Health inspection·February 12, 2025

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few In an interview with Resident #17 on 02/10/25 at 11:12 AM, Resident #17 stated she received nutrition from the feeding tube at night while she slept. Resident #17 stated she was not sure about the specific hours that it was on. In an interview with LVN A on 02/11/25 at 2:23 PM, LVN A stated Resident #17 had a G-tube. LVN A stated Resident #17 received nutrition during the night but was not sure about the specific hours. LVN A stated if she was not sure what time the resident received nutrition, she would check the MAR and orders. LVN A stated Resident #17 ate food during the day. LVN A stated if there was a discrepancy in the order she would talk to the DON and call the dietician to confirm what the correct timing was for the order. LVN A stated the order for enteral nutrition showed the duration 6:00 AM to 10:00 PM but she thought it was supposed to be 10:00 PM to 6:00 AM. LVN A stated the audit review on the order showed the dietician, the DON and the MD all saw the order and approved it. LVN A stated an incorrect order like this could result in the resident gaining a lot of weight and the facility would not know why it was happening. In an interview with the ADON on 02/11/25 at 2:42 PM, the ADON stated she ran a report every day showing all new orders from the previous day and reviewed them. The ADON stated she reviewed them for indication, parameters of whether to give the medication or not, and duration. The ADON stated Resident #17 had a G-tube. The ADON stated Resident #17 received nutrition at night through the tube. The ADON stated Resident #17 received breakfast, lunch, and dinner every day as well. The ADON stated if she did not know what hours the G-tube was supposed to run, she would look it up in the MAR or plan of care to see what the correct hours were. The ADON stated the order currently stated the run time was from 6:00 AM to 10:00 PM. The ADON stated the correct time was 10:00 PM to 6:00 AM. The ADON stated this was an order she would have reviewed. The ADON stated if she saw an incorrect order, she would call the person who put in the order to confirm what the order should be. The ADON stated with the order written the way it was the resident could inadvertently receive extra nutrition. In an interview with the DON on 02/11/25 at 2:55 PM, the DON stated the charge nurses reviewed new medication orders. The DON stated she reviewed all new dietician orders. The DON stated when she reviewed orders she looked to see if there were any changes or new recommendations in the orders. The DON stated Resident #17 ate breakfast, lunch, dinner and snacks and received enteral nutrition only at night. The DON stated if she was not sure of the hours of the enteral nutrition, she looked it up in the orders. The DON stated the order in the computer stated the enteral nutrition was from 6:00 AM to 10:00 PM. The DON stated the correct time was 10:00 PM to 6:00 AM. The DON stated when an order for enteral nutrition was not put in correctly the resident was at risk of being overfed or underfed. Record review revealed the facility policy titled Medication Reconciliation implemented 04/10/23 stated the following: 5. Daily Processes: b. Verify medication labels match physician orders and consider rights of medication administration each time a medication is given. c. Obtain and transcribe any new orders in accordance with facility procedures. Obtain clarification as needed. e. Verify medications received match the medication orders. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675170 If continuation sheet Page 2 of 3 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 02/12/2025 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 0842 6. Monthly Processes: Level of Harm - Minimal harm or potential for actual harm c. Verify orders printed on new monthly physician order forms and medication administration records match current medication orders. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675170 If continuation sheet Page 3 of 3