Transport Aide F on 04/01/2025 at 08:25 AM revealed training completed on 03/25/2025 that consisted of securing a wheelchair in the facility van and securing a resident in a wheelchair with seat belt. The training included a return demonstration of securing a wheelchair and securing a resident in a wheelchair with a seat belt.

During a record review on 04/01/2025 at 08:30 AM of Van Driver Orientation List for Transport Aide F revealed training completed on 11/14/2024.

Record review04/01/2025 at 08:35 AM of Resident #10's EMR progress notes dated 03/26/2025 revealed a physical assessment of the resident by DON after returning from van transport. The physical assessment revealed resident sustained an 25 cm abrasion to his lower back.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 29 675001 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 675001 B. Wing 04/02/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Woodlands 125 Inspiration Blvd Eastland, TX 76448

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 0600 Record review on o4/02/2025 at 08:40 AM of facility safe assessment conducted on 03/26/2025 of Resident #11, Resident #12, Resident #13, and Resident #14 safe survey interviews conducted by ADM revealed Level of Harm - Immediate above residents did not feel safe when transported by facility van. The residents' stated van is not in good jeopardy to resident health or condition. safety

Record review on 04/02/2025 at 08:42 AM of facility safe assessment conducted on 03/27/2025 for Resident Residents Affected - Some #10 revealed Resident #10 did not feel safe when transported by facility staff due to staff did not follow training.

During a record review on 04/02/2025 at 08:45 AM of Transport Aide F facility counseling dated 03/26/2025 Transport Aide F was suspended pending investigation of van incident.

An Immediate Jeopardy was identified on 03/31/2025. While the Immediate Jeopardy was removed on 04/02/2025 at 09:23 AM, the facility remained out of compliance at a level of no actual harm with a potential for more than minimal harm and a scope of pattern, due to the facility monitoring the effectiveness of their Plan of Removal. The ADMN, the DON, and the RRN were informed of the Immediate Jeopardy was removed on 04/02/2025 at 9:23 AM.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 29 675001 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 675001 B. Wing 04/02/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Woodlands 125 Inspiration Blvd Eastland, TX 76448

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 that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Immediate jeopardy to resident health or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 44558 safety Based on observation, interview and record review, the facility failed to ensure each resident received Residents Affected - Some adequate supervision to prevent accidents for 3 of 14 (Resident #3, Resident #10 and Resident #11) residents reviewed for supervision.

1. The facility failed to provide supervision for Resident #3, who was care planned for wandering in unsafe places, to prevent him from eloping from the facility on 03/21/2025. The facility was unaware Resident #3 had exited the facility, through his unlocked window in the secure unit. The facility failed to provide adequate supervision in secured locked unit to prevent elopement on 12/05/2024 and 03/23/2025.

An Immediate Jeopardy (IJ) was identified on 03/21/2025. While the IJ was lowered on 03/28/2025 at 4:45 PM, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm with a scope of pattern, due to the facility's need to evaluate the effectiveness of their corrective actions.

2. The facility failed to ensure Resident #10, and Resident #11 were safely secured in the facility van while being transported to and from the facility.

An Immediate Jeopardy (IJ) was identified on 03/31/2025. While the IJ was lowered on 04/02/2025 at 9:23 AM, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm with a scope of pattern, due to the facility's need to evaluate the effectiveness of their corrective actions.

These failures placed residents at risk of injury due to not being supervised and placed them at risk of serious bodily harm, physical impairment, or death.

Findings include:

1.

Record review of Resident # 3's face sheet dated 03/24/2025 revealed a [AGE] year-old female admitted on [DATE REDACTED] with a readmission on 02/19/2025 with the following diagnoses cardiac issues, seizures, and traumatic brain injury.

Record review of Resident #3's Quarterly MDS, dated [DATE REDACTED], revealed: Section C - Cognitive Patterns Resident #3 had a BIMS of 14, meaning cognitively intact. Section GG Mobility Devices Resident #3 required

the use of a walker.

Record review of Resident #3's Care Plan updated on 03/21/2025 revealed:

Problem: start date 10/09/2024 I am on the memory care unit due to exit seeking behaviors. On 3/21/25 had actual Elopement through bedroom window-High Risk 20.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 29 675001 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 675001 B. Wing 04/02/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Woodlands 125 Inspiration Blvd Eastland, TX 76448

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 Goal: Resident will remain free from injury related to exit seeking/elopement attempts through next quarter.

Level of Harm - Immediate Approach: Start Date 03/21/2025 Consider Medication Review if behaviors continue or escalate; Start Date- jeopardy to resident health or 03/21/2025 safety Consider psych consult with increase in behaviors; Start Date- 03/21/2025 Ensure all basic needs are met Residents Affected - Some when resident.

becomes anxious or aggressive. Offer toileting, snack, fluids, comfort. Etc.; Start Date- 12/05/2024 Resident must be accompanied by staff while in courtyard. Start Date- 10/09/2024 Assess/ record/ report to MD risk factors for potential elopement such as: wandering,

repeated requests to leave facility, attempts to leave facility. Start Date- 10/09/2024 Check doors & windows for security and for

proper functioning and placement per facility protocol. Start Date-10/09/2024 Develop and activities program to divert.

attention and meet needs for social, cognitive stimulation; Start Date- 10/09/2024 Discuss with resident/ family risks of elopement.

and wandering; Start Date- 10/09/2024 If resident is missing from facility, follow elopement protocol, notify MD and family.

immediately, and document; Start Date- 10/09/2024 Placement on secure unit for high risk for elopement; Start Date: 10/09/2024.

Supervise closely and make regular compliance rounds whenever resident is in room.

Record review of Resident #3's physician orders revealed Start date of 10/09/2024 Admit to facility secure unit.

Record review of Resident #3's progress notes revealed:

Date 10/24/2024 at 4:52 PM documented by LVN C creating a map of the exits of the Secure Unit, when asked the Resident did not respond and only nodded to agree with the co-conspirators statement of getting out of here. This Nurse explained to Resident that his placement here was agreed between his mother and himself to promote independence in a safe environment. Resident stated, I don't care, I can leave if i want to. Further education given on importance of remaining safe as well as dangers surrounding facility. Resident was not agreeable to education and walked away.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 29 675001 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 675001 B. Wing 04/02/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Woodlands 125 Inspiration Blvd Eastland, TX 76448

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 Date: 12/05/2024 at 15:42 PM documented by LVN C Resident found by Staff on ALF Patio attempting to gain entry to ALF. ALF Patio is separated from Secure Unit Courtyard by 4ft locked fence. [NAME] located Level of Harm - Immediate pushed against fence beside bush. Resident states he hopped the fence to go to [nearby town]. Resident jeopardy to resident health or story changed multiple times and includes wanting to sit somewhere else and wanting fresh air. Resident safety assessed for injury, no skin impairments or bruising noted to any part of body, Resident denies pain. PCP notified, attempted to notify Mother voice mail not available. Resident previously given freedom to come and Residents Affected - Some go From Secure Unit Courtyard, at this time Staff must be present in area for Resident to venture outdoors to prevent injury from attempt to leave area and to prevent Resident eloping from facility.

