Health inspection·December 18, 2023

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain medical records in accordance with accepted professional standards and practices that were complete and accurately documented for 3 of 3 residents (R #1, R #2, and R #3) reviewed for accuracy of records. 1. The facility did not document R #1's nursing progress note on 12/09/23 reflecting LVN A's communication with NP regarding a follow up after R #1 had a fall on 12/05/23. 2. The facility did not completely document R #2 and R #3's neurological checks started on 11/18/23 and 12/05/23 for R #2 and on 10/26/23, 12/04/23, and 12/13/23 for R #3 for falls. This failure could place residents with falls at risk of not receiving adequate care and services. The findings included: Record review of R #1's face sheet reflected an [AGE] year-old male with original admission date of 06/12/23. His diagnosis included: unspecified dementia, muscle wasting and atrophy, vertigo, epilepsy, insomnia, depression, cognitive communication deficit, dysphagia, Alzheimer's disease, disease of stomach and duodenum, and history of malignant neoplasm of prostate. Record review of R #1's MDS assessment dated [DATE] reflected a BIMS score of 7 (cognitively severely impaired). Record review of R #1's care plan dated 12/13/23 reflected R #1 was at risk for falls related to impaired mobility, vertigo, and poor safety awareness. R #1's gait was unsteady and often forgot to ask for assistance. Date initiated: 06/12/23. Interventions: offer assistance to the bathroom upon rising, before meals, and at bedtime. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. Ensure the resident is wearing appropriate footwear. Medications as ordered. Provide a safe environment with even floors, free from spills/clutter, and adequate light. Therapy to evaluate and treat. Record review of R #1's progress notes dated 12/09/23 reflected there was no progress note documented for LVN A's communication with the NP regarding a follow up for the fall R #1 had on 12/05/23 and old bruising. Record review of R #1's progress notes dated 12/09/23-12/18/23 reflected no adverse or negative outcomes related to the lack of documentation. Page 1 of 4 675363 675363 12/18/2023 Windsor Nursing and Rehabilitation Center of Wesla 721 Airport Dr Weslaco, TX 78596

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of R #2's face sheet reflected a [AGE] year-old female with original admission date of 12/22/22. Her diagnosis included: chronic obstructive pulmonary disease, hypertension, muscle wasting and atrophy, chronic kidney disease, major depressive disorder, insomnia, anxiety disorder, schizophrenia, and type 2 diabetes. Record review of R #2's MDS assessment dated [DATE] reflected a BIMS score of 11 (cognitively moderately impaired). Record review of R #2's care plan dated 12/13/23 reflected R #2 was at risk for falls related to weakness and poor safety awareness. Date initiated: 09/28/23. Interventions: staff to ensure that resident is wearing appropriate footwear. Call light is within reach and encourage resident to use it for assistance as needed. Encourage the resident to participate in activities that promote exercise and physical activity for strengthening and improved mobility. Provide a safe environment with even floors, free from spills/clutter, and adequate light. Record review of R #2's neurological checks started on 11/18/23 reflected check Q8H#6 (check every 8 hours #6) was not documented as completed. Checks started on 12/05/23 reflected check Q8H#4, Q8H#5, and Q8H#6 (checks every 8 hours #4, #5, and #6) were not documented as completed. Record review of R #2's progress notes dated 11/18/23-12/18/23 reflected no adverse or negative outcomes related to the lack of documentation. Record review of R #3's face sheet reflected a [AGE] year-old male with original admission date of 06/26/23. His diagnosis included: muscle wasting and atrophy, dementia, cognitive communication deficit, dysphagia, hypertension, repeated falls, mood disorder, insomnia, anemia, and cirrhosis of liver. Record review of R #3's MDS assessment dated [DATE] reflected a BIMS score of 2 (cognitively severely impaired). Record review of R #3's care plan dated 12/13/23 reflected R #3 was at risk for falls related to weakness and poor safety awareness. R #3 had a history of falls prior to admission and had a history of frequent falls. Date initiated: 06/26/23. Interventions: ensure call light is within reach and encourage the resident to use it for assistance as needed. Encourage the resident to participate in activities that promote exercise and physical activity for strengthening and improved mobility. Ensure resident is wearing appropriate footwear. Fall mat. Offer assistance to the toilet every 2-3 hours while awake. Provide a safe environment with even floors, free from spills/clutter, and adequate light. Therapy to evaluate and treat. Review information on past falls and attempt to determine cause of falls. Record possible root causes. Alter remove any potential causes if possible. Educate resident/family/caregivers/team as to causes. Record review of R #3's neurological checks started on 10/26/23 reflected check Q8H#2 (check every 8 hours #2) was not documented as completed. Checks started on 12/04/23 reflected check Q8H#1 (check every 8 hours #1) was not documented as completed. Checks started on 12/13/23 reflected check Q8H#6 (checks every 8 hours #6) was not documented as completed. Record review of R #3's progress notes dated 10/26/23-12/18/23 reflected no adverse or negative outcomes related to the lack of documentation. 675363 Page 2 of 4 675363 12/18/2023 Windsor Nursing and Rehabilitation Center of Wesla 721 Airport Dr Weslaco, TX 78596

