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 (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: 675139 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 675139 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Healthcare Residence 1025 W Yeagua Groesbeck, TX 76642 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)