Health inspection·October 19, 2023

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 interview and record review, the facility failed to maintain medical records that were complete and accurate on four of six residents (Residents #1, #2, #3, #4) reviewed for resident records. The facility failed to ensure the medical records for Residents #1, #2, #3, and #4 included physician orders and consents for placement in the facility's secure unit as specified in the facility's policy. This failure could place residents at risk of involuntary seclusion. Findings included: Review of Resident #1's undated admission Record revealed the resident was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included unspecified psychosis, depression, anxiety, and seizures. Review of Resident #1's quarterly MDS, dated [DATE] revealed a BIMS score was not calculated based on her medical condition. Her Functional Status revealed she required limited assistance with all of her ADLs. Review of Resident #1's care plan, dated 09/05/23, revealed she had impaired safety awareness requiring a secured unit, and a deficit in memory, judgement, and decision making related to brain deterioration. Review of Resident #1's Elopement Risk Assessment, completed on 09/04/23, revealed she had previous elopements while living at home and verbalized not wanting to be at the facility. Review of all of Resident #1's physician orders revealed she had no order to admit to a secured unit. Review of Resident #1's EHR revealed no consent for admitting her to a secured unit. Review of Resident #2's undated admission Record revealed the resident was an 83-yea-old female admitted to the facility on [DATE] with diagnoses that included dementia, chemical imbalance in the brain, depression, and anxiety. Review of Resident #2's admission MDS, dated [DATE], revealed a BIMS score was not calculated based (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: 676176 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 676176 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Crowley Nursing and Rehabilitation 920 E Fm 1187 Crowley, TX 76036 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)