Health inspection·January 8, 2026

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 observation, interview and record review, the facility failed to ensure the residents' environment remained free from accidents as was possible and each resident received adequate supervision and assistance devised to prevent accidents for 1 of 9 residents (Resident #1) reviewed for accidents, hazards and supervision.The facility failed to ensure Resident #1 did not elope from the facility when Resident #1 left the facility in the middle of the night, without anyone knowledge, and ended up 0.4 miles from the facility trying to obtain a hotel room for the night.The noncompliance was identified as PNC. The IJ began on 12/10/25 when Resident #1 eloped from the facility. The facility had corrected the noncompliance before the investigator entered the facility.This failure could place residents at risk of serious injury or serious harm and placed residents at risk of heat or cold exposure, dehydration and /or other medical complications, of being struck by a motor vehicle.Findings included: Record review of Resident #1's Face Sheet, undated, documented a [AGE] year-old male was admitted to the facility on [DATE] with the following diagnoses: metabolic encephalopathy (a brain dysfunction from a chemical imbalance due to an underlying illness, causing confusion, memory issues, personality changes, or coma), enterocolitis due to clostridium difficile (a serious bacterial infection causing diarrhea, abdominal pain, and fever, often triggered by antibiotic use disrupting gut flora), protein-calorie malnutrition (a serious condition from not getting enough protein and/or calories, leading to poor growth, weight loss, weakened immunity and increased infections), hypertension (high blood pressure), acute pulmonary edema (a life-threatening emergency where fluid rapidly fills the lungs air sacs, causing sever shortness of breath), acute kidney failure (kidneys rapidly stop filtering waste and balancing fluids which leads to toxic buildup in the blood), intestinal obstruction - unspecified as to partial or complete obstruction (blockage - partial or complete - in the small or large intestine, preventing food, liquid, gas and stool from passing through) and cognitive communication deficit (difficulty with communication due to impaired thinking or neurological conditions affecting memory, attention, problem-solving and social cues, making it hard to organize thoughts, follow conversations, or understand instructions). Record review of Resident #1's initial Care Plan, dated 12/5/25, revealed the following:The resident has an alteration in neurological status related to metabolic encephalopathy. Interventions: cueing, reorientation as needed, pain management as needed, PT, OT and St evaluate and treat as needed.The resident has impaired cognitive function/dementia or impaired thought processes. Interventions: administer medications as ordered, engage the resident in simple, structured activities that avoid overly demanding tasks, keep the resident's routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion, monitor/document/report to MD any changes in cognitive function, specifically changes in: decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness and mental status.The resident is at risk for falls. Page 1 of 5 676455 676455 01/08/2026 Five Points Nursing and Rehabilitation 1625 Point West Parkway Amarillo, TX 79124

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Interventions: have residents' call light within reach and encourage residents to use. Ensure that the resident is wearing appropriate footwear when ambulating or mobilizing.Record review of Resident #1's Care Plan, updated on 12/10/25 after elopement, revealed the following:At risk for elopement as evidenced by: resident left the facility. Goal: will remain safe within facility unless accompanied by staff or other authorized person through review date. Interventions: resident placed one on one until family picked him up, assess/record/report to MD risk factors for potential elopement such as: wandering, repeated requests to leave facility, statements such as I'm leaving I'm going home, attempts to leave facility, elopement attempts from previous facility, home or hospital, supervise closely and make regular compliance rounds whenever resident is in room, if the resident is exit seeking, stay with the resident and notify the charge nurse by calling out, sending another staff member, call system, etc.Record review of Resident #1's Medicare 5-day MDS resident assessment, dated 12/10/25, documented the resident scored 5 of 15 on a mini-mental exam for cognitive awareness and he was not capable of making informed decisions and he was independently ambulatory.Record review of Resident #1's nurses notes documented the following:12/10/25 at 2:08 a.m. A local policeman called and asked if we had Resident #1 as a resident, I informed him that we did, they stated he was at a local hotel trying to get a room. The police brought Resident #1 back, spoke with Resident #1 and got him to his room. Resident #1 stated that he was being held hostage, I explained