Health inspection·December 8, 2025

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure the resident was provided with pharmaceutical services, including procedures that assure the accurate administration of drugs, to meet the needs of each resident for 1 of 7 residents (Resident #1) reviewed for pharmacy services. The facility failed to check Resident #1's BS on six different occasions between the dates of October 1, 2025, through October 23, 2025. This failure has the potential for the resident being placed in a hypoglycemic state or not receiving the therapeutic dosage. The findings include: Record review of Resident #1's admission record, dated 09/17/25, reflected a [AGE] year-old female with diagnoses that included end stage renal disease, atherosclerotic heart disease of native coronary artery without angina pectoris, acute combined systolic (congestive) and diastolic (congestive) heart failure, and type 2 diabetes mellitus with hyperglycemia, with a reported BIMS score of 15. Record Review of Resident #1's care plan, dated 9/17/25, reflected Resident #1 had been admitted with a diagnosis of DM. In the care plan it further reflected the facility was to administer diabetes medication as ordered by the doctor and to monitor/document for side effects and effectiveness. Record review of Resident #1's Order Summary Report, dated 09/17/25, reflected NovoLOG Injection Solution 100 UNIT/ML (InsulinAspart) Inject as per sliding scale: if 60 - 150 = 0 units; 151 - 200 = 2 units; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units; 401+ = 12 units, subcutaneously four times a day for dm IF BS >401 Re-check in 15 minutes. If Blood Sugar still 401 or greater, CALL MD Record review of Resident #1's MAR, dated 11/07/25, reflected six separate occasions where Resident #1's BS was not checked four times a day as ordered. On 10/04/25 at 11:30 AM, 10/11/25 at 11:30 AM, 10/15/25 at 8:30 PM, 10/18/25 at 11:30 AM, 10/19/25 at 11:30 AM, and 10/22/25 at 8:30 PM Resident #1's BS was not checked. No indication as to why the BS was not attempted was charted. An interview and record review with LPN on 11/07/25 at 3:33 PM was conducted. LPN stated all BS checks should be recorded when performed. LPN was shown the MAR and asked to assist in deciphering what could be inferred from the blank portions of the MAR where no record of BS checks can be observed. LPN stated if the MAR was blank then that would mean the procedure was not attempted. LPN further said if the procedure was attempted but if for some reason could not be completed, then the reason for not completing the BS check would be recorded on the MAR. LPN stated there was risk of harm to patients who needed to get their BS checked but did not. LPN said patients that need insulin need to have the BS checked first. LPN further stated if insulin was not administered as ordered then there was a risk of harm to the patient could be worsening of health conditions. An interview and record review with the DON on 11/07/25 at 4:20 PM. The DON stated all procedures and medication administration should be charted in the residents' records. The DON stated the facility had recently changed over to a new patient records system in June 2025 and she did not believe any BS checks had been missed. The DON was shown the October 2025 MAR for Resident #1 and asked what was to be inferred by the six blank (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: 455832 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 12/08/2025 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)