Health inspection·June 12, 2025

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to develop a baseline care plan within 48 hours of a resident's admission that included the instructions needed to provide effective and person-centered care of 1 (Resident #123) of 6 residents reviewed for baseline care plan completion. The facility failed to complete the advance directive section in the baseline care plan dated [DATE] for Resident #123 within the required 48-hour timeframe when the physician order was dated [DATE]. This deficient practice could place the residents at risk of not having their end of life wishes honored, such as receiving unwanted resuscitative measures. Findings included: Record review of Resident #123's OOH-DNR dated [DATE] was not completed with the physician's signature. Record review of Resident #123's baseline care plan dated [DATE], revealed: FOCUS: o Resident is a full code Date Initiated: [DATE] GOALS: o Facility will comply with resident/family wishes Date Initiated: [DATE] Revision on: [DATE] Target Date: [DATE] INTERVENTIONS/TASKS: o If resident has a cardiac arrest, initiate CPR ad call 911. Notify MD/RP and follow MD orders after notification. Date Initiated: [DATE] LN o Keep emergency cart well supplied and ready for use at all times Date Initiated: [DATE] LN. Record review of Resident #123's physician order dated [DATE], revealed an order for DNR (Do Not Resuscitate). Record review of Resident #123's electronic admission Record dated [DATE] reflected he was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included Type 2 Diabetes Mellitus (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), and dementia (a group of thinking and social symptoms that interferes with daily functioning). Record review of Resident #123's Quarterly MDS dated [DATE] revealed he had a BIMS score of 05, Page 1 of 10 455822 455822 06/12/2025 Windsor Nursing and Rehabilitation Center of Harli 820 Camelot Dr Harlingen, TX 78550

F 0655 indicating Resident #123's cognition was severely impaired. Level of Harm - Minimal harm or potential for actual harm Record review of Progress Notes dated [DATE] revealed Resident #123 Resident #123 was discharged to the hospital on [DATE] related to a fall with right side head trauma. Residents Affected - Few In an interview on [DATE] at 03:06 PM LVN A stated the ADONs update the Care Plans. LVN A stated code status would be in the report before the resident arrived for admission so it could be input code status in the computer during admission. In an interview on [DATE] at 03:46 PM LVN B stated when a resident was admitted the code status was immediately put in the computer. She said code status was reported before resident arrived. She said the code status was given by the hospital. LVN B stated the care plan was put in by the nurses. In an interview on [DATE] at 04:09 PM ADON C stated the admitting nurse would be the one who added the code status on admission. In an interview on [DATE] at 04:25 PM the DON stated the admitting nurse was responsible for putting a resident's code status in the computer. The DON stated the admitting nurse or Social Services would put the code status in PCC (electronic resident chart) Care Plan whether the code status was full code or DNR. Record Review of the facility policy subject titled, Baseline Care Plan date implemented [DATE], revealed policy statement The facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. Policy Explanation and Compliance Guidelines: a. The baseline care plan will: a. Be developed within 48 hours of a resident admission. b. Include the minimal healthcare information necessary to properly care for a resident including, but not limited to: ii. Physician's orders 455822 Page 2 of 10 455822 06/12/2025 Windsor Nursing and Rehabilitation Center of Harli 820 Camelot Dr Harlingen, TX 78550

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that residents who needed respiratory care were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 2 of 3 (Resident #63, Resident #345) residents reviewed for respiratory care. Residents Affected - Few 1. The facility failed to ensure Resident #63's oxygen was administered at the correct setting of 3 liters per minute on 06/10/2025 as ordered by the physician. 2. The facility failed to ensure Resident #345's oxygen was administered at the correct setting of 2 liters per minute on 06/10/2025 as ordered by the physician. These deficient practices could place residents who receive respiratory care at an increased risk of developing respiratory complications and a decreased quality of care. The findings included: 1.Record review of Resident #63's admission record dated 06/10/2025 reflected a [AGE] year-old male with an admission date of 05/27/2025 and with an initial admit date of 04/18/2025. Pertinent diagnoses included Shortness of Breath, Acute Kidney Failure, Muscle Wasting and Atrophy (loss of muscle tissue), Type 2 Diabetes Mellitus, and Hypertension (high blood pressure). Record review of Resident #63's person-centered care plan, initiated date 4/21/2025 reflected Resident #63 used oxygen therapy related to hypoxia. Intervention included oxygen settings: Oxygen via nasal cannula at 3 liters per minute continuous. Record review of Resident #63's physician order dated 06/10/2025, reflected oxygen at 3 LPM via nasal cannula for Shortness of breath every shift. Record review of Resident #63's Quarterly MDS assessment, dated 06/23/2025 reflected it was in progress. During an observation of Resident #63 on 06/10/2025 at 11:15 a.m. revealed the oxygen level on the oxygen concentration machine was at 2.5Liters Per Minute via nasal cannula. Observation of Resident #63 revealed the resident was in bed with head of the bed slightly elevated. No signs of respiratory distress noted. 2. Record review of Resident #345's admission record dated 06/10/2025 reflected he was a [AGE] year-old male admitted on [DATE]. His relevant diagnoses included end stage renal disease (a condition in which the kidneys lose the ability to remove waste and balance fluids), dependence on renal dialysis (relying on a process to filter waste and excess fluid from the blood, as the kidneys were no longer functioning properly), and Hypertension (high blood pressure). Record review of Resident #345's care plan dated 06/10/25 reflected in progress. Record review on 06/10/25 of Resident #345's order summary dated 06/10/25 reflected an active order of Oxygen at 2 liters via nasal cannula every shift for hypoxia. 455822 Page 3 of 10 455822 06/12/2025 Windsor Nursing and Rehabilitation Center of Harli 820 Camelot Dr Harlingen, TX 78550