he was on contact isolation due to infection. Resident #1 stated he didn't want to be here. Called and spoke with Resident #1's family member and voiced understanding to what had happened and stated the family member would come and get him so he would not be confined, and it would please him. LVN spoke with the Administrator and explained what was going on, 400 door not shutting or locking.12/10/25 at 2:10 a.m. Weekly Skin assessment: surgical incision present: yes, Location - 16 staples intact to center abdominal area, no redness, drainage or warmth noted.12/10/25 at 9:28 a.m. - Elopement Follow-up: currently: exit seeking, increase wandering, agitation, asking to leave or go elsewhere, 1 on 1 monitoring, patient to discharge by request.12/10/25 - Resident was interviewed at this time to determine resident can remain in facility, at this time, resident is one on one and wishes to go home with family member, Resident #1 states that he does not like being here because he must be isolated into his room. Family member is on their way from out of state and resident will discharge home with the family member. Currently, the resident is restless in room and remains one to one.12/10/25 at 10:38 a.m. - family member was here at this time to pick up resident, the family member understood that resident left facility last night and ended up in a hotel and was retuned by police. Family member was also given discharge instructions and medications. No further needs.12/10/25 at 12:44 p.m. - came in at 6:15 a.m. to sit with Resident, Resident was trying to leave the building. resident kept pacing from bed to bathroom to window, the resident kept wanting to leave. A family member picked resident up at 10:30 a.m. Record review of the Provider Investigation Report, dated 12/16/25, and filled out by the Administrator, reflected Resident #1 was last seen by staff at 12:20 a.m. during rounds. At approximately 1:10 a.m., the facility received a call from the local police department stating Resident #1 was at a local hotel approximately 0.4 miles away from the facility. It was 52 degrees outside, and Resident #1 was wearing a shirt, jeans, jacket and boots. Resident #1 stated he wanted to reserve a hotel room because he felt like a hostage at our facility because he was on contact isolation for C-diff. The local police department brought Resident #1 back to the facility, a skin assessment was conducted and there were no new injuries. Administrator arrived at facility and assessed all exit doors for function, initiated elopement in-service, interviewed staff, and verified Resident #1 was one on one. Resident noted to be asleep in his room. Staff posted at all exit doors until system cleaned by 676455 Page 2 of 5 676455 01/08/2026 Five Points Nursing and Rehabilitation 1625 Point West Parkway Amarillo, TX 79124

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few vendor. Staff reported that the door alarm did not function on hallway 400 and the door remained unlocked after several attempts to try to reset the lock. A nurse was able to get the door locked after a period of time. Maintenance checked all doors for proper function. Facility door vendor onsite to assess and repair doors that are malfunctioning. Resident #1 was discharged to a family member. Elopement in-service completed, elopement drills conducted per protocol, elopement assessments completed on all residents. Resident #1 had been in the facility for 5 days when the incident occurred. There was nothing in Resident #1 admission paperwork to indicate that he was an elopement risk. Record review of Resident #1's Weekly Skin Assessment, dated 12/10/25 at 2:10 a.m. documented the following:No bruises, skin tears, abrasions, lacerationsSurgical incision - yes Note Locations: 16 stables to center abdominal area - no redness, drainage or warmth noted. Record review of Resident #1's elopement evaluation sheet, dated 12/10/25 at 2:15 a.m., documented the following:Elopement:Note what door exited - 400 hallNote how long missing missing within 30 minutes, CNA had checked on him 30 minutes beforeWhere was the resident discovered - at a local hotelOther information related to the elopement - was trying to get a roomAny injuries NoCognition/Behavior at time of event - cognitive impairment, paces, exit seeking, restlessNursing description of the event - Local police department called and asked if we had Resident #1 residing in facility. Nurse informed him that we did, they stated he was at a local hotel trying to get a room. They brought Resident #1 back to the facility and spoke with Resident #1 when he got to his room. Resident #1 stated he was being held hostage. Nurse explained he was on contact due to infection. Resident stated he didn't want to be here.Resident statement related to event - I'm being held hostage, so I was getting a room.Interventions initiated by Nurse - 1 on 1 supervision During an interview on 1/7/26 at 11:16 p.m., LVN A stated he did take care of Resident #1 one night. LVN stated on 12/9/25, Resident #1 tried to elope on him, but he stopped him. LVN A stated he did not remember what Resident #1's BIMS score was but he seemed confused the