Date 12/10/2024 at 9:30 PM documented by LVN K Resident walking around in secure unit with walker . States, I need you to let me out of here. Resident continues to exit seek daily. All care was witnessed by staff.

Date 12/12/2024 at 2:30 AM documented by LVN O res up ambulating throughout night on unit with and at times without his walker, when amb without walker res has unsteady gait. becomes upset when staff encourage use of walker and remind res staff do not wish him to fall again with potential injuries a possibilities. Also res asked CNA to open secure unit doors, while standing at the front of unit by main doors.

this writer entered secure unit, res attempted to grab doors as they closed but was unable and almost fell attempting to. reminded res doors must remain closed and locked, he started yelling loudly and repeatedly, bull shit. when asked to have consideration for others who are sleeping he yells, I don't fucking care all attempts to calm res unsuccessful. res went back to his room on his own. has come out since 3 times and stood at front of unit doors pushing on handle of doors until alarm sounds, when staff attempted to redirect him from this behavior he again starts to yell and whenever staff opened door of unit to turn off or reset alarm

he again grabs at door trying to walk through door with staff in doorway. after these attempts he says I give up and I'm walking out of here tomorrow.

Date 12/12/2024 at 7:10 PM documented by LVN P Rsd held locked double doors of memory care unit until

they opened.

Attempted to exit and became angry and combative when staff attempted to intervene. CNA called out for assistance and staff immediately assisted. The rsd appeared very angry stating, I am leaving this place. I am going home to [NAME]! I'm going to walk!. Rsd was given emotional support by staff and the situation de-escalated. The rsd walked to his room in an

angry manner yelling profanities.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 29 675001 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 675001 B. Wing 04/02/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Woodlands 125 Inspiration Blvd Eastland, TX 76448

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 Date 12/13/2024 at 9:30 AM documented by LVN Q resident has been very restlessness and uncooperative with staff his attempt to leave the unit with holding the hand bars down for the full 15 seconds and then the Level of Harm - Immediate alarms were alarming, and the staff had to retrieve resident before he could leave the unit unattended that is jeopardy to resident health or when he became increased restlessness with agitation and aggressively pacing with rollator walker staff was safety unsuccessful with keeping him from exiting the unit while visitors were coming into unit and staff then was able to get to him within 3 feet of him exiting the unit, this nurse was summoned to unit STAT, on arrival this Residents Affected - Some nurse was able to calm him down and redirect him into sitting in the HR Desk where this nurse then called his mother to advise her of the above uncooperativeness and agitation then this nurse asked if she would attempt to talk with him to calm him down even more , he then was on the phone talking with his mother demanding her to come get him and take him home, she spoke with him approximately 10 minutes then he let this nurse speak with her again this nurse was advised that the mother was unable to come today due to

she has appointments and obligations already in motion and she was unable to change them on short notice

she did declare that she would be here this weekend sometime to visit him and she felt that would help him for this behavioral episode, that is when the resident agreed to go back into the unit without behaviors noted.

Date 12/13/2024 at 12:42 PM documented by LVN Q Resident is at the unit doors attempting to elope and exit seeking is in high risk at present time the unit is where he is with a staff at all times due to his quick and exit abilities are placing himself in harm's way this nurse has made a call into the office of FNP at present time this nurse is on hold in que for the answering service, staff was instructed to stay with resident to help protect him from being able to exit while the staff was assisting other residents.

Date 12/14/2025 at 2:30 PM documented by LVN R kitchen worker came through door that leads from kitchen into memory care kitchen. Res grabbed door and would not let go. CNA stood between res and door and called this nurse. This nurse went to memory care, finally convinced res to go outside into courtyard. Res and nurse sat on bench and talked for a while then went back inside to call his mother. Res talked to his mother for approx 15-20 min then went back to memory care.

Date 12/29/2024 at 10:16 AM documented by LVN Q noted at present time resident has been with pacing and becoming agitated about wanting to go home, this nurse has attempted to redirect resident with having him have the broom and dustpan so he can sweep to redirect his focus on wanting to leave, noted has worked at this point on his redirection.

Date 12/30/2024 at 12:40 PM documented by LVN P CNA reported to this nurse that the resident continues to show unprovoked aggressive behavior toward staff members. The rsd became angry this AM when the breakfast trays arrived when he wasn't immediately served before others and began cussing the CNA and banging on the table. The rsd has a hx of frequent angry outbursts with use of profanity and tendencies to use physical force. The rsd is actively exit seeking and has damaged two exit doors and his window facing

the courtyard in attempts to escape. The rsd is alert and is aware this behavior is not appropriate and verbalizes that he knows it is wrong. However, the rsd exhibits ST memory deficits and appears not to remember the behaviors or appears confused at times when questioned.

Date 01/02/2025 at 3:30 PM documented by LVN C Resident attempted to exit memory care Secured Unit while doors were open. Resident was immediately stopped by nearby Staff. Resident attempted to hit with walker, hit CNA with closed fist and proceeded to yelling and cuss at those stopping him. Resident would not be redirected from attempting to exit memory care.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 29 675001 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 675001 B. Wing 04/02/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Woodlands 125 Inspiration Blvd Eastland, TX 76448

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 Date 02/06/2025 at 5:28 AM Documented by LVN O res went to x 2 cnas and nurse on this hall telling staff to open the doors and let him out. Res also went to all exits multiple times since 0400 of unit pushing egress on Level of Harm - Immediate doors causing alarms to go off at these doors and not easily redirected, staff members on both sides of exit jeopardy to resident health or doors until res stopped pushing at doors, he also amb into doorway of other res rooms and not easily safety redirected. When encouraged to continue to rest through to morning meal went back to his room but yelled at

this writer once let me out loudly then entered his own room. Residents Affected - Some Date 02/07/2025 at 1:37 PM documented by LVN C Resident has continued previous behavior of pushing/pull on secured locked doors and pacing.

