F 0580
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room,
etc.) that affect the resident.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility failed to immediately notify a resident's representative when there
was a significant change in the resident's physical, mental, or psychosocial status for 1 of 5 residents
(Resident #1) reviewed for notification of changes in that:
The facility failed to ensure Resident #1's RP (Family Member A) was notified when Resident #1 had a
change in her condition on 06/12/24.
This deficient practice could place residents at risk of not having their family or legal representative notified
when having a change of condition.
The findings were:
Record review of Resident #1's admission Record [face sheet], dated 06/24/24 revealed she was admitted
to the facility on [DATE], readmitted on [DATE] with diagnoses which included unspecified dementia
(general decline in cognitive abilities that affect a person's ability to perform everyday tasks), schizoaffective
disorder (mental disorder characterized by abnormal thought processes and an unstable mood), and high
blood pressure; and her RP was Family Member A.
Record review of Resident #1's electronic physician orders revealed an order dated 05/14/2024 to admit
Resident #1 to Hospice B with diagnoses of Alzheimer's Disease (common type of dementia that results in
gradual decline in memory, thinking, behavior and social skills) and to notify Hospice B with any falls or
change in condition.
Record review of Resident #1's MDS, a Significant Change assessment, dated 05/17/24 revealed her
cognitive skills for daily decision making were severely impaired and she received Hospice Services.
Record review of Resident #1's care plan for Resident #1 was on services of hospice with Hospice B due to
terminal illness, with a start date of 05/20/24 revealed under interventions was Monitor for decreased
appetite, weight loss, skin break down, nausea/vomiting .report to hospice.
Record review of Resident #1's nurse's note, dated 06/12/24 at 17:32 (5:32 PM) by LVN C revealed CNA
got patient up in chair she was very lethargic, vitals taken unable to get BP [blood pressure] oxygen level
was 68% [normal is 94-100%] on room air. CNA placed patient in bed [sic] noted patient respirations are 16
applied oxygen and saturation level is 77% [normal is 94-100%] on 3L [liters] of oxygen. Called Hospice B
to tell them change of condition and needed nurse visit. The note did not indicate RP Family Member A was
notified of Resident #1's change of condition.
(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:
455533
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
455533
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/24/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Windcrest Nursing and Rehabilitation
8800 Fourwinds Dr
Windcrest, TX 78239
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 0580
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
In a telephone interview on 06/24/24 at 01:02 p.m., Resident #1's RP Family Member A stated she was not
contacted on 06/12/24 by the facility to inform her Resident #1 was unresponsive and she found out on
06/13/24, a day later Resident #1's condition had declined, when the hospice chaplain called her.
In a telephone interview on 06/24/24 at 10:33 a.m., LVN C stated she called Hospice B when Resident #1
had a change in her condition on 06/12/24 but did not call Resident #1' RP Family Member A because it
was up to hospice to notify the resident's family.
In an interview on 06/24/24 at 11:22 a.m., the DON stated the nurses should notify the resident's
responsible party immediately with any change of condition. The DON reviewed Resident #1's nurses note
on 06/12/24 stated the notes indicated the resident was lethargic, hospice had been contacted, and there
was no documentation the resident's RP had been notified; and the RP should had been notified. The DON
stated LVN C said it was hospice's responsibility to contact the family was the reason why she did not
contact Resident #1's RP. The DON said the nurses should contact the family even though hospice said
they would because it was the facility's obligation to contact the family as well. The DON stated the harm of
not notifying the resident's RP could cause the RP emotional distress if they were not aware there was a
change in their loved one's condition and they came to the facility and found the resident transitioning to the
end of life, that could be devastating to them.
In an interview on 06/24/24 at 12:10 p.m., the Administrator stated a resident's RP would be notified when
there was a change in their condition and not being notified could cause the RP to have distress or
emotional distraught or cause them to have a lack of trust in the facility. The Administrator stated she
thought this failure occurred because the nurse thought hospice would notify the family.
Record review of the facility's policy Change in a Resident's Condition or Status, revised February 2021),
revealed Our community promptly notifies the resident, his or her attending physician, and the resident
representative of changes in the resident's medical/mental condition .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
455533
If continuation sheet
Page 2 of 2
