Health inspection·March 22, 2023

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents' right to formulate an advance directive for 1 of 4 residents (Resident #85) reviewed for advanced directives, in that: The facility failed to ensure the completed OOH-DNR was in the facility for Resident #85. This failure could place residents at-risk of having their end of life wishes dishonored, and of having CPR performed against their wishes. Record review of Resident #85's face sheet, dated [DATE], revealed an admission date of [DATE] with diagnoses that included: dementia (group of symptoms affecting memory, thinking and social abilities severely enough to interfere with your daily life), major depressive disorder (persistent feeling of sadness and loss of interest), hyperlipidemia (abnormally high levels of fats (lipids) in the blood, which include cholesterol and triglycerides) and hypertension (high blood pressure). Record review of Resident #85's Quarterly MDS, dated [DATE], revealed the resident's BIMS score was 06, which indicated severe cognitive impairment. Record review of Resident #85's care plan, date initiated [DATE], revealed a problem area; Resident is a DNR and an intervention Ensure signed DNR is in medical record. Record review of Resident #85's electronic medical record revealed active orders as of [DATE], with an order, DNR (Do Not Resuscitate), dated [DATE]. Further review of the EMR revealed there was not an OOH-DNR on file for Resident #85. During a record review and interview with the SW on [DATE] at 12:35 p.m., the SW stated he is the one responsible for advanced directives. The SW confirmed Resident #85's OOH-DNR was not found in the electronic medical record. The SW stated he keeps copies of the documents and checked his binder for Resident #85's OOH-DNR and revealed he had only copies of Resident #85's MPOA. The SW revealed due to Resident #85's cognitive status she would be unable to sign another OOH-DNR so he would contact her family/MPOA and get it taken care of right away. The SW added that Resident #85 would have to be changed back to Full Code status in her electronic record until that document was completed and identified the potential harm could be the resident's wishes would not be followed. In an interview on [DATE] at 12:54 p.m., the DON stated she would have the Medical Records department search for the document to see if maybe it was never scanned into Resident #85's electronic chart. The DON confirmed Resident #85's code status would have to be changed back to Full Code without Page 1 of 25 675380 675380 03/22/2023 Windsor Nursing and Rehabilitation Center of Segui 1219 Eastwood Dr Seguin, TX 78155

F 0578 the OOH-DNR in place. The OOH-DNR was not located prior to exit. Level of Harm - Minimal harm or potential for actual harm Record review of the facility's policy titled, Residents' Rights Regarding Treatment and Advance Directives, dated [DATE], revealed, Policy: It is the policy of this facility to support and facilitate a resident's right to request, refuse and/or discontinue medical or surgical treatment and to formulate an advance directive. Residents Affected - Few 675380 Page 2 of 25 675380 03/22/2023 Windsor Nursing and Rehabilitation Center of Segui 1219 Eastwood Dr Seguin, TX 78155

F 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to ensure personal privacy during medical treatment and personal care for two of five residents (#41 and #68) observed for medication observation. Residents Affected - Few A. LVN G did not ensure residents personal health information was protected during medication administration for Resident #41. B. CMA F did not provide privacy during administration of Resident #68's Lidocaine Patch to his lower back. This failure could affect all residents in the facility that received care where privacy is required and could result in embarassment for the residents. The findings were: A. Observation on 03/19/23 at 11:22 a.m. revealed LVN G administered Insulin Lispro 10 units for Resident #41. Further observation revealed during the process of medication preparation, LVN G closed the laptop computer screen that displayed Resident #41's TARs; however, did not lock the laptop screen to prevent access to resident informtation when she left went to get Resident #41's insulin from the refrigerator (in the medication room). LVN G left the treatment cart (which had the laptop attached) at 11:25 a.m. and returned on 03/19/2023 at 11:32 a.m. Observation on 03/19/2023 at 11:32 a.m. revealed LVN G she was able to access the facility's electronic record (containing patient information) by double clicking on the facility's electronic record (via P icon) from the unlocked laptop screen without a pass word. During an interview on 03/19/2023 at 11:33 a.m., LVN G stated the P icon (used to access the electronic record) had a password. Further interview revealed she thought it was okay to leave the screen unlocked but further stated I should've logged out. B. Record review of Resident #68's facesheet (03/22/2023) revealed an admission date of 09/25/2022, diagnoses included Unspecified Dementia, Strain of Muscle Fascia and Tendon of Lower Back. Record review of Resident #68's careplan (10/20/2022) revealed Resident #68 had chronic pain and received scheduled and PRN medication. Record review of Resident #68's MDS (02/20/2023) revealed BIMS score of 11 (moderate impairment). Observation on 03/20/23 at 09:49 a.m. revealed CMA F administered Resident #68's Lidocaine Patch (in his room). Further observation revealed (during the administration of the patch) CMA F instructed Resident #68 to turn to his leftside, pulled down his pants to expose Resident #68's lower back area and applied the patch. CMA F did not pull Resident #68's privacy curtain (between the resident and his roommate) or closed the door. Resident resided in A bed near to the door and Resident #68's roommate was in his room at the time of the patch administration. During an interview on 03/20/2023 at 09:53 AM, CMA F acknowledged the privacy curtain or door wasn't closed and stated, I didn't close the door or pull the curtain, that's an important one, privacy, 675380 Page 3 of 25 675380 03/22/2023 Windsor Nursing and Rehabilitation Center of Segui 1219 Eastwood Dr Seguin, TX 78155

F 0583 I got nervous. Level of Harm - Minimal harm or potential for actual harm During an interview on 03/22/2023 at 2:37 p.m., the DON stated. there were no policy and procedure for Hippa or confidentiality of resident records other than the policy for dignity. Further interview with the DON revealed not providing privacy could result in visitors or residents visualizing the resident receiving care or if clinical records were not kept confidential people could potentially see personal health information. Residents Affected - Few During an interview on 03/22/23 at 03:07 p.m., Resident #68 stated, I didn't pay much attention to the curtains being pulled or door being open, but it'd be like mooning someone, I guess. Record review of the agency's policy and procedure titled Promoting/Maintaining Resident Dignity((01/13/2023) read in part, It is the practice of the facility to protect and promote resident rights and treat each resident with respect and dignity .compliance guidelines included .12. Maintain resident privacy. 675380 Page 4 of 25 675380 03/22/2023 Windsor Nursing and Rehabilitation Center of Segui 1219 Eastwood Dr Seguin, TX 78155

