Health inspection·November 10, 2022

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident #22 states she had a pain in the back of her head last night. (Resident was given PRN Tylenol at 10:45 PM). Resident #22 requested the police or an ambulance. Resident #22 stated she then had a panic attack while interacting with her roommate, and that is why she left. Resident #22 stated she was having a panic attack because she got angry with her roommate because she (her roommate) was sick. Resident #22 stated she left through the front door. Resident #22 stated the door had the exit number posted and that no one saw her. Resident #22 stated she used her cane to punch the numbers into the keypad. Resident #22 stated she left because the staff was not listening and because of the pain she was having. Resident #22 stated the staff did not want to help her. Resident #22 stated she rang the doorbell on a house across the street and the first house didn't open the door, so she rang a 2nd one. Resident #22 stated there was not much traffic, but it was dark. It was after dark: eleven (PM). Record review of MAR shows PRN pain medication given on 11/8/2022 at 10:45 PM for a pain level of 1-4 (mild pain). Record review of nursing note from 11/9/2022 at 7:00 AM indicates assessment upon return to facility with no injuries noted. Report from ER showed Tylenol given. Record review of Resident #22's Nursing notes dated 11/8/2022 at 10:45 PM, (28 minutes before she eloped) reflected Resident #22 was given the analgesic Tylenol, (a medication to relieve pain) for complaint of a headache with a pain level of 1-4. Analgesic medication was given by the nurse shortly before Resident #22's elopement. A pain level of 1-4 is considered mild pain. Record review of Resident #22 nurses notes dated 11/8/2022 at 11:32 PM reflected a telephone call; as per this RP, states that resident has been voicing desire to go home for several days, but it was not reported to staff, also stated that he (RP) was afraid she (Resident #22) would try to elope; instructed to let staff know next time please due to high risk for elopement and subsequent injury or death. Review of facility video camera footage on 11/10/22 beginning at 10:16 AM with Interim Administrator revealed Resident #22 enters the video screen and can read the pin code on the wall to exit the facility. Interim Administrator stated the facility is not a self-contained unit or secured unit, so he is going to check the policy for having the door pin code taped near the front door. Interim Administrator revealed the CNAs were doing their rounds in the halls but were unaware that the Resident # 22 had left or was near the front door. Interim Administrator revealed all doors have alarms when opened without the code, but the resident was able to use the code to exit. There were no signs that the resident was at risk of elopement or exiting the facility. Interim Administrator stated, there are a lot of things that could have happened with the resident leaving the facility; she could have been lost. Interim Administrator stated initially the resident was placed on 1 to 1 care meaning one staff always stayed with the resident on 11/9/22 from 7:15AM, when she returned from the hospital, until 2pm. They moved the resident to another room closer to the nurse's station, to allow more staff to see the resident walk down the hall and the staff are doing monitoring every 15 minutes for the residents. A referral was sent out to a couple of new facilities, but they do not have a date for transfer to another facility, pending evaluations for another facility to accept the resident. The numbers and code to exit the front door were changed yesterday and the numbers are no longer visible. If anyone wants the codes to get out, they have to get a staff member to let them out. Phone interview on 11/10/22 at 01:29 PM with night shift staff CNA #1, stated she has worked at the facility for about 8 years. CNA #1 stated she worked with Resident #22 on 11/8/2022 and she saw the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675689 If continuation sheet Page 2 of 3 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 675689 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/10/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Village Healthcare and Rehabilitation 615 N Ware Rd McAllen, TX 78501 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few resident around 10:15 PM in her room and she went in to check on her. CNA #1 stated Resident #22 told her that her head hurt and she went to tell the nurse and they went to check on the Resident #22. CNA #1 stated Resident #22 told her that she wanted to go to the hospital because she felt sick. When CNA #1 reported Resident #22 wanted to go to the hospital, the nurse went to check on Resident #22. CNA #1 stated she started doing her job on 11/8/2022 and she was told by another nurse that the resident had left. CNA #1 stated she did not notice the resident had left the facility. CNA #1 stated that she saw Resident #22 standing at her doorway after the nurse saw her, but that it was common for Resident #22 to stand at her doorway to ask for snacks or ask for things. CNA #1 stated the front door was locked during the night and that the staff have to enter a code to get out of the facility. (Resident #22 left via the front door) CNA #1 stated they check on the residents often and they know if a resident is exit seeking that they know to check on the residents more often if anything is going on with them, but Resident #22 did not give any signs that she was going to leave. CNA #1 stated they check on all the residents every two hours and as needed. Phone interview on 11/10/22 at 01:53 PM CNA #2 night shift staff on duty on 11/8/2022 stated she was not the CNA for Resident #22 that night. CNA #2 stated if she had seen anything she would have been able to redirect Resident #22 or alert staff about it and she was educated on elopement and wandering residents. Interview on 11/10/2022 @ 2:30 PM DON stated We don't have a policy that allows people to come and go. It's not in the admission packet. We don't have any residents that are elopement risks. The DON stated the resident used two canes to walk. The DON stated, she walks faster than me. DON stated, Resident #22 has a low BIMS score, so we are looking for a different facility. We have other residents with low BIMS score. No one was aware that Resident #22 left the facility. There was an access code that Resident #22 was able to read. DON stated, We (are now) doing Q 15-minute checks for Resident #22, and they will continue until we find placement for her. If they (the RP for resident #22) had said she wanted to leave we would have taken additional steps. Even without the code a resident could leave because if the door bar is held 15 seconds she could leave (per Fire code). We had kept the code posted for visitors, so they could leave. Interview on 11/10/2022 @ 4:00 Administrator stated, Before covid we didn't have a lock on the door. Administrator stated the code was placed at the door to assist families leaving. Administrator stated staff use a different number to get in and out and there was no harm to the resident. No policy or procedures were found by this surveyor or facility staff regarding elopement prevention other than an evaluation to determine elopement risks upon admission. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675689 If continuation sheet Page 3 of 3