Edinburg Nursing And Rehabilitation Center

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

police officer said he was going to contact the facility to verify Resident #1 was a resident at the facility and take the resident back. During an interview on 12/30/2025 at 8:50 a.m. the DON stated she did not notify

the Administrator that Resident #1 was brought back to the facility by a police officer. The DON stated the Administrator was out on vacation and did not want to bother her. The DON stated that since Resident #1 was returned safe and with no injuries, she felt there was no need to notify the Administrator. During an

interview on 01/01/2026 at 3:00 p.m., the Administrator stated that on 11/17/2025, she was not notified Resident #1 had been returned to the facility for being lost. The Administrator stated it was not until days later that the DON mentioned the incident. The Administrator stated she felt she did not report the incident to HHSC for the same reasons the DON did not notify her; Resident #1 had returned to the facility safely.

The Administrator said that on 12/06/2025, the HRC notified her that the resident had left the building in his own vehicle. The Administrator initiated a code purple, the code used to notify staff there was a resident missing. The Administrator said that at 6:45 p.m., she received a call from a nearby nursing facility reporting

they had Resident #1. The nearby facility was approximately 0.6 miles away. The Administrator said she sent three staff members to bring Resident #1 back to the facility. One of the three staff members drove Resident's truck back to the facility. The Administrator stated that Resident #1 had arrived at that other facility because he was confused as to which facility he was a resident of. The Administrator stated that Resident #1's RP had his truck picked up after the incident. The administrator stated that it was best that Resident #1 did not have a vehicle on premises because Resident #1 could hurt himself or others while driving. Resident #1 could become confused and cause an accident. Record review of TULIP (Texas Unified Licensure Information Portal) did not reflect a facility reported incident that corresponded to the allegations in the incident described above. TULIP is a web-based program used by facilities to report incidents involving residents. HHSC then takes that information and performs an investigation into those incidents reported. Record review of facility policy titled, Abuse, Neglect, and Exploitation dated 8/15/22, revealed:VII. Reporting/Response1. Reporting all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes:b. Not later 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury.

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Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

01/01/2026

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Edinburg Nursing and Rehabilitation Center

5215 S Sugar Rd Edinburg, TX 78539

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)

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

K, LVN Q, LVN R, LVN S, LVN U, Social Worker, and Human Resource Coordinator revealed the staff were all knowledgeable of the out on pass protocol and elopement protocol. The CNAs interviewed stated they were to report to their nurse immediately if and when a resident voiced, they wanted to go out on pass. The nurses interviewed stated they would verify that the family member that signed out the resident was approved to sign the resident out. They were aware and voiced understanding of the new expectations to verify all residents were signed out through the nurse's station and ensure all residents were signed back in. During an interview via telephone on 01/01/2026 at 4:02 p.m., the DA was able to verbalize understanding of the following in services received: Out on Pass Protocol and Elopement Protocol and Receptionist Competency-Front Door Safety and Resident Sign-Out Verification.

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