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 observation, interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. for 1 of 8 (#102) residents reviewed for care plans, in that: Resident #102 did not have care plan for smoking. This could affect residents with care plans and could result in residents not provided care by staff. The Findings were: Record review of Resident # 102's Quarterly MDS dated [DATE] section A1600 Entry date-11/24/2022, section C Cognition Patterns -BIMS score was 15/15 (cognitively intact), section J1300 Current Tobacco Use-yes. Section I Active diagnosis included renal insufficiency, diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), depression, schizophrenia characterized by significant impairments in the way reality is perceived and changes in behaviors and (, nicotine dependence Record review of Resident # 102's care plan (no date) revealed no care plan for smoking. Record review of Resident # 102's chart revealed no smoking assessments or Acknowledgement form for smoking since the time of the resident's admission to the facility. Observation on 3/20/2023 at 1:36 PM outside in designated smoking area, supervised by staff, revealed Resident # 102 was smoking. Interview on 3/20/2023 at 12:52 PM with Resident #102 revealed he had no concerns with smoking at the facility. Interview on 3/21/2023 at 2:16 PM SW stated he was responsible for the smoking assessments and the IDT TEAM was responsible for care plans, to include the SW. The SW stated the smoking assessments should be done every 3 months. The SW stated he missed Resident #102's smoking assessments and care plans. Record review of the Smoking Policy dated 9/14 revealed the Facility respects the resident rights to smoke, 5. Smoking/Tobacco acknowledge to be completed upon admission and as needed. 6. Smoking/Tobacco evaluation, plan of care and summary to be completed upon admission, quarterly, annual and for change of condition assessments. Record review of policy dated 9/14 Smoking/Tobacco Acknowledgement residents are required to sign and date. Record review of policy for Care Plans was not provided before exit. 675380 Page 5 of 25 675380 03/22/2023 Windsor Nursing and Rehabilitation Center of Segui 1219 Eastwood Dr Seguin, TX 78155

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review revealed the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good personal hygiene for 1 of 8 residents (Resident #71) reviewed for ADL care, in that: Residents Affected - Few The facility failed to assist Resident #71 maintain personal hygiene. This failure could place residents at risk of feelings of poor self-esteem and loss of dignity. The findings were: Record review of Resident #71's face sheet, dated 03/22/2023, revealed an admission date of 06/15/2021 with diagnoses that included: dementia (group of symptoms affecting memory, thinking and social abilities severely enough to interfere with your daily life), transient cerebral ischemic attack or TIA (temporary period of symptoms similar to those of a stroke), hemiplegia (paralysis), affecting right dominant side and lack of coordination. Record review of Resident #71's Quarterly MDS, dated [DATE], revealed the resident had a BIMS score of 99, which indicated severe cognitive impairment. Further review revealed Resident #71 was always incontinent of bladder and bowel and required extensive assistance of one-person for toilet use and personal hygiene. Record review of Resident #71's Care Plan, date initiated 06/16/2021, revealed a Problem: The resident has an ADL self-care performance deficit r/t dementia. Further review revealed an Intervention: The resident requires limited to extensive assistance x 1 staff for toileting. In an observation and interviews on 03/19/2023 from 11:17 a.m. to 11:26 a.m., revealed a strong odor that appeared to be urine upon entrance into the secured unit of the facility. Observation of 8 residents, including Resident #71 were sitting in the dining room while NA H passed out snacks. Resident #71 was sitting in a chair and waiting for a snack. Resident #71 was picking at and looking down at his pants and holding them up off his leg. Resident #71's pants were completely wet on the front and down the leg. In an observation during this same time, NA H walked up to Resident #71 and offered a snack, sat crackers and juice on the table and walked to the next resident without addressing personal care needs. CNA I entered the dining room and was asked if NA H or CNA I were responsible for Resident #71's personal care needs. CNA I stated both staff members are assigned to the unit and that she would attend to resident at that time. NA H was asked if she was trained to care for residents. NA H stated she was but that she had not noticed Resident #71 needing assistance. NA H identified the potential negative outcome of resident's personal care needs not being met as he could get a rash or maybe be uncomfortable. In an interview with the charge nurse, LVN G on 03/19/2023 at 11:27 a.m., LVN G confirmed both the NA H and CNA I are responsible for personal care needs of residents in the secured unit and toileting needs should be addressed as soon as possible. 675380 Page 6 of 25 675380 03/22/2023 Windsor Nursing and Rehabilitation Center of Segui 1219 Eastwood Dr Seguin, TX 78155

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 the resident environment remained as free of accident hazards as was possible and that each resident received adequate supervision to prevent accidents for 1 of 1 resident (Resident #102) and for 1 of 5 halls (Hall 500) observed for accidents/supervision, in that: 1. Resident #102 was missing his initial and quarterly assessments for smoking. 2. A dirty dish cart with sanitizing cleaner was left unattended on Hall 500 (secured unit) to which 7 residents had direct access. These failures could place residents at risk of living in an unsafe environment. The findings were: 1. Record review of Resident #102's Quarterly MDS dated [DATE] section A1600 Entry date-11/24/2022, section C Cognition Patterns -BIMS score was 15/15 (cognitively intact), section J1300 Current Tobacco Use-yes. Section I Active diagnosis included renal insufficiency, diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), depression, schizophrenia characterized by significant impairments in the wasy reality is perceived and changes in behaviores and (, nicotine dependence. Record review of Resident #102's care plan, undated, revealed no care plan for smoking. Record review of Resident #102's chart revealed no initial or quarterly smoking assessments or Acknowledgement form. Interview on 3/20/2023 at 12:52 PM with Resident #102 revealed he had no concerns with smoking at the facility. Interview on 3/21/2023 at 2:16 PM with the SW stated he was responsible for the smoking assessments and the IDT Team was responsible for care plans, to include the SW. The SW stated the smoking assessments should be done every 3 months. The SW stated he missed Resident #102's smoking assessments and care plans. No smoking assessment was completed. Record review of the Smoking Policy dated 9/14 revealed the Facility respects the resident rights to smoke, 5. Smoking/Tobacco acknowledge to be completed upon admission and as needed. 6. Smoking/Tobacco evaluation, plan of care and summary to be completed upon admission, quarterly, annual and for change of condition assessments. Record review of policy dated 9/14 Smoking/Tobacco Acknowledgement residents are required to sign and date. 2. In an observation on Hall 500, the facility's secured unit on 03/19/2023 at 11:27 a.m. revealed a rolling cart in the hallway on the opposite wall to the entrance of the resident's dining area. Observation of the cart revealed a large dish pan on top that contained a dirty plate and coffee cup 675380 Page 7 of 25 675380 03/22/2023 Windsor Nursing and Rehabilitation Center of Segui 1219 Eastwood Dr Seguin, TX 78155