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an observation on 06/10/25 2:35 p.m. revealed Resident #345 was observed laying on bed in his room. Resident #345 was sleeping. Resident #345's oxygen concentrator revealed it was set at 1.5 Liters Per Minute. In an interview on 06/10/2025 at 11:25 a.m. LVN D stated she was the nurse for Resident #63. LVN D agreed that the O2 setting was set at 2.5 Liters Per Minute. She stated the oxygen setting was supposed to be at 3 Liters Per Minute per physician orders. She stated that she checked the settings at the beginning of her shift. She was not sure who might have moved it. LVN D stated that she checked Resident #63's oxygen tubing and saturation in the mornings. She stated that she usually checked the oxygen once a day. LVN D stated that the negative outcome of keeping Resident# 63's oxygen setting at 2.5 Liters Per Minute was that the resident could go to respiratory distress. In an interview on 06/11/25 at 4:56 p.m. with the ADON C who stated that the nurse was responsible for checking the oxygen settings. She stated the nurse was supposed to check it every shift, whenever the patient comes back from doctors' appointments, and as needed. She stated the negative outcome of keeping it at a low setting would be that the patient would have hypoxia (low levels of oxygen), or respiratory distress. In an interview on 06/12/2025 at 4:00 p.m. with the DON, stated that the nurses assigned to that hall were responsible for checking the Oxygen settings. She stated that the nurses were to check the setting once per shift. The DON stated they were to follow oxygen settings on physician orders. The DON stated that the negative outcome could be that the resident could have a respiratory distress and hypoxia (low oxygen levels). In an interview on 6/12/2025 at 4:45 p.m. with the DON who stated that the facility did not have a policy on oxygen. 455822 Page 4 of 10 455822 06/12/2025 Windsor Nursing and Rehabilitation Center of Harli 820 Camelot Dr Harlingen, TX 78550

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and included the appropriate accessory and cautionary instructions, including the opened date on over the counter (OTC) medications in 1 of 23 medication carts (700 hallway Medication Cart) and one of two residents Resident#106. reviewed for medication storage in that: 1. The OTCs in the 700 hallway Medication Cart did not have an opened date written on the bottle. 2.On 06-12-2025 LVN G failed to administer Resident #106's medications and left a cup containing Resident #106's medication on her bedside table. These deficient practices could place residents at risk for adverse effects and not receiving the therapeutic effects of the medication or treatment. The findings included: 1. Observation on 06/10/25 at 4:39 p.m., of the Medication Cart 700 hallway with LVN B, revealed one over the counter (OTC) medications which did not have an opened date written on the bottle (Folic Acid 1000 micrograms). In an interview on 06/10/25 at 4:45 p.m., LVN B stated the OTCs should have an open date written on them. She said they were still within the expiration date but should have had an open date written on them. She said it was important to write the open date to know for how long the bottle had been opened. In an interview on 06/12/25 at 4:18 p.m., LVN E stated OTC medication should always have an opened date written on it that way everyone knows what date it was opened and possible contaminated to air or losing effectiveness or strength. In an interview on 6/12/25 at 5:00 p.m., ADON C stated that it was important to write the open date on the medication bottle to know for how long had been opened. ADON C said that nurses and medication aids were responsible to check the medication bottles, and to write an open date on a new medication bottle. In an interview on 06/12/25 at 5:47 p.m., DON stated that she knew the medication bottle was still within the expiration date. DON stated that she would make sure the bottles found (without an open date written on them) were disposed of because they did not know when the bottles were opened and she did not want residents to get medication that they did not know when it was opened. 2. Review of Resident #106's face sheet, dated 6/12/25, revealed a [AGE] year-old, female, with the diagnosis of Gastrostomy Status (the presence of a surgically created opening, called a gastrostomy, in the stomach, which is accessed via the abdominal wall.), Post gastric Surgery Syndromes (complications that can arise after stomach removal (gastrectomy) or surgery on the stomach). 455822 Page 5 of 10 455822 06/12/2025 Windsor Nursing and Rehabilitation Center of Harli 820 Camelot Dr Harlingen, TX 78550

