Health inspection·May 24, 2024

F 0577 Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. Level of Harm - Potential for minimal harm Based on observations and interviews, the facility failed to post, in a place readily accessible to residents, family members, and legal representatives of residents, the results of the most recent survey of the facility for 1 of 1 facility reviewed for resident rights. Residents Affected - Many The facility did not have the survey results available and accessible to residents and visitors without having to ask for them on 5/21/24, 5/22/24, and 5/23/24 during the survey period. This failure resulted in residents, family members, and legal representatives of residents having a lack of knowledge of the facility's past inspections, violating resident rights. The findings were: In an observation on 05/21/24 at 9:09 a.m., there was no sign indicating where the survey results were located and no survey results were observed at the entrance, lobby area, or at the nursing station. In an observation on 5/22/24 at 8:50 a.m., there was no sign indicating where the survey results were located and no survey results were observed at the entrance, lobby area, or at the nursing station. In the resident council group meeting on 5/22/24 at 10:00 a.m. the residents stated they were not aware of being able to read previous survey results and denied knowledge of a sign indicating where the survey results were or a binder or book in the facility or an area where they could read the previous survey results. The residents stated they were not aware they could read the results and would like to be able to. In an observation and interview on 5/23/24 at 1:15 p.m., the DON stated the results used to be in the lobby area and she was unsure of where the sign was regarding the survey results or where the survey results were located and would check with the Administrator. The Administrator was able to show surveyor an approximately 4-inch x 8-inch piece of paper behind a framed glass case hanging on the wall at the entrance that was typed and indicated the survey results were available for viewing behind the receptionist area and to please see a staff member for assistance. The Administrator stated the reason for them to ask a staff member for assistance to access and read the results was on several occasions pages were torn out and were missing so they were placed behind the receptionist area as a solution but were still available upon request. In an observation on 5/23/24 at 6:00 p.m., the survey results were in a binder clearly marked on a Page 1 of 24 675380 675380 05/24/2024 Windsor Nursing and Rehabilitation Center of Segui 1219 Eastwood Dr Seguin, TX 78155

F 0577 Level of Harm - Potential for minimal harm Residents Affected - Many conversation table between two chairs in the entrance/lobby area and readily accessible to anyone wishing to view them. In an interview on 5/24/24 at 11:05 a.m., the Administrator stated he was unsure of when the survey results had been placed behind the receptionist area. The Administrator stated the consequences could be a knowledge deficit for people who wanted to view them. On 5/24/24 at 2:16 p.m., the DON stated they did not have a policy on survey results being readily accessible. 675380 Page 2 of 24 675380 05/24/2024 Windsor Nursing and Rehabilitation Center of Segui 1219 Eastwood Dr Seguin, TX 78155

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record reviews, the facility failed to ensure the MDS assessment must accurately reflect the resident's status for 1 (Resident #3) of 24 residents reviewed for assessments. Residents Affected - Few Resident #3 was ordered an RCS diet with pureed texture and fortified foods, and her annual MDS assessment with an ARD of 05/03/2024 did not reflect she was on a therapeutic diet. This deficient practice affects residents with specialized care and could result in inaccurate or missed care. The findings included: Record review of Resident #3's electronic face sheet dated 05/22/2024 reflected she was admitted to the facility on [DATE]. Her diagnoses included: Alzheimer's disease (a type of dementia that affects memory, thinking and behaviors), chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs), diabetes mellitus (a disease in which the body does not control the amount of glucose (a type of sugar) in the blood and the kidneys make a large amount of urine) and anxiety (a feeling of worry, nervousness and unease). Record review of Resident #3's annual assessment with an ARD of 05/03/2024 reflected she scored a 03 out of 15 on her BIMS which signified her cognition was severely impaired. She was dependent on staff for ADLs, and she was prescribed a mechanically altered diet and not therapeutic. Record review of Resident #3's comprehensive person-centered care plan revised on 04/05/2024 reflected on a reduced concentrated sweets diet, pureed texture, regular liquids. Record review of Resident #3's Active Orders as of: 05/23/2024 reflected Diet, Reduced Concentrated Sweets Diet Pureed Texture, regular liquids consistency, start date, 08/27/2023. Observation on 05/23/2024 at 08:15 a.m. of Resident #3 revealed she was lying in bed with her food tray on her bedside table. Her food was of a pureed texture. Record review on 05/23/2024 at 08:15 a.m. of Resident #3's meal ticket, it read RCS, pureed, regular liquid diet. During an interview on 05/24/2024 at 1:27 p.m. with the DON, she stated reduced concentrated sweets was a therapeutic diet and should have been indicated on Resident #3's annual MDS assessment. She stated the accuracy of the MDS assessment was important because it communicated the type of care a resident required. During an interview on 05/24/2024 at 2:50 PM with the MDS nurse she stated Resident #3 was on an RCS diet which was therapeutic and she did not know how it was missed on her 05/23/2024 MDS assessment, but that the assessment was inaccurate. She stated accuracy of the MDS assessment was important for communication about care for a resident and the care could be missed or inaccurately provided. She stated she was accountable for the MDS accuracy. During an interview on 05/24/2024 at 03:06 PM with CNA C revealed, she worked on Resident #3's hall 675380 Page 3 of 24 675380 05/24/2024 Windsor Nursing and Rehabilitation Center of Segui 1219 Eastwood Dr Seguin, TX 78155