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interviews with R #2 and R #3 on 12/13/23, and with R #1 on 12/18/23 indicated they were not good historians and/or could not provide relevant information. Interview with LVN A on 12/13/23 at 4:45 PM. LVN A said she worked on 12/05/23 with R #1 and found R #1 on the bathroom floor at around 9 AM. LVN A said she assessed R #1 and followed the fall protocol including initiating the neurological checks. LVN A said neurological checks were started on 12/05/23, checks were normal, and there were no concerns that R #1 had hit his head. LVN A said neurological checks would be able to indicate if R #1 hit R #1's head or if R #1 had anything else going on internally. LVN A said the neurological checks were completed 4 times every 15 minutes, 2 times every 30 minutes, 2 times every 1 hour, 4 times every 4 hours, and then 6 times every 8 hours, until 72 hours were completed. LVN A said the neurological checks were initiated after the fall and then the next nurses took over to complete the neurological checks until the 72 hours were completed. LVN A said the neurological checks were done by several nurses. LVN A said she worked on 12/09/23 with R #1 and communicated a follow up with the NP regarding R #1 having bruising to the right side of R #1's back/hip area and to the back of R #1's right ear. LVN A said the NP indicated the bruising looked old and was related to the fall on 12/05/23. LVN A said she documented all progress notes in R #1's EMR. Interview with NP on 12/18/23 at 4:40 PM. NP said LVN A had reported the bruising to the on-call service on 12/09/23. NP said the on-call NP did not give any new orders as the bruising was noted to be old as it was related to the fall on 12/05/23. Interview with DON on 12/18/23 at 5:00 PM. DON said on 12/09/23, LVN A had informed DON that LVN A followed up with the on-call NP regarding R #1 having some bruising from the fall on 12/05/23. DON said the NP did not give any new orders as the bruising was old. DON said perhaps LVN A did not document in R #1's EMR regarding the communication with the on-call NP but DON knew LVN A did speak to the on-call NP. DON said neurological checks were initiated for head concerns or falls, especially if the fall was unwitnessed and the facility did not know if the resident hit their head. DON said the neurological checks are completed for 72 hours. DON said there would be no reason for the neurological checks to be discontinued unless the resident was sent to the hospital or was no longer at the facility for another reason. DON said the nurses need to ensure to document the neurological checks. DON said there have been no indications or concerns that neurological checks are not being completed appropriately. DON said the neurological checks started on 11/18/23 and 12/05/23 for R #2 and on 10/26/23, 12/04/23, and 12/13/23 for R #3 were for falls. DON said the neurological checks should have been complete as R #2 and R #3 were not sent to the hospital on those days and were available in the building. DON said perhaps the nurses just forgot to document in R #2 and R #3's EMR. DON said although there was no negative outcome to the residents, the neurological checks need to be documented completely. DON said if there was a thorough assessment done, then DON does not believe there would be a negative outcome for the resident due to the lack of documentation. Interview with ADM on 12/18/23 at 5:35 PM. ADM said was made aware of the concern regarding the incomplete documentation for R #1, R #2, and R #3. ADM said there were no concerns or indications reported that the neurological checks were not completed or that staff did not follow protocols, but documentation was important. Documentation in Medical Record Policy date implemented 10/24/22 reflected Policy: Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's 675363 Page 3 of 4 675363 12/18/2023 Windsor Nursing and Rehabilitation Center of Wesla 721 Airport Dr Weslaco, TX 78596

F 0842 progress through complete, accurate, and timely documentation. Level of Harm - Minimal harm or potential for actual harm Policy Explanation and Compliance Guidelines: Residents Affected - Few 1. Licensed staff and interdisciplinary team members shall document all assessments, observations, and services provided in th3e resident's medical record in accordance with state law and facility policy. 675363 Page 4 of 4