Health inspection·March 30, 2025

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for one(Resident #1) of 5 residents reviewed for care plans. The facility failed to revise Resident #1's care plan to reflect the most recent fall on 03/25/2025. This failure could affect residents by placing them at risk of not receiving appropriate interventions to meet their current needs. Findings Included: Review of Resident #1's face sheet dated 03/28/2025 reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included essential primary hypertension(a condition characterized by persistently elevated blood pressure without an identifiable underlying cause), major depressive disorder (a common mental health condition characterized by persistent low mood, loss of interest or pleasure, and other symptoms that significantly interfere with daily functioning), delirium (a sudden change in mental state characterized by confusion, disorientation, and difficulty focusing), and anxiety (intense, excessive, and persistent worry and fear about everyday situations). Review of Resident #1's quarterly MDS, dated [DATE], reflected a BIMS score of 15, indicated she was moderate cognitive intact. Review of Resident #1 's care plan dated 03/28/2025, reflected date initiated 09/19/2024 and revised on 09/19/2024 Resident # 1 had an actual fall on 09/18/2024. Review of Resident #1's incident report dated 03/25/2025, reflected that Resident # 1 had slipped off the bed and it was unwitnessed. During an interview with the ADM on 03/30/2025 at 3:20 PM, the ADM stated that the MDS Coordinator was responsible for updating the care plans. The ADM stated it was expected for the MDS Coordinator to update the care plan so the needs of Resident # 1 would be met. During an interview with the MDS Coordinator on 03/30/2025 at 3:26 PM, the MDS Coordinator stated Page 1 of 2 675356 675356 03/30/2025 Windsor Nursing and Rehabilitation Center of Bastr 400 Old Austin Hwy Bastrop, TX 78602

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few she was responsible for updating care plans. The MDS Coordinator stated she did not update the date of the most recent fall and only added Resident #1's intervention on 03/25/2025 of nonskid tape. MDS Coordinator stated when the care plan was not updated the resident's needs would not have been met. Review of the facility policy Care Plans Revisions Upon Status Change dated 10/24/2022 reflected The purpose of this procedure is to provide a consistent process for reviewing and revising the car plan for those experiencing a status change. The comprehensive care plan will be reviewed, and revised as necessary, when a resident experiences a status change. 675356 Page 2 of 2