Health inspection·May 22, 2023

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that resident received adequate assistance with the use of an assistance device for one resident (R#1) of one resident reviewed for accidents and supervision. CNA A and CNA B failed to properly transfer R#1 using a gait belt from bed to wheelchair. The failure placed residents, who required assistance with gait belt transfers at risk for accidents, falls and injuries. Findings included: Review of R#1's quarterly MDS assessment dated [DATE] reflected (R#1) was an [AGE] year-old female who admitted to the facility on [DATE] with a readmission date of 6/26/2022. R#1's active diagnoses included Alzheimer's disease (type of brain disorder that causes problem with memory, thinking), dementia (a group of symptoms that affects memory, thinking and interferes with daily life), heart failure (a progressive heart disease that affects pumping action of the heart muscles), muscle wasting and atrophy (wasting away of muscles), difficulty in walking, muscle weakness, unsteadiness on feet, pain in right knee, hypertension (high blood pressure), cardiomegaly (enlarged heart), and acute kidney failure. Rt#1 had a BIMS score of 09, which indicated moderate cognitive impairment. Resident #1 required substantial/maximal assistance with sit to stand ability. Helper does more than half the effort. Review of Resident #1's care plan, revision on 3/1/2023 reflected R#1 was at high risk for falls related to Alzheimer's and dementia. The goal was to minimize risks and injuries. R#1 has ADL self-care performance deficit related to dementia. Interventions for transfers states R#1 requires total assistance with transfers. Observation on 5/18/2023 at 3:23pm of bed to wheelchair (w/c) transfer of R#1, revealed, CNA A lifted bed to appropriate height. CNA A and CNA B placed gait belt around R#1's waist while R#1 was in bed. First attempt to place gait belt by CNA A and CNA B revealed, gait belt placed twisted around R#1's waist and was unable to be secured. Second attempt, gait belt straightened out by both CNA A and CNA B, but gait belt was backwards, and CNA A was unable to secure gait belt properly. A third attempt was made by both CNA A and CNA B. Gait belt was correctly placed around R#1. CNA B struggled to secure/tighten gait belt and could not fasten gait belt securely around R#1's waist. Gait belt was greater than two fingers width of space and was noticeably loose around R#1. Transfer continued and (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 3 Event ID: 675170 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 675170 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Nursing and Rehabilitation Center of San D 138 S Fm 1329 San Diego, TX 78384 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)