F 0761 Level of Harm - Minimal harm or potential for actual harm Record review of Resident #106's care plan dated 4/2/25, revealed The resident requires enteral feedings via Gastrostomy tube related to history of post gastric surgery with (dumpling) syndrome and surgical complications. History of benign neoplasm of the colon with partial resection of colon; she was unable to tolerate PO feedings without adverse outcome (nausea, vomiting). Interventions: Flush feeding tube with 10mL of water before and after medication administration as ordered. Residents Affected - Few Review of Resident #106's MDS assessment, dated 4/4/25, revealed a BIMS of 15, a cognitive score indicating no impairment. Feeding tube while not a resident and while a resident. Observation of Resident #106's medication administration on 6/12/25 at 7:03 a.m. revealed a medication cup was left on the bedside table. The cup contained Tramadol (ordered for treatment of pain), while LVN G went into the restroom to wash her hands. An interview with LVN G on 6/12/25 at 8:20 a.m. who stated she did not normally leave medications at a resident's bedside, but she went to wash her hands and left the medication with Resident #106. She added that medication was to be administered to the resident and the nurse should stay with the resident while the medication was administered because if medication left unattended could get lost, thrown away or another resident could grab it. An interview on 6/12/25 at 5:06 p.m. with ADON C who confirmed medications to be administered should not be left at the bedside. When asked if the practice of leaving medication at bedside was common, he replied, 'No, we never do that. She said the nurse should have taken the medication with her while washing her hands because another resident could get the medication. An interview on 6/12/25 at 6:00 p.m. with DON who stated that medications should not be left unattended because another resident could grab it accidentally and could have an adverse reaction. Review of the facility policy and procedure titled House Stock Medications dated 10/01/2019 revealed: The Facility maintains a supply of commonly used over-the-counter (OTC) medications considered as house stock or floor stock medications (not resident-specific), as permitted by state regulations, to be administered only upon receipts of an order form an authorized prescriber 455822 Page 6 of 10 455822 06/12/2025 Windsor Nursing and Rehabilitation Center of Harli 820 Camelot Dr Harlingen, TX 78550

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to maintain clinical records on each resident that were complete and accurately documented in accordance with accepted professional standards and practices for 1 (Resident #123) of 6 residents reviewed for accuracy and completeness of clinical records. The facility failed to obtain the physician's signature on the OOH-DNR form for Resident #123 dated [DATE]. This deficient practice could affect residents who require care and monitoring and place them at risk of receiving or not receiving advanced directives to meet their needs. Findings included: Record review of Resident #123's electronic admission Record dated [DATE] reflected he was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included Type 2 Diabetes Mellitus (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), and dementia (a group of thinking and social symptoms that interferes with daily functioning). Record review of Resident #123's OOH-DNR form dated [DATE] was not completed with the physician's signature. Record review of Resident #123's baseline care plan dated [DATE], reflected the following: FOCUS: o Resident is a full code Date Initiated: [DATE] GOALS: o Facility will comply with resident/family wishes Date Initiated: [DATE] Revision on: [DATE] Target Date: [DATE] INTERVENTIONS/TASKS: o If resident has a cardiac arrest, initiate CPR ad call 911. Notify MD/RP and follow MD orders after notification. Date Initiated: [DATE] LN o Keep emergency cart well supplied and ready for use at all times Date Initiated: [DATE] LN. Record review of Resident #123's physician order dated [DATE], reflected an order for DNR (Do Not Resuscitate). Record review of Resident #123's Quarterly MDS dated [DATE] reflected he had a BIMS score of 05, indicating Resident #123's cognition was severely impaired. Record review of Progress Notes dated [DATE] revealed Resident #123 was discharged to the hospital on [DATE] related to a fall with right side head trauma. In an interview on [DATE] at 03:06 PM LVN A stated for an OOH-DNR form, she would make sure there was a provider's signature. In an interview on [DATE] at 03:46 PM LVN B stated the admitting nurse was responsible for contacting the physician for the signature if one was not on the OOH-DNR form. She said the code status was 455822 Page 7 of 10 455822 06/12/2025 Windsor Nursing and Rehabilitation Center of Harli 820 Camelot Dr Harlingen, TX 78550

