Health inspection·August 28, 2024

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few health disorder), other symptoms and signs concerning food and fluid intake, and Atherosclerosis native arteries of extremities w rest pain, right leg (disease that causes the arteries that supply the legs and feet to narrow and harden). Record review of Resident #3's assessment and care screening MDS assessment dated [DATE] reflected she had a BIMS score of 5, which indicated severe cognitive impairment. Resident #3 did not have any mood issues, delirium, behavioral symptoms, or rejection of care issues. Resident #3 was totally dependent on staff for all her ADLs. Record review of the clinical note entry created by LVN A, dated 12/09/2023, indicated Resident #3's family members requested that [LVN A] call 911 to send Resident #3 to the hospital because she looked lethargic and not responding to verbal stimuli, vital signs 163/66 pulse 130, temperature 97.8 Resident #3 not swallowing her food and spitting her dentures out, swelling noted to left wrist, physician, DON and supervisor notified. Record review of Resident 3's electronic heath record revealed the following vital signs for 12/8/23 were as follows blood pressure1138/84, pulse 76, temperature 98, vital signs for 12/7/23 were as follows blood pressure 133/81, pulse 89, temperature 97.2, vital signs for 12/6/23 were as follows blood pressure 122/69, pulse 95, temperature 98, and vitals for 12/05/23 were as follows blood pressure 129/90, pulse 77, and temperature 97.6. Record review of Resident 3's electronic heath record revealed Resident #3 labs that were completed on 12/1/24 showed red blood cell were 3.26 normal range is 3.62, her hemoglobin was 9.1 and normal range is 10.9, her hematocrit was 28.3 normal range is 31.2, lymph percentage was 14.6 and normal range is 16. All other lab results for Resident #3 were in normal range. During an interview on 08/28/2024 at 3:00 p.m., LVN A stated he was the Nurse on the long-term care hall who worked with Resident #3. LVN A stated that he could not recall 12/09/23. He said it had been a long time ago, and he could not recall how Resident #3 looked or if she responded to verbal stimuli. LVN A stated that he could not recall what time 911 was called or what time the emergency medical services arrived. LVN A stated that nurses were required to chart the time 911 was called and what time emergency medical services came to get the resident. During an interview on 08/28/2024 at 4:46 p.m., LVN B stated that if a resident needed to go to the hospital and emergency medical services picked them up the nurses' note would contain time resident left, what they left for and what symptoms they had. During an interview on 08/28/2024 at 5:03 p.m., the ADON stated that his expectations of documentation were that the staff note assessment of resident, reason resident left, what time resident left and how the resident left the facility. The ADON stated that if there is no nurses note then there should be a SBAR. The ADON reviewed the nurses note and stated that the note was incomplete. The ADON stated that if you did not document you did not do it and it is unacceptable for staff not to complete the nurses note or SBAR. During an interview on 08/28/2024 at 5:15 p.m., the DON stated that her expectation of documentation for a resident who had a change in condition was for the nurses to put in either a nurses note, SBAR or a telehealth visit. The DON stated one of those three would need to be completed. The DON stated that if 911 were called nurses would not have time to complete an SBAR as that would be considered an emergent situation, but the call to 911 for the resident to be sent to the hospital would (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455832 If continuation sheet Page 2 of 3 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 455832 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Gardens 2535 W Pleasant Run Lancaster, TX 75146 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete require physician orders . The DON stated that nurses if able should conduct an assessment, call physician, get orders, place vitals in nurses note. The DON stated that there were no SBAR, no physician orders and the nurse note created by LVN A was incomplete for Resident #3 as note required at least the time 911 came and took the resident. Record review of the facility's policy titled, Change in Resident's Condition of Status, revised on 02/2021 indicated, .2. Prior to notifying the physician or healthcare provider, the nurses will make detailed observations and gather relevant and pertinent information for the provider, including (for example) information promoted by the Interact SBAR Communication Form .6. The nurse will record in the resident's medical record information relative to changes in resident's medical/mental condition or status. Event ID: Facility ID: 455832 If continuation sheet Page 3 of 3