Date 02/09/2025 at 2:59 PM documented by LVN C This Nurse could intervene Resident began screaming at that person This is my house I can go wherever the f**k I want. This Nurse stood between the two and prevented Resident from entering further into the room. Resident attempted to punch This Nurse, This Nurse leaned out of the way and prevented injury to either party. DON notified and instructed This Nurse to call Residents mother and have them talk on the phone. Residents Mother stated to This Nurse I don't know what to do about it She spoke with Resident via phone, Resident finally left the other persons room. After the end of the phone call Resident began pacing and trying to exit secure doors.

Date 02/12/2025 at 5:01 AM documented by LVN O wanting staff to let him out, becomes angry when staff not able to, pushing at doors and setting off alarms on doors, only then does he back off the doors,

Date 02/22/2025 at 4:50 PM documented by LVN C Resident has been exit seeking this shift. Pacing unit from door to door attempting to pry them open. Resident has been attempting to push past staff when doors are open.

Date 02/26/2025 at 5:59 AM documented by LVN O res had behaviors through this night shift, cursing at staff when he would demand to be let out of secure unit or being given the code to the doors and staff explained that were unable to do so, res pushing and pulling at all exit doors all throughout night shift, res multiple times pulling at doors hard and almost falling backwards, staff steading res with their hands trying to keep res safe from falling and he would yell don't touch me and attempt to swing at staff. staff would encourage res not to do so for his safety. he would curse at staff and continue doing so despite encouragement. res caused alarms to go off numerous times pushing at doors.

Date 02/27/2025 at 5:29 AM documented by LVN K resident continues with negative mood, continues to exit seek throughout the shift, redirected away from doors, requires constant monitoring, denies any pain, stated, are you going to let me out of here to get my pick up and go to [ Nearby City]? This nurse reassured him that

she would not be assisting him in leaving facility.

Date 03/02/2025 at 4:34 documented by LVN O res up walking without walker this shift and continues to ask staff and demand staff let him out of unit, continues to push at doors to attempt to exit,

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 29 675001 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 675001 B. Wing 04/02/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Woodlands 125 Inspiration Blvd Eastland, TX 76448

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 Date 03/03/2025 at 5:47 AM documented by LVN O res continues to attempt to leave secure unit and pushes at doors, earlier in shift got through door at end of unit that leads to AL dining room, after pushing Level of Harm - Immediate door for 15 seconds setting off egress and releasing door, (as safety required sign on door states to do) jeopardy to resident health or required 3 staff members to get res to back into unit safely and reset door, res also attempted same safety maneuver on other dining room door that leads to outside at front of building but staff were able to get between res and door and keep him in building and safe. Residents Affected - Some Date 03/04/2025 at 2:06 PM documented by SW Writer Contacted resident's mother, [insert name] to discuss recent. behaviors of pushing on the exit door to the parking lot for 15 plus seconds until the door open and then going outside to a parking lot which is next a four-lane busy highway. Resident's mother is in agreement that resident needs to be in a unit that has a fence between the road/street or no assess to the street for his safety.

Date 03/07/2024 at 4:44 AM documented by LVN O res continues exit seeking this shift and pushing at doors, cursing at staff when unable to let him out of unit, res gait is unsteady when not using walker,

Date 03/14/2025 at 3:51 AM documented by LVN K states, i wanna go home.

Date 03/21/2025 at 2:47 PM documented by LVN C Resident displaying exit seeking behavior: pushing on doors, attempting to

push past Staff to Exit . will continue to monitor for exit seeking behaviors.

Date 03/21/2025 at 8:55 PM documented by LVN S at 19:59 code white was called after being unable to locate resident and finding his window open. This nurse located resident in front of [City name] Dialysis center and accompanied resident safely back to facility. Upon assessment no injuries noted to rt, rt denies pain . Rt stated I don't want to be her anymore! I want to leave RT placed on Q 15 minute checks for 24 hours. RT RP [RP name] called, situation explained stating she understands situation and has no further questions or complaints. PCP faxed. All windows in facility checked, maintenance [name] coming to ensure windows are in compliance with regulations. Rt moved to different room, resting in bed peacefully.

Date 03/21/2025 at 9:51 PM documented by DON Res smiling and states I want to go home. I'm going home. Discussed risks of leaving facility against medical advice and risks associated with elopement. Verbalizes understanding and states I know, but I

don't care.

Date 03/22/2025 at 5:48 AM documented by LVN K Resident awake, sitting on side of bed . resident alert and oriented, talking with staff, stating he will bust out again. Continue to monitor closely

Date 03/23/2025 at 4:52 PM documented by LVN C Resident exit seeking this shift. Eloped from Memory Care unit into ALF and

was exiting ALF dining room door that leads to highway. Resident stopped outside door and escorted back to Memory Care. No injuries noted, Resident denies pain.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 29 675001 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 675001 B. Wing 04/02/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Woodlands 125 Inspiration Blvd Eastland, TX 76448

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 Date 03/24/2025 at 1:07 PM documented by DON Clarification to note on 06/23/25 at 1652: Spoke with on duty memory care CNA on date of entry. CNA states res approached door in memory care dining room. Level of Harm - Immediate Resident pushed on door, causing door alarm to sound. CNA immediately recognized and responded to jeopardy to resident health or alarm. CNA reports res was standing outside door of memory care dining room next to building. Res safety immediately redirected resident back through memory care dining room door without difficulty. Staff will perform 1 on 1 resident observation at this time until further placement arrangements can be made. Residents Affected - Some

During an observation on 03/21/2025 at 7:10 PM, Resident #3 was observed sitting at desk with CNA A. CNA A said she was the only staff that was working on the secured unit. CNA A stated if something was to happen, she would have to leave the residents to make a phone call for help or leave the unit to call for help from the other unit.

During an observation on 03/21/2025 at 8:15pm, there was no lock on Resident #3's bedroom window and two of the dining room windows facing the street did not have a lock. Resident #3 had been moved to another room with an interior window that had a lock and faced the gated courtyard.

During an interview on 03/24/2025 at 2:40 PM, LVN C stated she was working on 03/23/2025 but was not on

the secure unit when she heard the alarm go off. LVN C stated when she entered the secure unit, she saw CNA E standing at the door (that exited out of the secure unit dining area into the parking lot) attempting to turn the door alarm off. LVN C stated she exited thru the secure door that entered the ALF and noticed the door exiting the ALF dining room (north side of building facing the major highway) was open. LVN C stated

she located Resident #3 outside of the ALF door with his walker.

During an interview on 03/25/2025 at 10:35 AM, the DON stated Resident #3 was placed on 15-minute safety rounds checks after his elopement on 03/21/2025 for 24 hours. Staff was responsible to ensure Resident was safe and not trying to exit seek. The resident was then placed on 1:1 supervision on 03/24/2025 at 4:54pm until he was to be transferred to another facility. The DON stated the ADMN and MM were responsible to ensure the locks were placed on window. The DON stated not having locks on the windows led to failure of Resident #3 being able to exit his window.