F 0842 given by the hospital. Level of Harm - Minimal harm or potential for actual harm In an interview on [DATE] at 04:09 PM ADON C stated if any resident or RP said they wanted a DNR code status, she would notify the doctor. Residents Affected - Few In an interview on [DATE] at 04:25 PM the DON stated an OOH-DNR form for any resident would be honored with a doctor's verbal order. Record review of the facility's Documentation in Medical Record policy date implemented [DATE] reflected the following: Policy: Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation. Record review of the facility's Residents Rights Regarding Treatment and Advanced Directives policy date implemented [DATE] revealed: 1.On admission, the facility will determine if the resident has executed an advanced directive, and if not, determine whether the resident would like to formulate an advanced directive. 3.On admission, should the resident have an advanced directive, copies will be made and placed on the chart as well as communicated to the staff. 455822 Page 8 of 10 455822 06/12/2025 Windsor Nursing and Rehabilitation Center of Harli 820 Camelot Dr Harlingen, TX 78550

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** Based on observation, interview and record review, the facility failed to maintain an infection control program designed to prevent the development and transmission of disease and infection for 1 (Resident #346) of 3 residents reviewed who were in isolation. Residents Affected - Few CNA F did not don PPE before entering Resident #346's. Resident #346 was under contact isolations physician orders. This failure could place residents who resided in the facility, as well as employees and visitors, at risk of communicable diseases. The findings included: Record review of Resident #346's face sheet dated 06/11/25 revealed a [AGE] year old female admitted to the facility on [DATE], with the diagnosis of hypertension (high blood pressure), chronic kidney disease (a condition where the kidneys are damaged and can't filter blood as well as they should), and heart failure (a condition where the heart does not pump enough blood to meet the body's needs). Review of Resident #346 Physician Orders dated 6/6/2025 revealed Contact Precautions Dx: ESBL (bacteria that make them resistant to a broad range of antibiotics, including penicillin's and cephalosporins.) to the urine every shift until 6/13/2025. Review of Resident #346's care plan dated 6/7/2025 revealed the resident has infection of the urinary tract related to ESBL. Interventions: Contact isolation precautions as indicated by the physician. Review of Resident #346's MDS dated [DATE] revealed BIMS score of 12 which means moderate cognitive impairment. Observation on 06/11/25 4:50 p.m. revealed Resident #346 was on contact isolation precautions. Outside Resident #346's room was an isolation sign, personal protective equipment on the door that had masks, gloves and gowns available. Certified Nurse Aide (CNA) CNA F entered Resident #346 (contact isolation precautions) room up to the foot of the bed without any personal protective equipment. In an interview on 06/11/2025 at 4:52 p.m., CNA F stated when there were isolation precautions in place for Resident #346, the staff needed to put gloves, and gown before entering room. CNA F stated she went into the room really quick because the call light was on. CNA F stated it was important to wear personal protective equipment before entering the room to prevent the spread of germs to other residents. In an interview on 06/11/2025 at 5:05 p.m., Licensed Vocational Nurse (LVN) LVN B stated the isolation cart should contain gown, gloves, and mask outside of room and available to staff and family that enter the rooms when a resident was diagnosed with contact isolation precautions for ESBL to the urine. LVN D stated that all staff and visitors should have worn personal protective precautions before entering rooms to prevent the spread of infection to other residents. 455822 Page 9 of 10 455822 06/12/2025 Windsor Nursing and Rehabilitation Center of Harli 820 Camelot Dr Harlingen, TX 78550

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few In an interview on 6/12/25 at 5:03 p.m., ADON C stated all staff and visitors should wear personal protective equipment before entering the isolation rooms because this prevents the spread of infection to other residents. In an interview on 06/12/25 at 5:15 PM, DON stated contact Isolation precautions should be followed by all staff because of the potential for spreading infections to other residents. DON stated that in-services (training) on infection control were the key to prevent this to happen again. Review of facility's policy titled Infection Prevention and Control Program dated 5/13/2023 revealed; Isolation Protocol (Transmission-Based Precautions): a. A resident with an infection or communicable disease shall be placed on transmission-based precautions as recommended by current CDC guidelines. Review of CDC guidelines revealed: https://www.cdc.gov/infection-control/hcp/basics/transmission-based-precautions.html: Use personal protective equipment (PPE) appropriately, including gloves and gown. Wear a gown and gloves for all interactions that may involve contact with the patient or the patient's environment. Donning Personal protective equipment upon room entry and properly discarding before exiting the patient room is done to contain pathogens. 455822 Page 10 of 10