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few and a bucket on the side of the cart which contained a used knife, fork, and spoon. Further observation revealed a red bucket on the second shelf that contained a sudsy liquid and a rag. Further observation revealed there were no staff within eyesight and 7 ambulatory residents were wandering near the area of the cart as they gathered for the noon meal. In a continued observation in the secured unit (Hall 500) on 03/19/2023 at 11:46 a.m., CS Staff S entered Hall 500 and asked if assistance was needed. When asked where to find staff for Hall 500 CS Staff S revealed CNA staff are probably providing care to residents in a room and the charge nurse is at the nurse's station through the closed doors. CS Staff S was asked about the rolling cart in the hallway, and she stated that she would need to get the nurse to answer why it was there. CS Staff S walked through the closed doors of the secured unit to the nurses station and returned with the charge nurse. In an observation and interview with LVN G on 03/19/2023 at 11:48 a.m., LVN G revealed she is the charge nurse for Hall 400 and Hall 500. LVN G revealed the liquid in the red bucket to be a cleaning solution staff use following each meal to clean and sanitize the tables. LVN G revealed the dirty dish cart was to be brought to the unit after meals to clear dirty dishes and clean tables. LVN G verified the dirty dish cart should not be in the hallway with unattended residents. LVN G revealed potential harm could be the safety of residents if a resident took a knife and staff were unaware or the dangers if a resident ingested the cleaning solution. During interview with LVN G, CNA staff for Hall 500 entered the hallway from a resident's room. LVN G educated CNAs of the risk to residents of leaving the dirty dish cart unattended and then removed the cart from the unit. In an observation and interview with [NAME] J on 03/19/2023 at 12:45 p.m., [NAME] J revealed the cleaning solution in red buckets which is prepared for cleaning surfaces after meals is called Solution QA Sanitizer. On the front of the bottle were the words, DANGER. On one side of the solution were Precautionary Statements, HAZARDS TO HUMANS .DANGER. Corrosive. Causes irreversible eye damage and skin irritation. Harmful if swallowed or absorbed through the skin. Do not get in eyes, on skin or on clothing. In an interview with the DON on 03/19/2023 at 11:52 a.m., the DON confirmed the dirty dish cart should not be in the hallway with unattended residents. Record review of the facility's policies with the DON revealed the facility did not have a safe environment policy. 675380 Page 8 of 25 675380 03/22/2023 Windsor Nursing and Rehabilitation Center of Segui 1219 Eastwood Dr Seguin, TX 78155

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 6 resident (Resident #36) reviewed for incontinent care, in that: While providing incontinent care for Resident #36, CNA A made multiple pass with the same wipe and used a back to front motion to clean Resident #36's genitals. CNA did not clean Resident #36's buttocks. This deficient practice could place residents at-risk for infection and skin break down due to improper care practices. The findings were: Record review of Resident #36's face sheet, dated 03/21/2023, revealed an admission date of 03/02/2015 and, a readmission date of 02/08/2021, with diagnoses which included: Alzheimer's disease (brain disorder that causes problems with memory, thinking and behavior), Chronic kidney disease(gradual loss of kidney function) , Mood disorder (general emotional state or mood is distorted or inconsistent with circumstances and interferes with the ability to function), Hypertension (High blood pressure), Hyperlipidemia (too much lipids (fat) in the blood). Record review of Resident #36's Quarterly MDS, dated [DATE], revealed Resident #36 did not have a BIMS score and, had severe cognitive impairment. Resident #36 was indicated to always be incontinent of bladder and bowel and needed extensive assistance to total care with his activities of daily living. Review of Resident #36's care plan, dated 10/20/22, revealed a problem of The resident has bladder incontinence ALWAYS related to dx Alzheimer's / lack of awareness, with an intervention of Monitor/document for s/sx UTI, notify MD for any changes in status Observation on 03/21/2023 at 11:34 a.m. revealed while providing incontinent care for Resident #36, CNA A used the same wipe to do multiple passes to clean the resident's genital. CNA used a back to front motion to wipe the resident's scrotum. CNA A, while cleaning the resident's buttocks, cleaned between the cheeks but not the surface of the cheeks. During an interview on 03/21/2023 at 11:55 a.m. with CNA A, she confirmed she had wiped back to front instead of using a front to back motion. She confirmed not changing wipes and using the same wipe to do multiple passes and cleaning only between the buttocks cheeks of the resident. She added she was nervous. During an interview with the DON on 03/22/2023 at 10:30 a.m., she confirmed the correct motion to clean the residents during perineal care was front to back to prevent fecal matter to get in contact with the urethra and possibly cause an infection. She confirmed a wipe should be used for one pass and confirmed the buttocks surface should have been cleaned, The DON reveled the staff received 675380 Page 9 of 25 675380 03/22/2023 Windsor Nursing and Rehabilitation Center of Segui 1219 Eastwood Dr Seguin, TX 78155

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few training on infection control and incontinent care at least annually. The staff skills were check yearly. The facility had a CNA instructor that would train the CNA and would spot check the staff while they provided care for infection control and quality of care. Review of annual skills check for CNA A revealed CNA A passed competency for Perineal care/incontinent care on 01/04/2023. Review of facility policy, titled Incontinent care proficiency checklist, undated, revealed [ .] wipe down center front to back with one stroke, then each side with clean side of cloth each time. For men wipe the head of the penis using a circular motion first then down the shaft of the penis and then the scrotum. Review of Hartman's Nursing assistant care The basics, Fifth edition, undated, revealed using a clean washcloth, wash and rinse buttocks and anal area. Work from front to back. Clean the anal area without contaminating the perineal area 675380 Page 10 of 25 675380 03/22/2023 Windsor Nursing and Rehabilitation Center of Segui 1219 Eastwood Dr Seguin, TX 78155