night before he eloped (12/9/25) and kept saying he did not want to be in the nursing home and kept trying to get out the door at the end of the hallway. LVN A stated he remembered Resident #1 had some kind of abdominal surgery and he was at the facility for strength training. During a follow-up telephone interview on 1/8/26 at 12:00 p.m., LVN A stated he did not inform anyone of Resident #1's attempted elopement the night before because Resident #1 failed to get out of the facility so reporting it was not necessary. An observation on 1/7/26 at 11:31 p.m. of the route that Resident #1possibly took to a local hotel, was driven by the investigator. Reviewing the odometer, the hotel was approximately 0.4 miles away from the facility going straight down the road that was in front of the facility, to a four-lane divided highway at a busy intersection. During an interview on 1/8/26 at 8:20 a.m., the Administrator stated three nurses could not get that door to lock on the 400 hallway. The Administrator stated she had staff stand by each exit door and she stood at the nurses' station to monitor all the staff that she had stationed at the exit doors. The Administrator stated she called the facility door security vendor, the company that takes care of the locking systems and any issues with the doors. The Administrator stated the facility door security vendor got to the facility about 1:00 p.m. on 12/10/25 and that afternoon and the locks were fixed at that time. The Administrator stated she had reduced the time to 4 seconds so the locking mechanism will activate. The Administrator stated Resident #1 just did not want to be in the facility from the get-go. The Administrator stated they put signs up on all the exit doors on how to reset the alarm once the door was open more than 5 seconds. The Administrator stated she also put large red emergency only signs on all the exit doors. During an interview on 1/8/26 at 8:57 a.m., the ST stated she remembered trying to get a BIMS score on Resident #1, but he was so anxious and non-compliant and kept saying he did not want to be 676455 Page 3 of 5 676455 01/08/2026 Five Points Nursing and Rehabilitation 1625 Point West Parkway Amarillo, TX 79124

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few here. The ST stated on the first day, she could not finish the BIMs test as the interview went bad. The ST stated Resident #1 did not want to talk, he wanted to leave the facility. The ST stated that when she went to Resident #1's room on the second day, Resident #1 was fully dressed and had his boots on and told her that he was going home. The ST stated on the second day, Resident #1 answered a few questions, but she could not remember which ones. During an interview on 1/8/26 at 9:45 a.m., Resident #1's family member stated Resident #1's dementia was really getting bad, and he did not want to be in the facility. Resident #1's family member stated Resident #1 was declining mentally and had just lost his wallet and did not remember how to work his phone anymore. Resident #1's family member stated they had been trying to get POA or Guardianship or something so they could be of help to Resident #1. Resident #1's family member stated Resident #1 wants to live on his own, but something needed to be done to ensure his safety. Resident #1's family member stated staff gave Resident #1 a BIMS test the morning after he eloped, and he did not do very good as he was very confused. Resident #1's family member stated Resident #1 told him that he was on isolation and not allowed to leave his room and he was really upset about it and just wanted to leave. During an interview on 1/8/26 at 12:30 p.m., the Maintenance Supervisor stated the lock on the 400 door was working the day before the elopement. The Maintenance Supervisor stated he checks the locks daily at 9:00 a.m., Monday through Friday. The Maintenance Supervisor stated he had never had any trouble with the lock on the 400 hallway not working. The Maintenance Supervisor provided a check list of items that are checked daily on each door. On 1/8/26 at 1:55 p.m., the door on 400 hallway was checked and it was in proper working order and locked, with a large red sign that read, Emergency Exit Only.Record review of the checklist titled: Door, Locks and Alarms: Test operation of doors and locks, dated 1/1/26, revealed the following:Check operation of magnetic door locks:Inspect door lock mounting and operation and inspect panic hardwareVerify system code and keypad operations.Any magnetically locked doors must automatically unlock during a fire alarm (verify this during you normal fire drill)Check any advanced features (optional equipment)Check patient transmitter to make sure the door stays locked and alarm sounds.Check delayed egress operation.Push door release hard for a fraction of a second- door should not open and alarm should not sound.Apply pressure to the door release for the pre-determined nuisance period setting (normally 1 - 3 seconds)Door should go into irreversible unlocking sequence - door alarm will sound; door will automatically open within 15 to 3- seconds.Close door and reset the alarm.Ensure signs are