During an interview on 3/25/25, the Administrator stated when Resident #3 returned from behavioral hospital

on 02/04/2025, she asked the maintenance director to make sure that all the windows hand locks in the secure unit, because there were several that did not have locks. The ADMN stated she did not go back and follow up to ensure they were done. The ADMN stated her expectation was that MM had put the locks in the windows. The ADMN stated what led to failure was that MM did not put locks on the windows and she failed to verify the windows had locks. The ADMN stared she had not reported the incident on March 23rd because even though Resident # 3 was able to exit the secure unit, he did not leave the property.

During an interview on 03/25/2025 at 1:15 PM the MD stated he had provided care for Resident #3. The MD stated due to Resident #3's traumatic brain injury he was not capable of making decisions on his own and was not safe to be out of facility on his own. The MD stated the facility was on a major highway and if Resident #3 were to have gotten out of the facility, he could have had the potential of being stuck by a motor vehicle. The MD stated having only one staff on the secure unit during a shift was not sufficient staff to supervise all the resident's needs.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 29 675001 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 675001 B. Wing 04/02/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Woodlands 125 Inspiration Blvd Eastland, TX 76448

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 Record review of facility policy titled, Wandering and Elopements dated 2001 revealed; The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least Level of Harm - Immediate restrictive environment for residents. If identified as at risk for wandering, elopement, or other safety issues, jeopardy to resident health or the residents' care plan will include strategies and interventions to maintain the residents' safety. safety

This was determined to be an Immediate Jeopardy (IJ) on 03/21/2025 at 4:31 PM. The Administration was Residents Affected - Some informed of the IJ. The Administrator was provided with the IJ template on 03/26/2025 at 12:30 PM.

Record review of Plan of Removal accepted on 03/27/2025 at 5:17 PM reflected the following:

FACILITY: [Facility Name]

Facility ID Number: 110493

SURVEY TYPE: Complaint Survey

SURVEY DATE: 3/26/2025

Plan for REMOVAL

Plan to remove immediate jeopardy.

The facility allegedly failed to ensure a resident with a known history exit seeking and elopement received with adequate supervision in a secured locked unit to prevent elopement.

F-F689

On 3/26/2025 the Administrator notified Medical Director of immediate jeopardy.

Starting on 3/26/2025 the Director of Nursing/Designee will initiate in-service on adequate supervision to prevent a resident from leaving the facility, including policies on elopement/missing resident. In the event a resident starts exhibiting exit seeking behavior that are not controlled with the following interventions redirection, assessing for unmet needs, assessing for pain, hunger, toileting, personal care, and increase in activities, the care plan team will evaluate the need for 1:1 and or alternate placement. This will be discussed

during clinical morning meeting and quarterly care plan meetings for residents who reside on the secure unit. All staff including new hires and agency will be in-serviced on this policy prior to beginning their next shift.

This will be completed by 3/26/2025.

On 3/26/2025 12 residents residing on the secure resident, none are actively exit seeking, they are not attempting to climb out windows or exit doors. Residents were assessed by IDT round to include Administrator, Director of Nursing, Regional Nurse Consultant and direct care staff. Residents were assessed with an elopement risk assessment.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 29 675001 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 675001 B. Wing 04/02/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Woodlands 125 Inspiration Blvd Eastland, TX 76448

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 On 3/26/2025 The policies for one on one have been created to include the following: Residents are placed

on one on one there will be a third designated person assigned to the resident & not part of the usual staffing Level of Harm - Immediate pattern. Criteria for 1:1 would be a resident exhibiting self-harm and uncontrolled behaviors posing risk to self jeopardy to resident health or and others. 1:1 supervision is defined as resident will be within line of sight of staff. Interventions used prior safety to placing a resident on 1:1 would be redirections, assessing pain, hunger, unmet need, toileting, and personal items. Residents Affected - Some

On 3/25/2025 the Resident #3 was discharged to a more a different facility with a more secure unit to eliminate the risk of elopement by this resident.

Ad-Hoc QAPI meeting was held on 3/26/2025, with the Medical Director, NHA (Nursing Home Administrator), Regional Nurse Consultant, Director of Nursing, and Assistant Director of Nursing to review the alleged deficiency, policy and procedure, and the plan for removal of immediacy.

Starting on 3/26/2025, IDT (Interdisciplinary team), including Administrator, Director of Nursing an Assistant Director of Nursing will review the head count and checks window to ensure they are secure with L bracket to prevent opening more than 6 inches in the secure unit of the facility daily Monday to Friday, and Manager on Duty Saturday and Sunday. Any negative findings will be immediately brought up to the Administrator/Designee for further action, if necessary. This will continue daily for the next 14 days. Then weekly there after.

Starting 3/26/2025 RDO or designee will provide physical oversight at facility weekly x4 weeks and then monthly x 2 months.

The Administrator/designee will monitor compliance by physical plant rounds Monday through Friday; Manager on Duty will monitor on weekends. Any identified concerns will be addressed immediately and if trends and patterns are identified, the facility will conduct an Ad-Hoc QAPI meeting to discuss if additional interventions are needed to ensure compliance for next 2 months.

The Administrator will be responsible for ensuring this plan is completed on 3/26/2025.

The RDO/Designee will provide oversight of Administrator to ensure that the items on the plan of removal are reviewed and completed.

Surveyors monitored the facility's Plan of Removal and confirmed it was sufficient to remove the IJ through

observations, interviews, and record review from 03/27/2025 at 5:17 PM to 03/28/2025 at 4:45 PM as follows:

During an observation on 03/25/2025 between 4:45 and 4:50 PM all window in the secure unit were observed to have L brackets placed in each window.

Record review of facility's EMR assessment section residents residing on secure unit on 03/28/2025 at 08:25 AM revealed elopement assessments for 12 residents currently residing on secure unit. 11 of 12 residents identified as elopement risk.

Record review of the facility provided agenda for the Ad-Hoc QAPI meeting held on 3/26/2025 revealed that

the MD had attended meeting and signed the agenda.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 29 675001 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 675001 B. Wing 04/02/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Woodlands 125 Inspiration Blvd Eastland, TX 76448

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 Record review of electronic medical records revealed the 12 residents on the secure unit had an elopement risk assessment completed on 03/26/2025. Level of Harm - Immediate jeopardy to resident health or Record review of facility provided policy revealed a policy titled One on One Resident Supervision. safety

During an interview on 03/25/2025 at 8:40 AM the ADMN stated Resident #3 had been excepted to another Residents Affected - Some facility and would be transported today to new facility.