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise; was offered sufficient fluid intake to maintain proper hydration and health; or was offered a therapeutic diet when there is a nutritional problem and the health care provider orders a therapeutic diet for 1 of 8 residents (Resident #50) reviewed for assisted nutrition and hydration, in that: Residents Affected - Few Resident #50 did not receive her supplement, ice cream during lunch service. This failure could affect residents with therapeutic diets and could result in residents weight loss. The Findings were: Record review of Resident # 50's admission Record dated 3/22/2023 revealed she was admitted on [DATE] with diagnoses of Dementia, bipolar disorder, chronic kidney disease, mild cognitive impairment and anemia. Record review of Resident # 50's diet order card dated 3/21/2023 revealed ice cream was included as part of her diet; all other food items were on her tray . Record review Resident # 50's diet card on the lunch tray, dated 3/20/2023 was documented as regular diet with ice cream . Record review of Resident # 50's telephone order dated 11/10/2022 revealed an order for ice cream two times a day with lunch and supper. Record review of Resident # 50's Quarterly MDS 1/19/2023 revealed section C cognition patterns BIMS score was 8/15 (moderate cognitive impairment), section K -swallowing/nutritional statusK0200-height/weight-62/136, K0300 weight loss--no or unknown. Record review of Resident # 50's care plan dated 2/13/2023 revealed resident #50 is on a regular diet, regular texture, regular, encourage died diet as ordered, offer supplements if intakes is less than 50%. Observation on 3/20/2023 at 1:23 PM in Resident # 50's room, during lunch, her lunch tray did not have ice cream. Interview on 3/20/2023 at 1:22 PM with Resident #50 stated she did not see ice cream on her lunch tray for today and had not eaten any for her lunch today . Interview on 3/20/2023 at 1:27 PM with the Charge nurse for Resident #50's, RN K, verified she did not have no ice cream on her tray and will get some for her. Interview on 03/20/23 5:25 PM the Administrator stated will search polices for kitchen, but not sure they will have all of them . The policy below was the policy he provided for resident's 675380 Page 11 of 25 675380 03/22/2023 Windsor Nursing and Rehabilitation Center of Segui 1219 Eastwood Dr Seguin, TX 78155

F 0692 therapeutic diet. Level of Harm - Minimal harm or potential for actual harm Record review of the Job description of the Certified Dietary Manager (dated) revealed Responsible for the daily operations of the dietary department, according to the facility policy and procedures and federal/state regulations. CDM provided leadership and guidance to ensure the food quality, safety standards, and client expectations are satisfactorily met. Essential Functions: Operations Management-Interview, train, coach and evaluate dietary staff. Food Service Management: participates in menu planning, including responding to client preferences, .therapeutic diets, inspect meals and assure the standards for .serving times are met. Food safety assure safe , storage, preparations, an service of food, protect food in all phases in preparation, .service, , transportation,, ensure proper sanitation and safety practices of staff. Residents Affected - Few Record review of Tray Service policy dated October 1, 2018, revised June 1, 2019, was documented, The facility believes that accurate tray service and adequate portion sizes are essential to the residents' well -being and safety. The facility will ensure that diets are served accurately and in the correct portions and that resident preferences are met. 6. The Nutrition and Foodservice Manager or consultant will conduct in-service with the nutrition, foodservice as needed to ensure all serving staff are familiar with the portion sizes and therapeutic and mechanically altered diets. 675380 Page 12 of 25 675380 03/22/2023 Windsor Nursing and Rehabilitation Center of Segui 1219 Eastwood Dr Seguin, TX 78155

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to ensure medication error rates are not 5 percent or greater during observation of two CMAs, one LVN, and one RN administering medication to one of five residents (#19). There were seven errors in 31 opportunities for errors, resulting in a 22 percent medication error rate. Residents Affected - Few Resident #19's 09:00 a.m. medications were not administered within one hour before or one hour after the scheduled time by CMA E. This failure could affect residents who receive medication and could result in residents not receiving the highest possible therapeutic outcome for the medication regimen. The finding were: Record review of Resident #19's facesheet dated 03/22/2023 revealed an admission date of 10/21/2022 and diagnoses of Unspecified Dementia, Unspecified Severity, without behavioral disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety, Schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves), Gastroesophageal Reflux Disease without Esophagitis, Anemia, Pain in Left Lower Leg, and Essential Hypertension. Record review of resident #19's Physician's order (11/6/2022) and MARs for March 2023 revealed the following medications: Meloxicam 15 mg give one tablet by mouth one time a day (scheduled at 09:00 a.m.). Ferrous Sulfate Tablet 325 mg give one tablet by mouth one time a day (scheduled at 09:00 a.m.). Propanolol 60 mg give 60 mg by mouth one time a day (scheduled at 09:00 a.m.). Senokot S oral tablet 8.6-50 mg give two tablets by mouth two times a day (scheduled at 09:00 a.m. and 21:00 p.m.). Topiramide 25 mg give 25 mg by mouth one time a day (scheduled at 09:00 a.m.). Vitamin C 500 mg one tab give one tablet by mouth two times a day (scheduled at 09:00 a.m. and 21:00 p.m.). Record review of Resident #19's MDS (03/02/2023) revealed a BIMS score of 11 (moderately impaired). Further review revealed she was assessed for receiving antipsychotic and opioid medications. During an observation on 03/19/2023 at 11:04 a.m., CMA E administered Resident #19's morning medications. Further observation revealed CMA E was pouring Resident #19's medications using the electronic MARS (03/2023). Review of Resident #19's electronic MARs at this time revealed the medications poured to be given were scheduled at 09:00 a.m. (two hours after the scheduled time). During an interview with CMA E on 03/19/2023 at 11:04 a.m. CMA E stated, the medications were past due. During further interview CMA E revealed I didn't have time to give Resident #19's medication on time because they had to give 500 hall first then 400 hall. CMA E acknowledged the medications had 675380 Page 13 of 25 675380 03/22/2023 Windsor Nursing and Rehabilitation Center of Segui 1219 Eastwood Dr Seguin, TX 78155

