Inspection·April 25, 2025

F 0602 Protect each resident from the wrongful use of the resident's belongings or money. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure the right to be free from misappropriation of property for 1 (Resident #1) of 8 residents reviewed for misappropriation of property. Residents Affected - Few The facility failed to prevent a diversion (misappropriation) of Resident #1's Tylenol #3 tablets (used to treat pain) for a total of 10 tablets. This failure could place residents at risk for decreased quality of life, misappropriation of property, increased/uncontrolled pain, and dignity. Findings include: Record review of Resident #1's clinical record revealed an [AGE] year-old female resident admitted to the facility originally on 09/25/2019 and readmitted on [DATE] with diagnoses to include malignant neoplasm of unspecified site of the right female breast (a fast-growing cancer of the breast that spreads to other areas of the body), polyneuropathy (a generalized term for peripheral nervous system disorders that impact nerve function in multiple areas of the body), osteoarthritis (a type of arthritis that occurs when flexible tissue at the ends of bones wears down), gout (a disease in which defective metabolism of uric acid causes arthritis, especially in the smaller bones of the feet, deposit of chalkstones (a chalky deposit of sedum urate sometimes occurring in the joints of person affected by gout), and episodes of acute pain, and restless leg syndrome (a nervous system problem that causes you to feel an unstoppable urge to get up and pace or walk). Record review of Resident #1's clinical record revealed her last MDS was a quarterly completed 04/08/2025 listing a BIMS score of 11 indicating she was moderately cognitively impaired, and she had a functionality of requiring set-up/clean up assistance for most of her activities of daily living. Resident #1 was listed as having pain Occasionally, that affected her sleep Occasionally, that interfered with therapy activities Occasionally, and interfered with her day-to-day activities Occasionally. Record review of Resident #1's Medication Administration Report with Schedule for April 2025 revealed the following order: - Acetaminophen-Codeine Oral Tablet 300-30 MG (Acetaminophen w/ Codeine) Give 1 tablet by mouth every 6 hours as needed for Pain -D/C Date- 04/24/2025. (Tylenol #3) Record review of Resident #1's clinical record revealed a care plan with the admission date of 06/27/2022, which revealed the following: (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: 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 04/25/2025 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)