During an observation and record review on 03/25/2025 at 4:00 PM Resident #3 was not located on the secure unit. Record review revealed he had been discharged to another facility.

Record review on 03/28/2025 at 09:00 AM, observed and reviewed in-services for staff located at nurses station, for One on One, Resident Rights, Staffing on Secure Unit, Elopement, and Exit seeking. Observed sign-in sheets for each in-service. Observed DON conducting an in-service with a dietary staff member.

Record review of the facility provided agenda for the Ad-Hoc QAPI meeting held on 3/26/2025 revealed meeting was held and attendees had signed.

Record review of facility provided documents revealed facility was performing head count and window checks daily.

During an interview on 03/28/2025 at 09:10 AM, CNA A stated she was in-serviced on 03/27/2028 by DON

on resident rights, secure unit staffing, one on one, exit seeking, and elopement on 03/27/2025 by DON. CNA A stated one on one was making sure resident was in line of sight and staying with them and not helping with other residents. CNA A stated the secure unit should have 2 staff on all shifts, if resident was exit seeking should try to redirect and call for help if needed. If a resident elopes, she was to try to find the resident, let the charge nurse know, do room check and head count. Residents have the right to make their own choices, refuse care, and know what medicines they are getting.

During an interview on 03/28/2025 at 09:15 AM, NA G stated she was in serviced on 03/27/2025 by DON resident rights, one on one, staffing of secure unit, exit seeking and elopement on 03/27/2025 by DON. Staffing of secure unit with at least 2 staff unit each shift. NA G stated one on one meant always keeping resident in line of sight. NA G stated if residents were exit seeking to try to redirect or see if they are hungry. NA G stated residents had the right to refuse care, treated with respect, and make decisions.

During an interview on 03/28/2025 at 09:20 AM, LVN H stated she was in-services on 03/27/2025 by DON

on One-to One, Staffing on Secured Unit, Resident Rights, Exit Seeking, and Elopement on 03/27/2025 by DON. LVN H stated one on one meant keeping resident in line of sight and not leaving resident until another staff member can take over one on one. LVN H stated the secure unit should have been staffed with 2 staff at all times. LVNH stated if a resident was exit seeking staff should try to re-direct resident, offer food or see if the resident was in pain. LVN H stated residents had the right to refuse care, to be treated with respect and to make their own decisions.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 29 675001 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 675001 B. Wing 04/02/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Woodlands 125 Inspiration Blvd Eastland, TX 76448

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 During an interview on 03/28/2025 at 09:30 AM, CNA I stated the secure unit should have 2 staff at all times, one on one meant to keep the resident in line of sight and to not leave them without someone to take the Level of Harm - Immediate staff's place. CNA I stated for elopement should let charge nurse know, check all rooms, all areas of facility jeopardy to resident health or to try to locate resident. CNA I stated she had in-services on 03/27/2025 by ADON before her shift. CNA safety stated residents had the right to refuse care, treated with respect, and make decisions. CNA I stated other in-services she had today included Exit Seeking, Resident Rights, Staff on Secure Unit, and Elopement. Residents Affected - Some

During an interview on 03/28/2025 at 09:45 AM, AD said she received in-services on 03/28/2025 by DON on resident rights, one on one, secure unit staffing and elopement secure unit staffing. The AD stated one on one was keeping the resident in line of sight and secure unit should have 2 staff on all shifts. The AD stated if

a resident was trying to elope to try to re-direct, get other staff to help. The AD stated if resident had eloped check on other residents, try to find missing resident and report to ADM, DON and other staff. The AD stated residents had the right to make their own choices, be treated with respect and have needs taken care of.

During an interview 03/28/2025 at 09:55 AM, NA F stated she had been in-serviced on 03/28/2025 by DON

on one on one, resident rights, staff on secure unit, elopement and exit seeking. NA F stated one on one meant staying with resident and keeping your eyes on them. NA F stated if resident eloped need to try to find them, call DON and ADM and let other staff know someone is missing. NA F stated residents had to the right to refuse care, treated with respect, and make decisions. Transport Aide F stated the residents had the right to be treated with respect, and to make their own choices.

During an interview on 03/28/2025 at 10:28 AM, CNA J stated she worked night shift and had in-services 03/27/2025 by DON on one on one, staffing of secure unit, elopement, exit seeking, and resident rights. CNA J stated she would assist on secure unit when needed and one on one meant to keep the resident in line of sight and not leave the resident. CNA J stated if a resident was exit seeking to try to re-direct them or offer them something to eat and if a resident elopes to let all staff know, try to locate resident and notify ADM and DON and make sure all other residents are accounted for. CNA J stated residents had to the right to refuse care, treated with respect, and make decisions.

During an interview on 03/28/2025 at 11:05 AM, LVN K stated she had [TRUNCATED]

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 29 675001 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 675001 B. Wing 04/02/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Woodlands 125 Inspiration Blvd Eastland, TX 76448

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 0725 Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Level of Harm - Immediate jeopardy to resident health or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 44558 safety Based on observation, interviews, and record review, the facility failed to have sufficient nursing staff to Residents Affected - Some provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident and determined by considering the number, acuity, and diagnoses of the facility's resident population with accordance with 1 of 13 residents (Resident #3) reviewed for sufficient staffing

The facility failed to provide sufficient staffing of Secured Locked Unit for resident with known history of elopement that required 1:1 supervision on 03/24/2025.

An Immediate Jeopardy (IJ) was identified on 03/21/2025. While the IJ was lowered on 03/28/2025 at 4:45 PM, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm with a scope of pattern, due to the facility's need to evaluate the effectiveness of their corrective actions.

This failure could place the residents at risk of residents' needs, safety and psychosocial well-being not being met.

The findings include:

Record review of Resident # 3's face sheet dated 03/24/2025 revealed a [AGE] year-old female admitted on [DATE REDACTED] with a readmission on 02/19/2025 with the following diagnoses cardiac issues, seizures, and traumatic brain injury.

Record review of Resident #3's Quarterly MDS, dated [DATE REDACTED], revealed: Section C - Cognitive Patterns Resident #3 had a BIMS of 14, meaning cognitively intact. Section GG Mobility Devices Resident #3 required

the use of a walker.

Record review of Resident #3's Care Plan updated on 03/21/2025 revealed:

Problem: start date 10/09/2024 I am on the memory care unit due to exit seeking behaviors. On 3/21/25 had actual Elopement through bedroom window-High Risk 20.

Goal: Resident will remain free from injury related to exit seeking/elopement attempts through next quarter.