F 0759 to be given one hour before or one after the scheduled time. Level of Harm - Minimal harm or potential for actual harm During an interview on 03/22/2023 at 2:37 p.m., the DON stated if medications are given after the scheduled time, depending on the medication, it could have a negative effect on the residents. Residents Affected - Few Record review of the agency's policy and procedure titled Medication Administration (10/01/2019), read in part, 2. Administration: L. Medications are administered within 60 minutes of scheduled time, except before .routine medications are administered according to the established medication administration scheduled for the facility. 675380 Page 14 of 25 675380 03/22/2023 Windsor Nursing and Rehabilitation Center of Segui 1219 Eastwood Dr Seguin, TX 78155

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen, in that: Residents Affected - Some 1.a. Food items were not sealed, dated in the kitchen refrigerator. b. Two fryer baskets on a cookie tray, were dirty. 2. The chlorine sanitizer in the dish machine was not at the required concentration to sanitize the dishes and utensils. The daily dish machine temperature and sanitizer log were not completed for February/March 2023. The facility was utilizing expired chlorine testing strips to test the chlorine level of the dish machine. This deficient practice could place residents who received meals and/or snacks from the kitchen at risk for food borne illness. The Findings were: Observation on 3/19/2023 beginning at 9:23 AM in the kitchen, with [NAME] N revealed the following food items in the refrigerator: a.- 1/2 and 1/2 milk carton was open with no date -5lb cheddar cheese block was not sealed and no date. -butter block was not sealed and no date. -container of chocolate pudding was dated 3/12/2023, and today date was 3/19/2023. b.-two fryer baskets were not cleaned since Friday (3/17/2023) and they were on the deep fryer bin, on top of cooking sheet. The two fryer baskets were crusted with food and grease. Interview on 3/19/2023 at 9:24 AM in the kitchen, with [NAME] N confirmed the food items in the refrigerator were not sealed and dated. [NAME] N stated the 2 fryers had been left on the deep fryer and she had not cleaned them after use on Friday, 3/12/2023. [NAME] N threw food items away and stated the food items if opened, should be sealed and dated by kitchen staff . [NAME] N stated the night shift should look and check there refrigerator for expired food items and to check if food items need to be sealed and dated. 2. Observation and interview on 3/20/2023 beginning at 10:48 AM revealed the dietary aide (DA) T, ran the facility's dish machine in the dish room. The dish machine was a low-temperature machine that used a chemical sanitizer to sanitize dishes and utensils. The machine reached 120 degrees Fahrenheit during the wash cycle. After the cycle was completed, (DA) T stated checked the chlorine level of the water in the dish machine by placing a chlorine test strip in the water. The test strip turned the color of a very pale lavender, indicating the chlorine level was in the range of 10 parts per million (ppm) when compared to the color chart on the test kit container. DA T tried the chlorine test 675380 Page 15 of 25 675380 03/22/2023 Windsor Nursing and Rehabilitation Center of Segui 1219 Eastwood Dr Seguin, TX 78155

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some strip #2 from container it was in , then she tried #2 other chlorine test strip from a 2nd container that help the chlorine test strip, the range continued to be 10 parts per million (ppm) when compared to the color chart on the test kit container. Surveyor asked to see both chlorine test strip containers the 1st container expired on 8/2018, the 2nd container expired on 7/2020. The surveyor asked for the dish machine temperature log, she DA T stated she documents the dish machine sanitizer when she used the dish machine and had no problems with sanitizer . DA T continued to run the dish machine dirty dishes from breakfast and place dished them (4 trays of bowls and cups) on a shelf (4 trays of bowls and cups). Observation on 3/20/2023 at 11:33 AM revealed DA U was using bowls from the shelf and putting dessert for lunch service while talking with the Certified Dietary Manger (CDM), in the kitchen. Record review of the daily dish machine temperature and sanitizer logs revealed it was were missing temperature and sanitizer PPM's for February 6-28, 2023 and in March 1-19, 2023. Interview on 3/20/2023 at 11:15 AM CDM and surveyor discussed concerns with food items in refrigerator, two fryer baskets and the dish machine sanitizer. The CDM stated she had a new container of chlorine test strips dated 8/2024. The CDM stated she would in-service staff on storing food items in refrigerator. The CDM found the dish machine log and stated she reviewed them every month and in-serviced staff with any current updates or if they needed to be trained on their job duties. The CDM stated she missed reviewing the dish machine logs in March 2023. The CDM stated she was not sure what to do about the dish machine sanitizer not working. The surveyor discussed again the situation about the dish machine sanitizer and DA T's continued dish machine use and placing the dishes back on the shelf when they had not been properly sanitized. The CDM stated maybe they could use disposable, but she would talk about it with her manager. The DM stated she would call the company for the dish machine to get further advice. Interview on 3/20/2023 at 11:58 AM with the Administrator, the surveyor discussed situation in the kitchen, food items in refrigerator, two fryer baskets, and kitchen staff using dishes for dessert, the dish machine sanitizer too low and the DM not sure what to do next. The surveyor stated I wanted to come talk to him, due to CDM not sure what to do and lunch was going to be served soon. The Administrator stated he was going to the kitchen to see what was going on. The surveyor went to kitchen, Administrator and DM stated the new chlorine test strips worked and had the correct sanitizer. Interview on 3/21/2023 at 2:59 PM with the consultant dietician stated the CDM made her aware of the kitchen concerns, meals late, food items in refrigerator, dish machine logs and DA T using 2 expired containers of chlorine test strips to test the chlorine sanitizer on dish machine cycle. The consultant dietician stated she will in-service staff in the kitchen; This was all she said for the meals being late. The consultant dietitian stated the harm to residents would be the food flavor would not be good, general food quality, cross contamination, and the sanitizer would cause cross contamination and food borne illness. Record review of the Job description of the Certified Dietary Manager (dated) revealed Responsible for the daily operations of the dietary department, according to the facility policy and procedures and federal/state regulations. CDM provided leadership and guidance to ensure the food quality, safety standards, and client expectations are satisfactorily met. essential Functions: Operations Management-Interview, train, coach and evaluate dietary staff. Food Service Management: participates in menu planning, including responding to client preferences, .therapeutic diets, inspect meals and assure the standards for .serving times are met. Food safety assure safe , storage, preparations, an 675380 Page 16 of 25 675380 03/22/2023 Windsor Nursing and Rehabilitation Center of Segui 1219 Eastwood Dr Seguin, TX 78155

