Health inspection·May 15, 2025

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few 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 observations, interviews, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible and each received adequate supervision to prevent accidents for 1 of 9 residents (Resident #1) reviewed for accidents and supervision. The facility failed to supervise Resident #1 who eloped from the facility on 03/30/2025 when he exited through an unlocked sliding door at the end of hallway 200 and was found outside in the driveway. The non-compliance was identified as PNC. The Immediate Jeopardy (IJ) began on 03/30/2025 and ended on 04/28/25. The facility had corrected the non-compliance before the survey began on 05/13/2025. This deficient practice could place residents at risk of harm, serious injury, or death. The findings included: Record review of Resident #1's face sheet revealed the resident had diagnoses including unspecified Parkinsonism (a neurological condition that effect movement), Dementia (decline in cognitive abilities),Osteoarthritis (a joint disease resulting in breakdown of bone cartilage), Dystonia (movement disorder), Dysphagia (difficulty swallowing), Psychosis (a condition that causes disassociation from reality), Major Depression Disorder. Record review of Resident #1's Quarterly MDS assessment, dated 3/17/25, revealed Resident #1 had a BIMS score of 3, indicating severe cognitive impairment. Further review of MDS assessment did not indicate a history of wandering behavior. Record review of Resident #1's Care plan revealed resident had no prior history of elopement and the Care Plan was updated on 3/30/25 to reflect actual elopement and as risk for elopement with interventions of providing structured activities, distraction with diversions to include food, conversation, television, books, determine need for exercise, compliance rounds and supervision. Resident required no special supervision prior to this elopement. Record review of Form 3613-A Self-Report Incident, dated 4/4/25, revealed facility identified and reported an elopement incident that occurred when Resident #1 eloped from the facility on 3/30/25 at 4:00 p.m. in accordance with state guidelines and completed internal investigation, in-services and monitoring. Further review revealed Resident #1 was found outside the facility near the laundry room by another resident who then brought Resident #1 to the 200 Hall door and informed staff. (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: 676242 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 676242 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ganado Nursing and Rehabilitation Center 107 E Rogers Ganado, TX 77962 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)