Approach: Start Date 03/21/2025 Consider Medication Review if behaviors continue or escalate; Start Date- 03/21/2025

Consider psych consult with increase in behaviors; Start Date- 03/21/2025 Ensure all basic needs are met when resident.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 29 675001 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 675001 B. Wing 04/02/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Woodlands 125 Inspiration Blvd Eastland, TX 76448

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 0725 becomes anxious or aggressive. Offer toileting, snack, fluids, comfort. Etc.; Start Date- 12/05/2024 Resident must be accompanied by staff while in courtyard. Start Date- 10/09/2024 Assess/ record/ report to MD risk Level of Harm - Immediate factors for potential elopement such as: wandering, jeopardy to resident health or safety repeated requests to leave facility, attempts to leave facility. Start Date- 10/09/2024 Check doors & windows for security and for Residents Affected - Some proper functioning and placement per facility protocol. Start Date-10/09/2024 Develop and activities program to divert.

attention and meet needs for social, cognitive stimulation; Start Date- 10/09/2024 Discuss with resident/ family risks of elopement.

and wandering; Start Date- 10/09/2024 If resident is missing from facility, follow elopement protocol, notify MD and family.

immediately, and document; Start Date- 10/09/2024 Placement on secure unit for high risk for elopement; Start Date: 10/09/2024

Supervise closely and make regular compliance rounds whenever resident is in room.

Record review of Resident #3's physician orders revealed Start date of 10/09/2024 Admit to facility secure unit.

Record review of Resident #3's progress notes revealed:

Date 03/23/2025 at 4:52 PM documented by LVN C Resident exit seeking this shift. Eloped from Memory Care unit into ALF and

was exiting ALF dining room door that leads to highway. Resident stopped outside door and escorted back to Memory Care. No injuries noted, Resident denies pain.

Date 03/24/2025 at 1:07 PM documented by DON Clarification to note on 06/23/25 at 1652: Spoke with on duty memory care CNA on date of entry. CNA states res approached door in memory care dining room. Resident pushed on door, causing door alarm to sound. CNA immediately recognized and responded to alarm. CNA reports res was standing outside door of memory care dining room next to building. Res immediately redirected resident back through memory care dining room door without difficulty. Staff will perform 1 on 1 resident observation at this time until further placement arrangements can be made.

During an observation on 3/24/2025 at 9:55 AM Resident #3 was sitting in his room on his bed, no staff was

in his room or within the proximity of his room.

During an observation on 03/24/2025 between 12:35 and 12:40 PM, CNA B was sitting at the dining room table assisting a resident with eating their lunch, NA Z was assisting another resident in the resident's room. One resident was trying to open doors and another resident was scraping food from one plate to another plate (that were not theirs) and pouring food on to the floor. CNA B appeared flustered while trying to provide care for the three residents in the dining area. Resident # 3 left the dining area and went to his room.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 29 675001 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 675001 B. Wing 04/02/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Woodlands 125 Inspiration Blvd Eastland, TX 76448

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 0725 During an observation and interview on 03/24/2025 at 3:20 PM, Resident #3 was standing in the hallway on

the secure unit with his walker. Resident #3 stated he wanted to go home and that is why he ran away Level of Harm - Immediate yesterday. Resident #3 went into his room and sat on his bed. CNA B was observed walking away from jeopardy to resident health or Resident #3's room, no staff were observed in room with Resident #3. safety

During an interview on 03/24/2025 at 4:20 PM, CNA B stated she and NA Z were the staff who had been Residents Affected - Some working on the secure unit that day. CNA B stated she was not aware Resident #3 was supposed to be on 1:1 supervision. CNA B stated she and NA Z were taking turns watching Resident #3. CNA B stated 1:1 supervision meant a staff constantly with a resident. CNA B stated when a resident was on 1:1 supervision staff documented on a log their observations of resident. CNA B stated she had not been notified Resident #3 was on 1:1 supervision by the nurse or the DON. CNA B stated she had not been given a log to document 1:1 supervision. CNA B stated whoever was doing the 1:1 supervision should have been writing it down. CNA B stated the DON or nurse had not told her that she needed to do one on one for Resident #3.

During an interview on 03/24/2025 at 4:30 PM, NA Z stated she had not been notified that Resident #3 was

on 1:1 supervision.

During an interview on 03/25/2025 at 10:35 AM, the DON stated Resident #3 was placed on 1:1 supervision

on 3/23/2025, after he exited the secure unit, until a new placement could be found. The DON stated her expectation was that Resident #3 be within line of sight of staff. The DON stated that if Resident #3 was in his room, he could not be seen by staff. The DON stated the aides on the secure unit were responsible to provide 1:1 supervision for Resident #3 and different staff would come and assist on the secure unit.

The DON stated she was not aware there was times Resident #3 was not on 1:1 supervision.

During an interview on 03/25/2025 at 11:45 PM, the ADMN stated her expectation was that Resident #3 was placed on 1:1 supervision on 3/23/2025 after he exited the building. The AMDN stated her expectation of 1:1 supervision was that Resident #3 should have been within line of site of a staff at all times. The ADMN stated NA Z, CNA B and LVN P were responsible for 1:1 supervision along with department staff throughout the day. The ADMN stated if Resident #3 was in his room there should have been a staff member within line of site. The ADMN stated she was not aware Resident # 3 had been in his room without staff. The ADMN did not have an explanation to why staff did not know about the 1:1 supervision., she stated staff should have been notified at the beginning of their shift. The ADMN stated they did not have a policy for 1:1 supervision.

During an interview on 03/25/2025 at 1:15 PM, the MD stated he had provided care for Resident #3. The MD stated due to Resident #3's traumatic brain injury he was not capable of making decisions on his own and was not safe to be out of facility on his own. The MD stated the facility was on a major highway and if Resident #3 were to have gotten out of the facility, he could have had the potential of being stuck by a motor vehicle. The MD stated having only one staff on the secure unit during a shift was not sufficient staff to supervise all the resident's needs.

Record review of facility policy title, Staffing, Sufficient and Competent Nursing dated August 2022, Our facility provides sufficient numbers of nursing staff with the appropriate skills and competency necessary to provide nursing and related care and services for all residents in accordance with resident care plans and the

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 29 675001 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 675001 B. Wing 04/02/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Woodlands 125 Inspiration Blvd Eastland, TX 76448

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 0725 facility assessment.'

