Health inspection·February 17, 2023

F 0656 -was able to understand, Level of Harm - Minimal harm or potential for actual harm -was cognitively independent, -extensive assist for bed mobility, transfers, personal hygiene, Residents Affected - Few -trouble falling or staying asleep or sleeping to much nearly every day. Record review of Resident #10's care plan dated 02/01/23 did not reveal a care plan for the hypnotic Ambien 5 mg to give 1 tablet by mouth at bedtime. On 02/14/23 at 9:18 AM Resident #10 was observed sitting at the edge of the bed, wearing a pink house dress, hair was nicely combed and was wearing red lipstick. Resident had had her nails done. In an interview on 02/16/23 at 11:50 AM LVN/MDS F said she reviewed Resident #10's care plan for the Ambien medication. LVN/MDS F said she could not find the care plan for the Ambien. LVN/MDS said the Ambien should have been care planned because Resident #10 started on the medication on 01/19/23. LVN/MDS said the nursing department, the nurses, ADONs and MDS are responsible for developing the care plan and they have 7 days to complete it. LVN/MDS F said any changes or new orders are reviewed during the morning meeting with the nursing department, Medical Records clerk, Social Worker, and the therapy department. LVN/MDS F said she did not know why the care plan was not developed but it should have been done. LVN/MDS said the negative outcome for Resident #10 would be a risk for falls due to the hypnotic. In an interview on 02/16/23 at 1:22 PM CNA G said Resident #10 was alert and oriented. Resident #10 required extensive assistance for her ADLs and was totally dependent on staff for dressing. Once Resident #10 was in her wheelchair she could go on her own. CNA G said Resident #10 would complain that she was unable to sleep, and CNA would ask if Resident #10 had received her medication and Resident #10 would say that she had. CNA G said they would review the care plan to check what type of care a new resident requires or if there are any changes for a resident that was already there. In an interview on 02/16/23 at 1:30 PM Resident #10 said she still took medication to help her sleep. Resident #10 said she was given the medication every night, but it took a while for her to fall asleep. Resident #10 said she was unable to sleep without the medication because every little noise would wake her. Resident #10 said some of the male residents would sit at the end of the hall in the sitting area to talk. Resident #10 said she felt as if they were in the room with her and would be unable to sleep. Resident #10 said with the medication she was able to sleep all night. In an interview on 02/16/23 at 1:38 PM LVN H said the MDS nurses would come daily and ask the nurses if there were any changes in resident condition and the MDS nurses would also assess the residents that had changes to their orders to develop/revise their care plan. LVN H said the charge nurse would then review the care plans in the system. LVN H said anything new will be on report and the nurses need to review it every shift. The nurse should also document on the computer any changes in orders for residents. LVN H said they must document everything so the staff on other shifts could know what type of care to provide and the MDS team to know they should update the care plan. In an interview on 02/16/23 at 01:58 PM The DON said once they get an order from the physician and the assessment of the resident is completed, the MDS Case Manager should develop the care plan. The DON said it should be between 48-72 hours because of obtaining the consent from the responsible (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455822 If continuation sheet Page 2 of 7 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 455822 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Nursing and Rehabilitation Center of Harli 820 Camelot Dr Harlingen, TX 78550 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 0656 Level of Harm - Minimal harm or potential for actual harm party. The licensed nurses and the social worker would initiate the process for the care plan. The MDS nurses are responsible for developing the care plans. DON said she does not know how the medication was overlooked by the team. The MDS team is the last in the process. DON said the negative outcome for Resident #10 would be minimal because the team reviews the side effects and staff know to observe for side effects because it would be in the orders. Residents Affected - Few 2. Record review of Resident # 317's admission record dated 02/02/23 documented a [AGE] year-old male with an admission date of 02/02/23. Resident #317's diagnoses include: malignant neoplasm (cancer) of bladder, liver transplant status, obstructive and reflux uropathy (blockage in your urinary tract), major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest), primary generalized osteoarthritis (degenerative joint disease). Record review of resident # 317's active physician orders dated 02/14/23 documented an order for an antibiotic named Levaquin (Levofloxacin) Oral Tablet 500 milligram, give 1 tablet by mouth one time a day every other day for diagnosis urinary tract infection. Order for antibiotic entered 02/08/23 with a start date 02/09/23 and end date 02/19/23. Record review of resident # 317 MDS dated [DATE] documented a BIMS score of 14 which indicated the resident was cognitively intact. Record review of Resident # 317s care plan with an admission date 02/02/23 and an initiated date 02/03/23 failed to mention antibiotic care plan, goals, or interventions. An interview with the MDS Case Management Specialist/RN on 02/16/23 at 08:50 a.m. revealed Resident # 317's care plan for the antibiotic Levaquin should have been initiated on 02/09/23 by the nurse entering the order. MDS Case Management Specialist/RN reviewed Resident 317's record and acknowledged care plan had not been initiated. She mentioned that if the nurse entering the order failed to enter the care plan, the MDS Case Management Specialist or the DON would initiate the care plan. She further mentioned