Health inspection·August 21, 2025

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 6 residents (Resident #1) reviewed for quality of care, in that:The facility failed to conduct a weekly skin assessment for Resident #1 on due on 08/13/25 but not completed. These failures placed residents at risk of physical harm, pain, and a decreased quality of life. Findings included: Record review of Resident #1's admission record, dated 08/21/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included: type 2 diabetes mellitus with unspecified complications (a condition where your body has trouble using insulin, a hormone that regulates blood sugar), peripheral vascular disease (problems with your blood vessels in your arms, legs, and organs but not in the heart or brain), chronic pain syndrome (when your body's pain signals stay on even after an injury has healed, causing ongoing pain, often in the brain and nerves), essential primary hypertension (high blood pressure with no single identifiable cause), and anxiety disorder (mental health condition where someone experiences intense, excessive, and persistent worry or fear that is difficulty to control and interferes with daily life).Record review of Resident #1's admission MDS assessment, dated 08/07/2025, reflected the resident had a BIMS score of 13, which indicated cognitively intact. Resident #1 required substantial/maximal assistances in the area of putting on/taking off footwear. Resident #1 required to partial/moderate assistance in the area of shower/bathe self and lower body dressing. Record review of Resident #1's care plan, dated 08/21/2025, reflected Resident #1 was care planned for potential for pressure ulcer development R/t Hx of ulcers, immobility with an intervention of follow all facility policies/protocols for the prevention/treatment of skin breakdown. Review of Resident #1's physician orders, dated 08/21/2025, reflected Resident #1 had an order for weekly skin assessment with directions every evening shift every Wednesday. Resident #1's weekly skin assessments had a start date of 08/06/2025. Review of Resident #1's weekly skin assessment in the EMR on 08/21/2025, reflected Resident #1 did not have a weekly skin assessment when an assessment was due on 08/13/2025 but not completed. Resident #1 was not in the facility at the time of the investigation therefore no interview was conducted. During an interview with the ADON on 08/21/2025 at 2:00 PM, the ADON stated the purpose a weekly skin assessment would be to observe any current or potential skin issues/skin breakdown. The ADON stated that LVN A was responsible for completing Resident #1's skin assessment on 08/13/2025. The ADON stated if a resident's weekly skin assessment was not completed then the resident could have a new developed skin issue/breakdown that could be missed. During an interview with the LVN A on 08/21/2025 at 2:15 PM, LVN A stated the purpose a weekly skin assessment would be to find any skin issues or skin breakdown. LVN A stated she was responsible for completing the weekly skin assessment for Resident #1 on 08/13/2025. LVN A stated that she did not remember receiving a notification via the EMR that Resident Residents Affected - Few Page 1 of 2 675139 675139 08/21/2025 Windsor Healthcare Residence 1025 W Yeagua Groesbeck, TX 76642

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few #1 weekly skin assessment was due on 08/13/2025. LVN A stated if a resident did not receive a weekly skin assessment, that resident could have a skin issue that go untreated. During an interview with the DON on 08/21/2025 at 2:20 PM, the DON stated the purpose of a skin assessment was to identity and address any skin concerns. The DON stated all residents were supposed to receive weekly skin assessments. The DON stated LVN A was responsible for completion of Resident #1's weekly skin assessment. The DON stated she was not aware that LVN A had not completed Resident #1 weekly skin assessment on 08/13/2025. The DON stated that if a resident did not receive weekly skin assessment, then the resident could have a skin condition go untreated. The DON stated she expected for weekly skin assessments to be conducted as scheduled. During an interview with the ADM on 08/21/2025 at 2:50 PM, the ADM stated the purpose of a skin assessment was to ensure residents did not have any adverse skin issues from the previous week. The ADM stated all residents were supposed to receive weekly skin assessments. The ADM stated he was not aware that LVN A had not completed Resident #1's weekly skin assessment on 08/13/2025. The ADM stated that if a resident did not receive weekly skin assessment, then the resident could have skin integrity issues that go untreated. The ADM stated he expected for weekly skin assessments to be conducted as scheduled. The ADM stated the facility did not have a policy for weekly skin assessment but provide the facility's Pressure Ulcers/Skin Breakdown - Clinical Protocol policy. A record review of the facility's Pressure Ulcers/Skin Breakdown - Clinical Protocol policy, revised dated April 2018, reflected, Assessment and Recognition1. The nursing staff and practitioner will assess and document an individual's significant risk factors for developing pressure ulcers; for example, immobility, recent weight loss, and history of pressure ulcer(s).3. The staff and practitioner will examine the skin of newly residents for evidence of existing pressure ulcers and other skin conditions. Monitoring 1. During resident visits, the physician will evaluate and document the progress of wound healing especially for those with complicated, extensive, or poorly healing wounds. 675139 Page 2 of 2