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some service of food, protect food in all phases in preparation, .service, , transportation,, ensure proper sanitation and safety practices of staff. Record review of Policy General Kitchen Sanitation dated 12/1/2011, The consultant dietician will monitor each facility to ensure that the facility maintains clean, sanitary kitchen facilities in accordance with the county health department regulations and the sated and Federal Food codes. 1. All food preparation area, food-contact surfaces, dining facilities and equipment are cleaned and sanitized after each use, including kitchen, and food-contact surfaces of equipment, except cooking surfaces of equipment and pots and pans that are not used to holed or store food and are used solely for cooking purposes. 3. Food-contact surfaces of all cooking equipment are kept free of encrusted grease deposits and other accumulated soil. Record review of Policy Mechanical cleaning and sanitizing of Utensils and portable equipment dated 12/1/2011 revealed the consultant dietitian will monitor each facility to ensure these cleaning and sanitizing requirements of the county health department and state and federal Food Codes for mechanical cleaning are followed. The following guidelines should be used to ensure adequate sanitation practices are in place. Guidelines: 2. The automatic detergent dispenser and or liquid sanitizer injector is working properly. 7. The machine that uses chemicals for sanitizing is in use, the following guidelines are used: c. chemicals added for sanitation purposes are automatically dispensed. d., Utensils and equipment are exposed to the final chemical sanitizing rinse in accordance with the manufacturer's specifications for time and concentration. F. chemical sanitizers used shall meet the following requirements: 1) A minimum of 50 part per million (ppm) of available chlorine at a temperature not less than 75 degrees Fahrenheit less than 75 degrees. d. A test kit or other device that accurately measures the ppm concentration of the solution is available and used. A simple Dish Machine Temperature and Sanitizing Log follows this policy. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2017, U.S. Department of H&HS, revealed: 4-501.114 Manual and Mechanical Warewashing Equipment, Chemical Sanitization -Temperature, pH, Concentration, and Hardness. A chemical SANITIZER used in a SANITIZING solution for a manual or mechanical operation at contact times specified under 4-703.11(C) shall meet the criteria specified under §7-204.11 Sanitizers, Criteria, shall be used in accordance with the EPA-registered label use instructions, and shall be used as follows: (A) A chlorine solution shall have a minimum temperature based on the concentration and PH of the solution as listed in the following chart; mg/L pH 10 or Less pH 8 or Less 25-49 120 degrees F 120 degrees F 50-99 100 degrees F 75 degrees F 4-501.116 Warewashing Equipment, Determining Chemical Sanitizer Concentration. Concentration of the SANITIZING solution shall be accurately determined by using a test kit or other device. 675380 Page 17 of 25 675380 03/22/2023 Windsor Nursing and Rehabilitation Center of Segui 1219 Eastwood Dr Seguin, TX 78155

F 0814 Dispose of garbage and refuse properly. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review the facility failed to dispose of garbage and refuse properly for 1 of 1 facility in that: Residents Affected - Few The one dumpster side door was open, a trash bag was on the ground near the dumpster and trash was scatted on the ground near the dumpster. This could affect all residents and could result in pest in the facility. The Findings were: Observation on 3/19/2023 at 9:41 AM with [NAME] N revealed the one dumpster side door was open, a trash bag was on the ground near the dumpster and trash was scattered on the ground near the dumpster. Interview on 3/19/2023 at 9:42 AM with [NAME] N confirmed the one dumpster side door was open, a trash bag was on the ground near the dumpster and trash was scattered on the ground near the dumpster. [NAME] N picked up trash, threw it in the dumpster and closed the side door. Interview on 3/20/2023 at 11:27 PM with the dietary manager listened to the surveyor's concerns in kitchen and stated she will in-service staff. Interview on 3/20/2023 at 5:25 PM with the Administrator stated will search for kitchen polices, but not sure they will have all of them. Record review of Garbage Receptacles policy dated October 1, 2018, revised on June 1, 2019, revealed, the facility will maintain garbage receptacles in a clean and sanitary manner to minimize the risk if food hazards. 675380 Page 18 of 25 675380 03/22/2023 Windsor Nursing and Rehabilitation Center of Segui 1219 Eastwood Dr Seguin, TX 78155

F 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to designate a member of the facility's interdisciplinary team who is responsible for working with hospice representatives to coordinate care to the resident provided by the LTC facility staff and hospice staff and obtain the required information for 2 of 3 (Resident #70 and #87) residents reviewed for hospice services, in that: 1. The facility failed to obtain Resident #70's most recent hospice plan of care, names and contact information for hospice personnel involved in hospice care of each resident, documentation by specific interdisciplinary hospice staff providing services. 2. The facility failed to obtain Resident #87's most recent hospice plan of care, names and contact information for hospice personnel involved in hospice care of each resident, documentation by specific interdisciplinary hospice staff providing services. This failure could place the resident who received hospice services at-risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care and communication of resident needs. The findings were: 1. Record review of Resident #70's face sheet, dated 03/22/2023, revealed the resident was admitted to the facility on [DATE] with diagnoses that included: Alzheimer's Disease (type of brain disorder that causes problems with memory, thinking and behavior), peripheral vascular disease (PVD, systemic disorder that involves the narrowing of peripheral blood vessels), hyperparathyroidism of renal origin (complication of kidney disease characterized by elevated parathyroid hormones), and hypertensive chronic kidney disease (damage to the kidney due to chronic high blood pressure). Record review of Resident #70's Quarterly MDS dated [DATE] revealed a BIMS of 03, which indicated severe cognitive impairment. Further review revealed the resident had a life expectancy of less than 6 months and had received hospice care while a resident at the facility. Record review of Resident #70's comprehensive care plan initiated 08/04/2022 revealed a problem Admit to Hospice Company A Dx. Moderate Protein Calorie Malnutrition/deficiency. Call [phone number] for any changes in condition, questions or concerns. No labs or x-rays without hospice approval. RN Hospice nurse to pronounce. Record review of Resident #70's electronic medical record active orders as of 03/22/2023 revealed an order on 06/21/2022 for: Admit to Hospice Company A Dx. Moderate Protein Calorie Malnutrition/deficiency. Call [phone number] for any changes in condition, questions or concerns. No labs or x-rays without hospice approval. RN Hospice nurse to pronounce. Record review of Resident #70's electronic medical record, miscellaneous documents section, category Hospice, revealed only a hospice election and physician certification of terminal illness form were uploaded. 2. Record review of Resident #87's face sheet, dated 03/22/2023, revealed the resident had an 675380 Page 19 of 25 675380 03/22/2023 Windsor Nursing and Rehabilitation Center of Segui 1219 Eastwood Dr Seguin, TX 78155