Level of Harm - Immediate This was determined to be an Immediate Jeopardy (IJ) on 03/21/2025 at 4:31 PM. The Administration was jeopardy to resident health or informed of the IJ. The Administrator was provided with the IJ template on 03/26/2025 at 12:30 PM. safety

Record review of Plan of Removal accepted on 03/27/2025 at 5:17 PM reflected the following: Residents Affected - Some FACILITY: [Facility Name]

Facility ID Number: 110493

SURVEY TYPE: Complaint Survey

SURVEY DATE: 3/26/2025

Plan for REMOVAL

Plan to remove immediate jeopardy.

The facility failed to provide sufficient staffing of Secured Locked Unit for resident with a known history exit seeking and elopement that required 10-15 minute safety checks and 1:1 supervision.

F 725

On 3/26/2025 the Administrator notified the Medical Director of the immediate jeopardy.

On 3/26/2025 None of the 12 residents residing on the secure unit are identified as inappropriate for the secure unit at this time. The 12 residents residing in the secure unit were assessed by the IDT team to include the Administrator, Director of Nurses, Regional Nurse Consultant and direct care staff for appropriate placement. An elopement risk assessment was also completed on all 12 residents on 3/26/2025.

On 3/26/2025 The policies for one on one have been created to include the following: Residents are placed

on one on one there will be a third designated person assigned to the resident & not part of the usual staffing pattern. Criteria for 1:1 would be a resident exhibiting self-harm and uncontrolled behaviors posing risk to self and others. Interventions used prior to placing a resident on 1:1 would be redirections, assessing pain, hunger, unmet need, toileting, and personal items.

On 3/25/2025 the resident #3 was discharged to a different facility with a more secure unit to eliminate the risk of elopement by this resident.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 29 675001 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 675001 B. Wing 04/02/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Woodlands 125 Inspiration Blvd Eastland, TX 76448

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 0725 Starting on 3/26/2025 the Director of Nursing/Designee will initiate in-service for all staff including new hires and agency prior to working next scheduled shift including weekends and nights on adequate supervision to Level of Harm - Immediate be defined as two facility staff members at all times present on the secure unit. Staffing from other jeopardy to resident health or departments will be reassigned to work in the secure unit if needed for both day and night shifts. Residents safety change of condition are discussed with the care plan team during the morning meeting, quarterly, and as needed. The facility will access the need for additional interventions when evaluating the changes in a Residents Affected - Some resident's condition.

Ad-Hoc QAPI meeting was held on 3/26/2025, with the Medical Director, NHA (Nursing Home Administrator), (Regional Nurse Consultant), Director of Nursing, and Assistant Director of Nursing to review the alleged deficiency, policy and procedure, and the plan for removal of immediacy.

Starting on 3/26/2025, IDT (Interdisciplinary team), including the Administrator, Director of Nursing an Assistant Director of Nursing, will review staffing schedules in the secure unit to determine two staff are always in the secured unit daily Monday to Friday, and Manager on Duty Saturday and Sunday. Any negative findings for sufficient staffing will be immediately brought up to the Administrator/Designee for further action, if necessary. Administrator/Designee will send additional staff including center leadership team, center staff and/or agency as needed to meet sufficient staffing needs.

Starting 3/26/2025 RDO or designee will provide physical oversight at facility weekly x4 weeks and then monthly x 2 months.

The Administrator/designee will monitor compliance by reviewing staffing schedule and assignment sheet and staff present Monday through Friday. The Weekend Manager on Duty will monitor compliance on weekends by reviewing staffing schedules and assignment sheets. Any identified concerns will be addressed immediately and if trends and patterns are identified, the facility will conduct an Ad-Hoc QAPI meeting to discuss if additional interventions are needed to ensure compliance for next 2 months.

The Administrator will be responsible for ensuring this plan is completed on 3/26/2025.

The RDO/Designee will provide oversight of Administrator to ensure that the items on the plan of removal are reviewed and completed.

Surveyors monitored the facility's Plan of Removal and confirmed it was sufficient to remove the IJ through

observations, interviews, and record review from 03/27/2025 at 5:17 PM to 03/28/2025 at 4:45 PM as follows:

Surveyors monitored the facility's Plan of Removal and confirmed it was sufficient to remove the IJ through

observations, interviews, and record review from 03/27/2025 at 5:17 PM to 03/28/2025 at 4:45 PM as follows:

During an observation on 03/25/2025 between 4:45 and 4:50 PM all window in the secure unit were observed to have L brackets placed in each window.

Record review of facility's EMR assessment section residents residing on secure unit on 03/28/2025 at 08:25 AM revealed elopement assessments for 12 residents currently residing on secure unit. 11 of 12 residents identified as elopement risk.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 29 675001 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 675001 B. Wing 04/02/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Woodlands 125 Inspiration Blvd Eastland, TX 76448

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 0725 Record review of the facility provided agenda for the Ad-Hoc QAPI meeting held on 3/26/2025 revealed that

the MD had attended meeting and signed the agenda. Level of Harm - Immediate jeopardy to resident health or Record review of electronic medical records revealed the 12 residents on the secure unit had an elopement safety risk assessment completed on 03/26/2025.

Residents Affected - Some Record review of facility provided policy revealed a policy titled One on One Resident Supervision.

During an interview on 03/25/2025 at 8:40 AM the ADMN stated Resident #3 had been excepted to another facility and would be transported today to new facility.

During an observation and record review on 03/25/2025 at 4:00 PM Resident #3 was not located on the secure unit. Record review revealed he had been discharged to another facility.

Record review on 03/28/2025 at 09:00 AM, observed and reviewed in-services for staff located at nurses station, for One on One, Resident Rights, Staffing on Secure Unit, Elopement, and Exit seeking. Observed sign-in sheets for each in-service. Observed DON conducting an in-service with a dietary staff member.

Record review of the facility provided agenda for the Ad-Hoc QAPI meeting held on 3/26/2025 revealed meeting was held and attendees had signed.

Record review of facility provided documents revealed facility was performing head count and window checks daily.

During an interview on 03/28/2025 at 09:10 AM, CNA A stated she was in-serviced on 03/27/2028 by DON

on resident rights, secure unit staffing, one on one, exit seeking, and elopement on 03/27/2025 by DON. CNA A stated one on one was making sure resident was in line of sight and staying with them and not helping with other residents. CNA A stated the secure unit should have 2 staff on all shifts, if resident was exit seeking should try to redirect and call for help if needed. If a resident elopes, she was to try to find the resident, let the charge nurse know, do room check and head count. Residents have the right to make their own choices, refuse care, and know what medicines they are getting.

