Health inspection·November 17, 2023

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few dose recommendation made by pharmacy. On 11/16/2023 the medication error was discovered. The ADON said the old medication was supposed to be taken out as soon as possible, and it was possible for the medication to be taken out before 11/16/2023. The new medication arrived on 10/25/2023. The ADON said the old medication should have been removed when they received the order, before they got the new medication, and that did not happen. The old medications were left in the medication cart. The ADON said the order was taken by her. The ADON said usually it would be the charge nurses that take the old medications out, but she could have. The ADON said that most of the time the medication aid will verify the medications to ensure it is the right one during routine med passes. There were two medication passes a day for more than three weeks that were wrong. The ADON said the facility failed to remove the discontinued medication and failed to verify the dose of the medication. The ADON said many things could happen to a resident with the wrong medications. The ADON said the breakdown was no one took the old medication out for three weeks. The ADON said the order was probably not communicated. The ADON said the medication aides are supposed to put discontinued medications in a locked cabinet they have access to, and that was not done. The ADON said discontinued medications show up as discontinued on the MAR. The ADON said nurses also communicate medication changes during shift change, and nurses have a 24-hour report as well. A record review of the 24-hour report from 10/25/2023 correctly indicated a change in medication dose for Resident #9's memantine from 10 mg to 5 mg that was written by the ADON. During an interview with the ADON on 11/17/2023 at 10:30 AM she said that discontinued medications are supposed to be taken from the medication cart and left in the med room under two locks and collected at least once a month for destruction. During an interview with the Corporate Nurse on 11/17/2023 at 10:15 AM she said the Pharmacist did a cart check on 11/14/2023. She said the Pharmacist looked to see if there were any expired medications, and they pull them out as well. She said the pharmacy missed it as well, but she does not look at every cart. She said the Pharmacist picks a cart at random and submits what cart she looked at on her report. A record review of the Monthly Consultant Pharmacist Report compiled on 11/14/2023 indicated an expired medication was found in a medication cart. The pharmacist indicated both medication carts were inspected. Record review of facility medication administration policy and procedures dated 10/24/22 indicates mediations are administered by licensed nurses, or other staff who are legally authorized to so in this state, as ordered by a physician and in accordance with professional standards of practice. Staff are required to review MAR to identify medication to be administered. Staff are required to compare medication source (bubble pack, vial, etc.) with MAR to verify resident name, medication name, form, dose, route and time. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675170 If continuation sheet Page 2 of 4 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 11/17/2023 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)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review the facility failed to establish and maintain an Infection Prevention and Control Program designed to help prevent the standard and transmission-based precautions to be followed to prevent the spread of infections or diseases for 2 of 4 units reviewed for laundry services. Residents Affected - Some -Laundry Aide A left the laundry bin with clean linens uncovered on units 100 and 200. These failures could affect residents and staff and place them at risk for healthcare associated cross contamination, infections, and COVID-19 (coronavirus). The findings included: Observation on 11/14/23 at 01:50 PM Laundry Aide A delivered clean linens to the 100 care unit. The bin was left uncovered when Laundry Aide A went into a resident's room to deliver clean linen. An unknown resident was observed to grab a pair of socks from the uncovered laundry bin. The surveyor notified Laundry Aide A and the socks were retrieved. Interview on 11/16/23 at 02:39 PM the Administrator stated the Housekeeping Supervisor is out for personal reasons and this surveyor would have no way of contacting her at the moment. Administrator stated she does not know the laundry process. Observation on 11/16/23 at 04:21 PM revealed Laundry Aide A delivered clean linen on the 200 care unit, the laundry bin was left uncovered. A the same time, the ADON observed clean linen being delivered to the 200 care unit hall residents in an uncovered laundry bin by Laundry Aide A. ADON/Infection Control Prevention stated she was going to look at the policy and get back with this surveyor to see what the policy stated about how clean linen should be delivered in care units. During an interview on 11/16/23 at 04:28 PM the ADON/Infection Control Prevention stated the Infection Control Policy was reviewed and laundry bins should have been covered as to prevent cross contamination. The ADON stated in-service will immediately be conducted and the facility would ensure laundry bins are covered at all times while clean linen is being distributed in care units. During an interview on 11/17/23 at 04:25 PM with Laundry Aide A stated she brought the laundry bin full of clean linen covered from outside but once inside, Laundry Aide A stored the laundry bin cover in a utility room when she passed out the clean linen to residents. Laundry Aide A stated she kept the laundry bin uncovered as it was easier to pass out the clean linen. Laundry Aide A stated the laundry bin should be covered at all times while in care unit areas, so residents are not tempted to grab clothing out of the bin and to prevent cross contamination. Laundry Aide A stated she did not know when the last time she in-services on infection control and the procedures of passing out clean linen in care unit areas. Record review of Infection Prevention and Control Program dated 5/13/2023 stated: 12. Linens: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675170 If continuation sheet Page 3 of 4 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 11/17/2023 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)

F 0880 a. Level of Harm - Minimal harm or potential for actual harm Laundry and direct care staff shall handle, store, process, and transport linens to prevent spread of infection. Residents Affected - Some c. Clean linen shall be delivered to resident care units on covered linen carts with covers down. d. Linen shall be stored on all resident care units on covered carts, shelves, in bins, drawers, or linen closet FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675170 If continuation sheet Page 4 of 4