F 0849 Level of Harm - Minimal harm or potential for actual harm initial admission date of 10/08/2021 with a re-admission on [DATE] with diagnoses that included: dementia (group of symptoms affecting memory, thinking and social abilities severely enough to interfere with your daily life), acute kidney failure (kidneys suddenly become unable to filter waste products from your blood) and cerebrovascular disease (group of disorders that affect the blood vessels and blood supply to the brain). Residents Affected - Few Record review of Resident #87's Quarterly MDS, dated [DATE], revealed an unscored BIMS score. Further review revealed the staff assessment for mental status scored Resident #87 as severely impaired never/rarely made decisions. Continued review of Resident #87's MDS revealed the resident had a life expectancy of less than 6 months and had received hospice care while a resident at the facility. Record review of Resident #87's Care Plan with a date initiated 03/15/2022, revealed Admit to Hospice Company B. Dx: End Stage Alzheimer's No labs or X-Rays ordered without Hospice approval. Call Hospice Company B for any changes in condition, concerns, questions or falls @ [phone number] [fax number] RN Hospice Nurse to pronounce. Record review of Resident #87's electronic medical record active orders as of 03/22/2023, revealed an order on 03/15/2022 for: Admit to Hospice Company B with DX of Alzheimer's Admit to Hospice Company B. Dx: End Stage Alzheimer's No labs or X-Rays ordered without Hospice approval. Call Hospice Company B for any changes in condition, concerns, questions or falls @ [phone number] [fax number] RN Hospice Nurse to pronounce. Record review of Resident #87's electronic medical record, miscellaneous documents section, category Hospice, revealed only a hospice election and physician certification of terminal illness form were uploaded. In an interview with LVN O on 03/22/2023 at 11:55 a.m., LVN O revealed all records regarding resident care was kept in the resident's electronic medical record. LVN O revealed that only hospice residents have additional paper records kept in hospice binders. LVN O was unable to locate a hospice binder for Resident #70 or Resident #87. LVN O was asked who is responsible for organizing hospice services for residents and LVN O stated the SW meets with families when the doctor orders hospice so the family can choose which agency they want. LVN O was asked how resident care is coordinated between hospice and nursing staff and LVN O revealed when the hospice nurse is finished with the visit, they stop by the nursing station and give a report. In an interview with the SW on 03/22/2023 at 12:35 p.m., the SW revealed that after the resident/family had chosen which hospice agency they wanted to use he wouldn't play a part in the coordination of hospice services unless something was needed. In an interview with the DON on 03/22/2023 at 12:54 p.m., the DON was asked who is responsible for the coordination of hospice care for the residents. The DON revealed the ADON staff had been the point of contact at one time for the assigned hospice nurse case manager to update following each visit. The DON added the hospice nurses now communicate more closely with the charge nurses. Record review of the facility's hospice services agreement with Hospice Company A, with effective date, August 1, 2012, revealed, in 2.12 Plan of Care .The Hospice and Nursing facility will jointly develop and agree upon a coordinated Plan of Care which is consistent with the hospice philosophy ad is responsive to the unique needs of the Residential Hospice Patient and his/her expressed desire for hospice care. 3.2 (i) Hospice shall furnish Nursing Facility with a copy of the Plan of Care. 3.15 675380 Page 20 of 25 675380 03/22/2023 Windsor Nursing and Rehabilitation Center of Segui 1219 Eastwood Dr Seguin, TX 78155

F 0849 Level of Harm - Minimal harm or potential for actual harm Providing Information. At a minimum Hospice shall provide the following information to Facility for each Hospice Patient residing at Facility: A. Hospice Plan of Care . 6.1. Liaison. On or prior to the execution of this Agreement, Hospice and Nursing Facility shall each designate two (2) representative(s) to serve as designees between them and to facilitate cooperative efforts in performance of their respective obligations under this Agreement. Residents Affected - Few Record review of the facility's hospice services agreement with Hospice Company A, with effective date, December 30, 2014, revealed, in 2.12 Plan of Care .The Hospice and Nursing facility will jointly develop and agree upon a coordinated Plan of Care which is consistent with the hospice philosophy ad is responsive to the unique needs of the Residential Hospice Patient and his/her expressed desire for hospice care. 3.2 (i) Hospice shall furnish Nursing Facility with a copy of the Plan of Care. 3.15 Providing Information. At a minimum Hospice shall provide the following information to Facility for each Hospice Patient residing at Facility: A. Hospice Plan of Care . 6.1. Liaison. On or prior to the execution of this Agreement, Hospice and Nursing Facility shall each designate two (2) representative(s) to serve as designees between them and to facilitate cooperative efforts in performance of their respective obligations under this Agreement. Record review of the facility's policies revealed the facility did not have a hospice policy. 675380 Page 21 of 25 675380 03/22/2023 Windsor Nursing and Rehabilitation Center of Segui 1219 Eastwood Dr Seguin, TX 78155

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an Infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 2 of 6 residents (Residents #36 and, #59) reviewed for infection control, in that: Residents Affected - Few 1. While providing incontinent care for Resident #36 CNA A did not wash or sanitize her hands between change of gloves. 2. While providing incontinent care for Resident #59 CNA C and CNA D cross contaminated the clean brief of the resident with the soiled incontinent pad. These deficient practices could place residents at-risk for infection due to improper care practices. The findings include: 1. Record review of Resident #36's face sheet, dated 03/21/2023, revealed an admission date of 03/02/2015 and, a readmission date of 02/08/2021, with diagnoses which included: Alzheimer's disease (brain disorder that causes problems with memory, thinking and behavior), Chronic kidney disease(gradual loss of kidney function) , Mood disorder (general emotional state or mood is distorted or inconsistent with circumstances and interferes with the ability to function), Hypertension (High blood pressure), Hyperlipidemia (too much lipids (fat) in the blood). Record review of Resident #36's Quarterly MDS, dated [DATE], revealed Resident #36 did not have a BIMS score and, had severe cognitive impairment. Resident #36 was indicated to always be incontinent of bladder and bowel and needed extensive assistance to total care with his activities of daily living. Review of Resident #36's care plan revealed a problem of The resident has bladder incontinence ALWAYS related to dx Alzheimer's / lack of awareness, with an intervention of Monitor/document for s/sx UTI, notify MD for any changes in status Observation on 03/21/2023 at 11:34 a.m. revealed while providing incontinent care for Resident #36, CNA A change her gloves after cleaning the resident and before touching the clean brief but did not sanitize or wash her hands. During an interview on 03/21/2023 at 11:55 a.m. with CNA A, she confirmed she did not use sanitizer or wash her hands between change of gloves. During an interview with the DON on 03/22/2023 at 10:30 a.m., she confirmed the staff should sanitize or wash their hands between change of gloves to prevent infection to the residents, The DON reveled the staff received training on infection control and incontinent care at least annually. The staff skills were check yearly. The facility had a CNA instructor that would train the CNA and would spot check the staff while they provided care for infection control and quality of care. 675380 Page 22 of 25 675380 03/22/2023 Windsor Nursing and Rehabilitation Center of Segui 1219 Eastwood Dr Seguin, TX 78155

