Inspection·October 26, 2023

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 observation, interview and record review, the facility failed to maintain and accurately document medical records on 1 (Resident #1) of 3 residents housed in the secure unit of the facility. The facility obtained a physician's order but failed to put the order in Resident #1's chart. This failure could place residents at risk of receiving care that is substandard, unable to meet their needs, and inaccurate medical records. Findings Included: Record review of Resident #1's face sheet, dated 10/26/23, revealed an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1's diagnoses included but are not limited to unspecified dementia, major depressive disorder, blindness in left eye, and polyneuropathy (damage or disease affecting peripheral nerves). Record review of Resident #1's MDS, dated [DATE], indicated a BIMS score of 05 indicating severe cognitive impairment. Resident #1 MDS, section E-Behavior revealed no prior behaviors. Record review of Resident #1's care plan, dated 9/13/23 with a revision on 10/23/23, revealed a focus of resident resides in the Secure Care Unit, related to diagnosis of dementia and risk for elopement. Interventions/Tasks indicated: Admit to Secure Care unit per MD orders. Record review of Resident #1's physician orders, dated 10/11/23, revealed no physician order for admit into the secure unit. Record review of Resident #1's progress notes, dated 10/21/23, unknown author, that Resident #1 was attempting to leave the facility. Per DON, the resident was to be moved to room [ROOM NUMBER]. Observation and interview on 10/26/23 at 10:56 AM revealed room [ROOM NUMBER] was in the locked unit on hall 2. Observed Resident #1 lying in bed with strong urine odor. Resident was unable to recall incident. When asked if someone pinched another resident, Resident #1 stated, I would more than likely hit them or slap them. I don't pinch. Observed Resident is oriented to person. Resident #1 did have an instance of asking for surveyor's name again. An interview on 10/26/23 at 2:39 PM with DON revealed the resident was an elopement risk and she had attempted to elope two times. DON stated when the on-call provider was notified, the provider (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 2 Event ID: 676341 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 676341 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Caprock Nursing & Rehabilitation 900 College Ave Borger, TX 79007 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)