Health inspection·November 29, 2023

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 resident's environment remained free of accidents and hazards and each resident received adequate supervision and assistance devices to prevent accidents for 2 of 2 residents (Resident #2 and # 170) whose records were reviewed for accidents and supervision. The facility failed to ensure Resident #2 and Resident #170's wander guards were checked for functionality. This failure could place residents at risk of elopement or leaving area without supervision. The findings include: 1.Record review of Resident #2's face sheet, undated, revealed the resident was an [AGE] year-old female admitted to facility on 01/07/19 with diagnoses of Dementia with behavioral disturbance, Bipolar Disorder II (a mental health condition defined by periods of mood disturbances), Anxiety (an emotion which is characterized by an unpleasant state of inner turmoil and includes feelings of dread over anticipated events), muscle wasting (loss of muscle mass), abnormal posture, Chronic pain, and hypertension (high blood pressure). In an observation on 11/28/23 at 09:28 AM Resident #2s wander Guard was placed on the wheelchair. Resident #2 had contractures of all extremities but could self-propel in a wheelchair around the facility without assistance. In an interview on 11/28/23 at 09:30 AM The ADON stated she checked the wander guard system every shift by pushing Resident #2 and wheelchair by the alarm. The ADON was not observed checking placement. 2.Record review of Resident # 170's face sheet, undated, revealed the resident was admitted to facility on 11/16/23 was a [AGE] year-old female with diagnoses of psychotic disorder with delusions due to known physical condition (fixed, false conviction in something that is not real or shared by other people). Record review of progress note dated 11/16/23 at 7:12 PM, written by unidentified LVN revealed Resident #170 had exit seeking behavior. Orders for Wander Guard documented. In an interview with the DON on 11/28/23 at 10:00 AM she said they check the alarms by placing the (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 10 Event ID: 675021 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675021 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Electra Healthcare Center 511 S Bailey St Electra, TX 76360 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)