placed on doors adjacent to the release device that read, ‘Keep pushing. Door will unlock after 15 seconds.'Test doors and hardware for proper operation and condition.Check door for proper seal when closed so that no air gaps exist between smoke or fire barrier doors.Confirm all door labels are clearly visible for inspection and are readily legible.Document results of inspection in Comments and note any discrepancies. Record review on 1/8/26 at 12:50 p.m. of Maintenance Logs from 11/3/25 to present revealed the door locks and alarms were checked Monday through Friday consistently. Record review on 1/8/26 at 1:25 p.m. of an elopement drill, conducted on 11/28/25 prior to Resident #1's elopement, was started at 9:00 p.m. and ended at 9:30 p.m. Performance Rating for the drill was good. Actions: Called a code orange, identified resident and room number and time last seen. Verify resident is not signed out. Notify Administrator, DON, family and compliance nurse, provide information regarding resident to search teams, if resident is not found in 30 minutes or less - contact police. Time resident was found, post event documentation review: nurses notes, elopement risk assessment, follow-up elopement nurses notes every shift for 72 hours, care plan updated. Record review of the work order/receipt, dated 12/11/25, from the door security vendor revealed he reworked the front door mag lock wires and reinstalled the strike place. We were able to replace a timer at the 676455 Page 4 of 5 676455 01/08/2026 Five Points Nursing and Rehabilitation 1625 Point West Parkway Amarillo, TX 79124

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few rear and a keypad for the front doors. We also had to rework the timers to have a pot alarm at the door that was triggered. Record review of the Missing Resident/Elopement Monitoring documentation from 12/10/25 to present. All areas were checked on a daily basis since the elopement of Resident #1.Does the locking mechanism or alarm function properly on all exit doors of the facility? If no, describe corrective action on the back of this form.Conduct at least 3 elopement drills per week. 1 drill between 6am to 2 pm, 1 drill between 2 pm to 10 pm, and 1 drill between 10 pm to 6 am. Did staff respond appropriately? Yes or no. If no, note corrective action on the back of this form.Through daily rounds and duties at least 5 days per week, observe for visitors allowing residents to exit the facility unsupervised. In compliance? Yes or no.Has the door code been changed for this month? Yes or no; if no, state corrective action taken below. Record review for the In-Service Training Report, dated 12/10/25 and titled, Elopement Response and Prevention Code Orange revealed the following:In case of a missing resident:Report to charge nurse immediately.Determine if resident is on authorized leave.Search the building and grounds including bathrooms, closets, etc.Notify Administrator and DON, responsible party, and physician.If not found in 30 minutes, report to the police, update responsible party.Upon return, the resident is to be assessed for injuries, physician notified of condition, and responsible party, appropriate staff, and police notified.Incident is to be documented in medical records.Elopement Prevention:Why is the resident wandering/exit seeking?Notify your charge nurse immediately when a resident is exit seeking.Do not leave the resident unattended until a resolution has been determined.Ask - does the resident need to use the bathroom, is he/she hungry, experiencing discomfort, boredom, wants to ambulate? Is the temperature uncomfortable?Is there an infection or is it worsening? Medication side effects? Increased confusion due to an underlying issue?Is the resident trying to find his/her room, bathroom, dining room, etc?Once a cause for wandering/exit seeking is identified, redirect the resident by providing ADL care, following new physician orders, decreasing sensory stimulation, providing the resident with familiar items, etc.Notify the on-call nurse of exit seeking behavior.When a door alarm sounds, staff must investigate and ensure all residents are accounted for. Do not silence the alarm without ensuring residents are safe.If the door releases after 15 seconds, the code must be entered to reset the door lock.The Elopement Binder (white binder) is located at the nurse's station with the Emergency Plan (red binder).This in-service was signed by 103 staff members. This failure was identified as past noncompliance IJ as the facility had instituted adequate corrective measure to prevent recurrence of the non-compliance. The facility had all doors and locking systems checked and repaired or replaced as needed, put up signs on all exit doors were to be used for emergency only, all staff were in-serviced on elopement and drills, and the facility held elopement drills three times a week with drills on three different shifts per week, with the last drill being conducted on 1/1/26. In addition, monitoring of visitors and staff were being conducted on a daily basis since 12/11/25, to ensure no one was allowing residents to exit the facility unsupervised. 676455 Page 5 of 5