During an interview on 03/28/2025 at 09:15 AM, NA G stated she was in serviced on 03/27/2025 by DON resident rights, one on one, staffing of secure unit, exit seeking and elopement on 03/27/2025 by DON. Staffing of secure unit with at least 2 staff unit each shift. NA G stated one on one meant always keeping resident in line of sight. NA G stated if residents were exit seeking to try to redirect or see if they are hungry. NA G stated residents had the right to refuse care, treated with respect, and make decisions.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 29 675001 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 675001 B. Wing 04/02/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Woodlands 125 Inspiration Blvd Eastland, TX 76448

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 0725 During an interview on 03/28/2025 at 09:20 AM, LVN H stated she was in-services on 03/27/2025 by DON

on One-to One, Staffing on Secured Unit, Resident Rights, Exit Seeking, and Elopement on 03/27/2025 by Level of Harm - Immediate DON. LVN H stated one on one meant keeping resident in line of sight and not leaving resident until another jeopardy to resident health or staff member can take over one on one. LVN H stated the secure unit should have been staffed with 2 staff safety at all times. LVNH stated if a resident was exit seeking staff should try to re-direct resident, offer food or see if the resident was in pain. LVN H stated residents had the right to refuse care, to be treated with respect and Residents Affected - Some to make their own decisions.

During an interview on 03/28/2025 at 09:30 AM, CNA I stated the secure unit should have 2 staff at all times, one on one meant to keep the resident in line of sight and to not leave them without someone to take the staff's place. CNA I stated for elopement should let charge nurse know, check all rooms, all areas of facility to try to locate resident. CNA I stated she had in-services on 03/27/2025 by ADON before her shift. CNA stated residents had the right to refuse care, treated with respect, and make decisions. CNA I stated other in-services she had today included Exit Seeking, Resident Rights, Staff on Secure Unit, and Elopement.

During an interview on 03/28/2025 at 09:45 AM, AD said she received in-services on 03/28/2025 by DON on resident rights, one on one, secure unit staffing and elopement secure unit staffing. The AD stated one on one was keeping the resident in line of sight and secure unit should have 2 staff on all shifts. The AD stated if

a resident was trying to elope to try to re-direct, get other staff to help. The AD stated if resident had eloped check on other residents, try to find missing resident and report to ADM, DON and other staff. The AD stated residents had the right to make their own choices, be treated with respect and have needs taken care of.

During an interview 03/28/2025 at 09:55 AM, NA F stated she had been in-serviced on 03/28/2025 by DON

on one on one, resident rights, staff on secure unit, elopement and exit seeking. NA F stated one on one meant staying with resident and keeping your eyes on them. NA F stated if resident eloped need to try to find them, call DON and ADM and let other staff know someone is missing. NA F stated residents had to the right to refuse care, treated with respect, and make decisions. Transport Aide F stated the residents had the right to be treated with respect, and to make their own choices.

During an interview on 03/28/2025 at 10:28 AM, CNA J stated she worked night shift and had in-services 03/27/2025 by DON on one on one, staffing of secure unit, elopement, exit seeking, and resident rights. CNA J stated she would assist on secure unit when needed and one on one meant to keep the resident in line of sight and not leave the resident. CNA J stated if a resident was exit seeking to try to re-direct them or offer them something to eat and if a resident elopes to let all staff know, try to locate resident and notify ADM and DON and make sure all other residents are accounted for. CNA J stated residents had to the right to refuse care, treated with respect, and make decisions.

During an interview on 03/28/2025 at 11:05 AM, LVN K stated she had in-service [AJB1] 03/27/2025 by ADON on resident rights, elopement, exit seeking, staffing on secure unit and one on one. LVN K stated the secure unit should have 2 staff on all shifts, one on one meant keeping resident in line of sight. LVN stated residents had the right to refuse care, to be treated with respect, and make their own decisions.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 29 675001 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 675001 B. Wing 04/02/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Woodlands 125 Inspiration Blvd Eastland, TX 76448

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 0725 During an interview on 03/28/2025 at 11:17 AM, NA L stated received in-services [AJB2] on 03/27/2025 by DON on resident rights, one on one, secure unit staff, elopement and exit seeking and staffing on secure Level of Harm - Immediate unit. NA L stated for resident's exit seeking to try to distract resident. Resident rights, the residents have the jeopardy to resident health or right to make their own choices, to be treated with respect and taken care of. NA L stated one on one means safety making sure you can see residents all the time you were with them, and the secure unit should have 2 staff

on all shifts. NA L stated if a resident eloped, he would let the charge nurse know immediately and would Residents Affected - Some begin looking for resident and making sure no one else is missing.

During an observation on 03/28/2025 at 12:01 PM, the DON was on the secure unit performing head count of the residents and checking on the residents and the staff.

During an interview on 03/28/2025 at 01:25 PM, the DON stated she prepared in-services for resident rights, one on one, Secure unit staffing, elopement and exit seeking. The DON stated she conducted in-services on 03/27/2025 with staff in-house on both shifts. DON stated all staff were provided handouts regarding information on all in-services. DON stated she was available to staff for any questions or concerns.

During an interview on 03/28/2025 at 01:35 PM, ADON stated she assisted DON with preparing in-services

on 03/27/2025 on resident rights, Secure unit staffing, one on one, Exit seeking, and elopement. ADON stated called staff not at facility or not able to come to facility for in-services and discussed in-service information with staff on phone. ADON stated handouts were available for all staff and would be given to staff unable to attend in person.

During an observation on 03/28/2025 at 01:40 PM observed all the windows on secure unit had L brackets

on the windows to prevent windows from being raised more than 6 inches.

During an interview on 03/282025 at 02:10 PM, MM stated he checked windows L brackets on secure unit daily and if any not working they would be fixed immediately. MM stated he had a log sheet to document that L brackets were checked and secure. MM stated he had in services 03/27/2025 by ADON on one on one, secure unit staffing, resident rights and elopement and exit seeking.

During an interview on 03/28/2025 at 02:45 PM, Housekeeper M stated she attended in-services on 03/28/2025 by DON for resident rights, one on one in secure unit. Staffing for secure unit, exit seeking and elopement. Housekeeper M stated one on one was keeping resident in line of sight and staying with the resident until someone else was available. Housekeeper M stated residents have the right to make choices and to kept clean and safe.

During an attempted interview on 3/28/2025 at 3:45 PM the MD's office did not answer phone and a message was left.

An Immediate Jeopardy was identified on 03/21/2025. While the Immediate Jeopardy was removed on 03/28/2025, the facility remained out of compliance at a level of no actual harm with a potential for more than minimal harm and a scope of pattern, due to the facility monitoring the effectiveness of their Plan of Removal. The ADMN, the DON, and the RRN were informed of the Immediate Jeopardy was removed on 03/28/2025 at 4:45 PM.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 29 675001