Health inspection·February 17, 2025

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and records review, the facility failed to ensure that medical records were accurately documented for three (3) of eight (8) residents (Resident #1, Resident #2, Resident #3) reviewed for accurate clinical records, in that: The facility failed to ensure Resident #1, Resident #2, and Resident #3's EMRs contained orders upon admission with corresponding clinical criteria to admit them to the secure unit. This deficient practice could result in errors in care and treatment and violate resident rights. Findings included: Resident #1 Review of Resident #1's face sheet dated 2/17/2025, reflected an [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included: Alzheimer's Disease (a progressive disease that destroys memory), Dementia (a group of conditions characterized by impairment of at least two brain functions), Hypertension (high blood pressure), Benign Prostatic Hyperplasia (enlargement of the prostate gland) and history of Colorectal cancer (cancer of the colon and rectum.) Review of Resident #1's admission MDS dated [DATE], reflected a BIMS of 0 (zero) suggesting severe cognitive impairment. Review of MDS Section E on behaviors reflected resident had rejected care and had wandering behaviors in the last 1 to 3 days. Further, behaviors reflected Resident #1's wandering placed him at risk of potential harm and intruded on the privacy of others, *Review of Resident #'1s undated care plan reflected the problem: Resident resides in the Secure Care Unit, related to diagnosis of dementia and Alzheimer's Disease and risk for elopement. Intervention included Admit to SecureCare unit per MD orders. Review of Resident #1's orders dated 2/16/2025 reflected the following order: May admit to the secure unit. Review of Resident #1's EMR orders from 1/31/2025 to 2/15/2025 revealed there were no clinical criteria/problems referenced for the resident's admission to the secured unit. Resident #2 (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 3 Event ID: 675821 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 675821 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/17/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Madisonville Care Center 411 E Collard Madisonville, TX 77864 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)