F 0880 Level of Harm - Minimal harm or potential for actual harm 2. Record review of Resident #59's face sheet, dated 03/21/2023, revealed an admission date of 07/31/2018 and, a readmission date of 06/25/2019, with diagnoses which included: Dementia(loss of cognitive functioning - thinking, remembering, and reasoning), Wernicke's encephalopathy(Degenerative brain disorder), Psychotic disorder(Mental disorders characterized by disconnection from reality which results in strange behavior) Residents Affected - Few Record review of Resident #59's Quarterly MDS, dated [DATE], revealed Resident #59 had a BIMS score of 3 indicating severe cognitive impairment. Resident #59 was indicated to always be incontinent of bladder and bowel and needed extensive assistance with her activities of daily living. Review of Resident #59's care plan revealed a problem of The resident has bladder incontinence r/t cognitive deficit, with an intervention of Check q 2 hrs and as required for incontinence. Wash, rinse and dry perineum (Space between anus and genitals). Change clothing PRN after incontinence episodes. Observation on 03/21/2023 at 12:21 a.m. revealed during incontinent care for Resident #59 provided by CNA C and CNA D, the soiled incontinent pad came in contact with the inside of the new brief when the CNAs were changing the brief and incontinent pad for Resident #59. During an interview on 03/21/2023 at 11:55 a.m. with CNA C, she confirmed the soiled incontinent pad should not have touched the clean brief. She revealed the brief may get dirty and then touched the resident skin. She confirmed she received infection control from the facility. During an interview with the DON on 03/22/2023 at 10:30 a.m., she confirmed the staff should have completely removed the soiled pad and brief before placing the clean pad and brief on the resident to prevent contact and cross contamination. The DON revealed the staff received training on infection control and incontinent care at least annually. The staff skills were check yearly. The facility had a CNA instructor that would train the CNA and would spot check the staff while they provided care for infection control and quality of care. Review of facility policy, titled Hand washing - Hand Hygiene, dated January 2018, revealed Use an alcohol based hand rub [ .] for the following situations [ .] Before and after direct contact with resident [ .] Before moving from a contaminated body site to a clean body site during resident care [ .] After contact with blood or bodily fluids [ .] After removing gloves. 675380 Page 23 of 25 675380 03/22/2023 Windsor Nursing and Rehabilitation Center of Segui 1219 Eastwood Dr Seguin, TX 78155

F 0940 Develop, implement, and/or maintain an effective training program for all new and existing staff members. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to develop, implement, and maintain annually an effective training program for individuals providing services under a contractual arrangement, consistent with their expected roles, that included but are not limited to the mandatory training topics of communication, resident rights, abuse and neglect, QAPI, infection control, compliance and ethics, and behavioral health for 3 of 3 contract employees (PT P, OT Q and ST R) reviewed for training, in that: Residents Affected - Some The facility failed to ensure required trainings were provided for PT P, OT Q and ST R working in the therapy department at the facility under a contractual agreement for the review period of March 2022 to March 2023. This failure could place residents at risk of being cared for by staff who have been insufficiently trained. The findings were: Record review of personnel records for PT P revealed a hire date of 01/02/2015. Further review of a training log, from a web-based training platform used by the facility, from January 2022 to March 2023, and provided by the HR Manager revealed no evidence of communication, ethics, or behavioral health trainings. Record review of personnel records for OT Q revealed a hire date of 01/02/2014. Further review of a training log, from a web-based training platform used by the facility, from January 2022 to March 2023, and provided by the HR Manager revealed no evidence of communication, resident rights, QAPI, ethics, or behavioral health trainings. Record review of personnel records for ST R revealed a hire date of 07/22/2014. Further review of a training log, from a web-based training platform used by the facility, from January 2022 to March 2023, and provided by the HR Manager revealed no evidence of communication, QAPI, ethics, or behavioral health trainings. In an interview with the HR Manager on 03/22/2023 at 9:48 a.m., the HR Manager revealed therapy staff have a different relationship with the facility. The HR Manager added that the therapy staff are contract however owned by the same corporate company as the facility. The HR Manager stated she had provided all training she had for therapy staff however would contact corporate office to asked if any additional training logs were available. In a follow-up interview with the HR Manager and DON on 03/22/2023 at 3:14 p.m., the HR Manager revealed no other trainings were available for PT P, OT Q and ST R and confirmed the staff had not received all the required trainings. The HR Manager revealed when corporate added the Phase 3 mandatory training requirements for all facility staff, they didn't get added to the therapy staff's modules to complete. Record review of the facility's policy titled, Training Requirements, dated 10/13/22, revealed, It is the policy of this facility to develop, implement, and maintain an effective training program for all new and existing staff, individuals providing services under a contractual arrangement, and 675380 Page 24 of 25 675380 03/22/2023 Windsor Nursing and Rehabilitation Center of Segui 1219 Eastwood Dr Seguin, TX 78155

F 0940 Level of Harm - Minimal harm or potential for actual harm volunteers, consistent with their expected roles. 6. Training content includes, at a minimum: a. Effective communication for direct care staff, b. Resident rights and facility responsibilities for caring of residents, c. Elements and goals of the facility's QAPI program, e.facility's compliance and ethics program, f. Behavioral health. Residents Affected - Some 675380 Page 25 of 25