Highland Pines Nursing Home

F-F689- Supervision to Prevent Accidents

1. The facility failed to put interventions in place to prevent Resident #1, who was confused from eloping.

2. The facility failed to follow their elopement policy

3. The facility failed to determine how Resident #1 eloped

Identify residents who could be affected

All residents have the potential to be affected.

Identify responsible staff/ what immediate action taken

1. Resident #1 elopement assessment and care plan was audited on 7/31/24.

2. Initiated staff interviews and established a timeline of the sequence of events.

3. The DON and Administrator received a 1:1 re-education by the Regional Nurse Consultant on the facility policy and procedure on supervision of a cognitively impaired resident assessed to be at risk for elopement

on 7/31/24.

4. Audit Elopement assessments on all residents currently in the facility completed on 07.31.2024.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 16 675133 Department of Health & Human Services Printed: 09/17/2025 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 675133 B. Wing 08/01/2024

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

Highland Pines Nursing Home 1100 N 4th St Longview, TX 75601

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 5. Elopement assessments have been reviewed and or revised and deemed appropriate by the IDT on 7/31/24. Level of Harm - Immediate jeopardy to resident health or 6. All residents triggering at risk for elopement were added to the elopement Book that is kept at each safety nurse's station. The elopement Book includes the resident's picture and face sheet completed on 7/31/24

Residents Affected - Few 7. Staff received re-education by the DON on the facility policy and procedure when resident exhibits exit seeking behavior on 7/31/24.

8. Staff received re-education by the DON on the facility policy and procedure in the event of a missing/wandering resident on 7/31/24.

9. Licensed Nurse and CNAs will complete an exit seeking behavior resident questionnaire starting on 7/31/24 and must complete prior to returning to work. If CNA observes resident exhibiting exit seeking behaviors, CNA will report to charge nurse.

10. The maintenance director has assessed all Exit doors in the facility to ensure that each are operating as manufacture recommendation.

11. Facility IDT has audited all key padded doors, changed codes, and areas of egress to ensure latching and lock functions are operable as designed on 7/31/24

12. Elopement assessments have been reviewed and or revised and deemed appropriate by the IDT.

13. Cameras were installed on the 300 hall exits on 7/31/24

14. A sign was placed at all exit doors reminding visitors to use the main entrance, ensure the doors are closed securely behind them. A sign was placed at all exit doors reminding visitors to use the main entrance, and ensure the doors are closed securely behind them. Staff educated not to give code out to any visitors and redirect family to use main entrance only. Charge nurses to remind families and visitors not allow residents to exit the facility with them and to notify staff if a resident is trying to leave?

In-Service conducted

In-service was conducted by Director of Nursing 7/31/24. The in-service is on Resident Supervision. The details of the in-service include:

? Walking Rounds

? Visualizing each resident during rounds

? Rounding every 2 hours

? Exit seeking behavior notification to DON and/or Administrator.

? 24hrs report sign off by outgoing nurse and incoming nurse.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 16 675133 Department of Health & Human Services Printed: 09/17/2025 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 675133 B. Wing 08/01/2024

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

Highland Pines Nursing Home 1100 N 4th St Longview, TX 75601

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 ? Immediately search the facility, rooms, common areas, perimeter of the building.

Level of Harm - Immediate ? Elopement binders jeopardy to resident health or safety ? Educate weekend supervisor on admission completion and necessary care planning.

Residents Affected - Few ? Proper completion of elopement assessments for charge nurses and ADON

The in-service was attended by licensed caregivers which include Registered Nurse, Licensed Practical Nurse, Certified Nursing Assistants, Qualified medication tech, Housekeepers, Maintenance, Kitchen Staff. Staff members who are unavailable for training on this date, they will not be allowed to return to work until training is complete. This in-service was initiated on 7/31/24 and completed on 8/1/24.

Implementation of Changes

The changes were started by the Director of Nursing. The changes were implemented effective on 7/31/24 and will be ongoing until all staff are re-educated. The Director of Nursing will ensure competency through verbalization of understanding by staff and completion of returned questionnaire.

Monitoring

The Administrator/Director of Nursing/Assistant Director of Nursing will be responsible for monitoring the implementation and effectiveness of in-service on 7/31/24.

? The Administrator/Director of Nursing/Designee will monitor/review each shift change report for signature validation daily x4 weeks, then weekly x2 weeks, then monthly and report any adverse finding during QAPI

? Director of Nursing/Designee will conduct a daily audit of Elopement assessment x4 weeks, then weekly x 2 weeks, then monthly and report any adverse findings during QAPI

? Residents will be monitored by staff every shift for any exit seeking behaviors. Any changes will be reported to the Administrator Director of Nursing/Designee immediately for appropriate action.

? DON/Designee new admissions audit within 24hrs for admission for completion and necessary care plan.

Involvement of Medical Director

The Medical Director met with the Interdisciplinary team on 7/31/24 and conducted an Ad HOC QAPI regarding Resident #1. The Medical Director was notified about the immediate Jeopardy on 7/31/24, the Plan of removal was reviewed and accepted by the Medical Director.

Involvement of QA

An Ad Hoc QAPI meeting was held with the Medical Director, facility administrator, director of nursing, and social services director to review plan of removal on 7/31/24.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 16 675133 Department of Health & Human Services Printed: 09/17/2025 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 675133 B. Wing 08/01/2024

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

Highland Pines Nursing Home 1100 N 4th St Longview, TX 75601

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 Who is responsible for implementation of process?

Level of Harm - Immediate The Director of Nursing will be responsible for implementation of New Process. The New Process/ system jeopardy to resident health or was started on 7/31/24.] safety

Record review of in-service training report dated 7/31/24 indicated the subject was Supervision of Cognitively Residents Affected - Few Impaired Residents (Wandering /Elopement) by the RNC. Attendees were the Administrator and the DON.

They were in serviced on the elopement policy and Elopement assessments.

Record review of in services dated 7/31/24 indicated the facility staff were educated on Elopement prevention and procedures to include, walking [NAME] [TRUNCATED]

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 16 675133