that care plans must be initiated within 48-72 hours, then the care plans are locked. She also mentioned that MDS Case Management Specialist has 7 days to complete resident's care plans. MDS Case Management Specialist stated that resident care plans are reviewed for accuracy daily during morning meetings and if there are changes of condition. An interview with CNA A on 02/16/ 23 at 01:25 p.m. revealed she had been caring for Resident # 317 less than 1 month. She stated she used care plans to care for Resident #317 as a way of communication between nurse's and CNA's. She stated care plans explain how to take care of residents, for example it describes how to assist a resident to use the restroom or with the resident's food. She stated she accesses care plans through a computer or asks the nurse for help in accessing the care plan. An interview with LVN A 02/16/23 at 01:30 p.m. stated though she mainly uses verbal communication between CNA's and nurses to care for resident's, nurse's do use the interventions and goals in care plans. She stated she accessed care plans through the computer via social worker progress notes or MDS notes. An interview with LVN/ADON 02/16/23 at 01:25 p.m. revealed nurses used shift report for communicating resident's care between nurses. She stated nurse's do check care plans once a day and follow through with goals and interventions detailed in care plans. LVN/ADON mentioned nurses and bed side nurses were responsible for initiating care plans upon admission and followed up by the DON/MDS Case Management Specialist who will review the baseline care plan. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455822 If continuation sheet Page 3 of 7 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 455822 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Nursing and Rehabilitation Center of Harli 820 Camelot Dr Harlingen, TX 78550 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few An interview with the DON 02/16/23 at 02:00 p.m. revealed care plans were developed after a nurse obtains an order. She stated licensed nurses or MDS nurses are responsible for initiating care plans and the MDS does the last check for the care plan. DON stated the nurse will initiate the corresponding care plan with the target problem after the nurse has done an assessment. DON stated the nurse has 48-72 hours to initiate a care plan so that the rest of the team member can have access to the care plan. The DON stated care plans are reviewed daily during team meetings and on a weekly basis. She further mentioned that for Resident # 317, the care plan should have been initiated already. She was not sure why the care plan had not been initiated or why how it had been missed. The DON mentioned the MDS had done the last comprehensive review on the care plan, but that it was a team effort to make sure the care plans were initiated. She stated, myself included, I am just as responsible. The DON stated regarding the negative outcome to the resident if the care plan is not developed, initiated or implemented, the risk assessment is minimal, side effects and potential for side effects is put in the order. An interview with LVN B on 02/17/23 at 09:30 a.m. revealed care plans are important for resident care. He stated they state goals and objectives. He also mentioned the RN initiated care plans and if care plans are not initiated in a timely manner, improvement may not be observed in residents. Record review of facility's Policy on Care Plan Revisions Upon Status Change dated 10/24/22 quoted in part: The purpose of this procedure is to provide a consistent process for reviewing and revising the care plan for those residents experiencing a status change. Policy Explanation and Compliance Guidelines: .the comprehensive care plan will be reviewed, and revised as necessary . procedure for reviewing and revising the care plan when a resident experiences a status change: the MDS Coordinator and the Interdisciplinary Team will discuss the Resident Condition and collaborate on intervention options .the care plan will be updated with the new or modified interventions .staff involved in the care of the resident will report resident response to new or modified interventions .care plans will be modified as needed by the MDS Coordinator or other designated staff member . the unit manager or other designated staff member will communicate care plan interventions to all staff involved in the resident's care . the unit manager or other designated staff member will conduct an audit on all residents experiencing a change in status, at the time the change in status is identified, to ensure care plans have been updated to reflect current resident need. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455822 If continuation sheet Page 4 of 7 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 455822 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Nursing and Rehabilitation Center of Harli 820 Camelot Dr Harlingen, TX 78550 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** FACILITY Infection Control Residents Affected - Few Based on observation, interview, and record review, the facility failed to maintain an Infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 1 of 4 residents (Resident # 87) reviewed for infection control, in that: 1. The facility failed to ensure LVN H followed proper hand hygiene before and after wound care of Resident # 87. LVN H failed to wash her hands for at least 20 seconds per facility policy. These deficient practices could place this and other residents at risk for infection. The findings include: Record review of Resident # 87's admission record dated 02/15/23 documented a [AGE] year-old female with an admission date of 12/23/22. Primary diagnosis include pressure ulcer of sacral region, stage 4, Muscle wasting and atrophy (shrinkage and weaking of the muscles), cognitive communication deficit (difficulty in communicating), low back pain, atherosclerotic heart disease of native coronary artery with unspecified angina pectoris (hardening of the heart's arteries with chest pain), essential (primary) hypertension (high blood pressure), hyperlipidemia (high lipid levels in the bloodstream). Record review of resident # 87's active physician orders dated 02/15/23 documented an order for: wound vac change to sacrum M (Monday), W (Wednesday), F (Friday) every day (sic) shift for wound healing. Cleanse with NS (normal saline), pat dry, apply foam to wound bed, apply suction pad and wound vac at 125 mm (millimeters of mercury)/Hg (high) every day shift every Mon (Monday), Wed (Wednesday), Fri (Friday) for stage 4 sacrum. Record review of Resident # 87's most recent MDS, dated [DATE] revealed the resident had a BIMS score of 13, indicating her cognitive status was intact. The MDS also revealed Resident # 87 either required substantial or maximal assistance for all the functional abilities and goals or the task was not attempted due to medical condition or safety concerns. Record review of Resident # 87 care plan initiated 12/26/22 documented: o The resident [# 87] had SKIN INTEGRITY: The resident is at risk for impaired skin integrity r/t (related to) fungal rash to abdominal folds with interventions: administer medications as ordered to address medical diagnosis/ conditions; monitor for effectiveness and adverse side effects, CNAs to monitor skin daily during care and report any signs of skin breakdown to licensed nurse and conduct skin inspections/examinations weekly as needed. Document findings. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455822 If continuation sheet Page 5 of 7 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 455822 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Nursing and Rehabilitation Center of Harli 820 Camelot Dr Harlingen, TX 78550 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 0880 o Level of Harm - Minimal harm or potential for actual harm The resident [# 87] had Stage IV pressure ulcer to sacral area or potential for pressure ulcer development r/t (related to) poor nutritional intake with interventions: Administer treatments as ordered and monitor for effectiveness . Assess/record/monitor wound healing weekly. Measure length, width, and depth where possible. Assess and document status of wound perimeter, wound bed, and healing process. Report improvements and declines to the MD .Monitor dressing Q (each) shift to ensure it is intact and adhering .report lose dressing to treatment nurse. Residents Affected - Few o The resident [# 87] had actual impairment to skin integrity of the sacrum r/t (related to) Stage IV decubitus ulcer with interventions: Monitor/document location, size, and treatment of skin injury. Report abnormalities, failure to heal, s/sx (signs and symptoms) of infection, maceration etc. to MD (Medical Doctor). Observation on 02/15/23 at 11: 15 a.m. of Resident # 87's wound care procedure, LVN H briefly set up for the procedure, gathered supplies and explained the procedure to the resident. Prior to beginning the procedure, Surveyor B timed LVN H while she washed her hands, only measuring 5 seconds on the clock. After the wound care procedure was over LVN H removed her soiled gloves and Surveyor B timed LVN H a second time while she washed her hands. LVN H washed her hands only 13 seconds on the clock before exiting the room the second time she was measured on the clock. In an interview with LVN H on 02/15/23 at 11:35 a.m., LVN H responded 20 seconds was the recommended time for hand washing prior to and after any patient care or procedure. She responded she was unsure if she had washed her hands for the recommended time, as she was not counting. LVN H responded that the greatest consequence of not performing proper hand hygiene on a resident would be infection to the resident. LVN H said that she had done this wound care many times and did not feel nervous or rushed by being observed and would not have forgotten to have counted for the recommended 20 seconds. She stated she must have counted too fast. LVN H responded she is aware she must wash hands before doing a procedure and before leaving the room. In an interview on 02/15/23 at 11:35 a.m., LVN/ADON responded 20 seconds was the recommended time for hand washing prior to and after any patient care or procedures. LVN/ADON mentioned the greatest consequence of improper hand hygiene to the resident would be infection. LVN/ADON mentioned she was not counting or watching LVN H as she washed her hands. LVN/ADON stated nurses get trained upon hire and spot checked for hand hygiene skills if needed. In an interview on 02/15/23 at 01:10 p.m., DON responded it was recommended to perform hand hygiene prior to and after any procedures or patient care. The DON mentioned it was recommended to use alcohol-based hand rub or to wash hands for 20 seconds if hands were visibly soiled. She responded it was best practice to wash hands for 20 seconds as recommended by their policy before and after wound care to prevent infection. After informing the administrator of the findings on 02/17/23 at 04:00 p.m., the administrator stated, we are just going to have to learn to how to sing the happy birthday song longer to meet the hand hygiene recommended time. Record review of facility policy and practices titled Hand Hygiene with an implemented date (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455822 If continuation sheet Page 6 of 7 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 455822 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Nursing and Rehabilitation Center of Harli 820 Camelot Dr Harlingen, TX 78550 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete 10/24/22, quoted in part, All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility . Hand hygiene technique when using soap and water: rub hands together vigorously for at least 20 seconds, covering all surfaces of the hands and fingers. Record review of Lippincott procedures, 2022, Hand Hygiene (Lippincott procedures - Hand hygiene (lww.com) quoted in part, Work up a generous lather by vigorously rubbing your hands together . for at least 20 seconds. Event ID: Facility ID: 455822 If continuation sheet Page 7 of 7