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few and delivered her meal trays often. She stated Resident #3 was on an RCS, pureed diet with regular liquids. Record review of the CMS Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.17.1, October 2019 reflected The RAI process has multiple regulatory requirements . (1) the assessment accurately reflects the resident's status. 675380 Page 4 of 24 675380 05/24/2024 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 consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental, and psychosocial needs that were identified in the comprehensive assessment, for 1 of 24 residents (Residents #3) reviewed for care plans. Resident #3 had compression stockings ordered to be on in AM and off in PM which was not reflected in her person-centered care plan. This deficient practice affected residents who require assistance with ADL's and could result in missed or inadequate care. The findings included: Record review of Resident #3's electronic face sheet dated 05/22/2024 reflected she was admitted to the facility on [DATE]. Her diagnoses included: Alzheimer's disease (a type of dementia that affects memory, thinking and behaviors), chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs), diabetes mellitus (a disease in which the body does not control the amount of glucose (a type of sugar) in the blood and the kidneys make a large amount of urine) and anxiety (a feeling of worry, nervousness and unease). Record review of Resident #3's annual assessment with an ARD of 05/03/2024 reflected she scored a 03 out of 15 on her BIMS which signified she was severely cognitively impaired. She was dependent on staff for ADLs. Record review of Resident #3's comprehensive person-centered care plan dated revised on 07/06/2023 reflected Resident has an ADL self-care performance deficit, Interventions, able to help pull clothes down at times but relies on extensive assistance x1 from staff to lift arms/legs into clothes. Record review of Resident #3's Active Orders as of: 05/23/2024 reflected KNEE HIGH COMPRESSION STOCKINGS 15-20 MMHG at bedtime for EDEMA APPLY IN THE MORNING AND REMOVE AT BEDTIME Verbal Active 09/08/2022 Observation on 05/23/2024 at 08:15 a.m. of Resident #3 revealed she was lying in bed and she did not have knee high compression stockings on her lower legs. Record review of Resident #3's EMAR dated 05/01/2024 to 05/31/2024 reflected she refused the Knee-High Compression Stockings daily. During an interview on 05/24/2024 at 1:27 p.m. with the DON, she stated she would look at the order to see if Resident #3 still required the stockings, and if not she would get the order discontinued. She stated a daily treatment for the resident should have been in the resident's comprehensive person-centered care plan as a part of her care. She stated care could be missed and the stockings may be care she no longer required. 675380 Page 5 of 24 675380 05/24/2024 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 During an interview on 05/24/2024 at 2:50 PM with the MDS Nurse she stated Resident #3's compression stockings needed to be in her comprehensive plan of care. She stated Resident #3 had the stockings ordered for daily, so they must have been an important part of care to reduce swelling in her legs. Record review of the CMS Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.17.1, October 2019 reflected the comprehensive care plan is an interdisciplinary communication tool. It must include measurable objectives and time limits and must describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The care plan must be reviewed and revised periodically, and the services provided or arranged must be consistent with each resident's written plan of care. 675380 Page 6 of 24 675380 05/24/2024 Windsor Nursing and Rehabilitation Center of Segui 1219 Eastwood Dr Seguin, TX 78155

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments for 2 (Residents #22 and #64) of 24 residents reviewed for care plans. 1.Resident #22's comprehensive person-centered care plan was not revised after her quarterly MDS assessment with an ARD of 05/09/24 to reflect she was incontinent of bladder. 2.Resident #64's comprehensive person-centered care plan was not revised after his quarterly MDS assessment with an ARD of 04/09/2024 to reflect he was always incontinent of bowel and bladder. This deficient practice affects residents who require assistance with ADL's and could place residents at risk of missing required care. The findings included: 1.Record review of Resident #22's electronic face sheet dated 05/22/2024 reflected she was admitted to the facility on [DATE]. Her diagnoses included: chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs), dysphagia (difficulty swallowing), asthma (inflamed airways, producing mucous which makes it difficult to breath), vascular dementia (brain damage caused by multiple strokes), and cerebral infarction (damage to tissues in the brain due to loss of oxygen to the area). Record review of Resident #22's quarterly MDS assessment with an ARD of 05/09/2024 reflected she was not a candidate for a BIMS which signified she was severely cognitively impaired. She sometimes could understand, but rarely could be understood. She was dependent on staff for her ADL care and was always incontinent of bowel and bladder. Record review of Resident #22's comprehensive person-centered care plan revision date of 05/08/2023 reflected has bowel incontinence r/t CVA. The care plan did not address she was always incontinent of bladder. During an interview on 05/24/2024 at 1:27 p.m. with the DON, she stated Resident #22 was always incontinent of bowel and bladder and that information needed to be reflected on the person-centered care plan. She stated revisions of care plans are completed after the MDS assessment and this one must have been missed, and she did not know why. She stated proper care for a resident was communicated through the care plan and care could be missed. During an interview on 05/24/2024 at 2:50 PM with the MDS nurse she stated Resident #22 was always incontinent of bladder and somehow she missed putting that information into her care plan revision. She stated the importance of updating and revising care plans to keep information of care accurate and current to meet the resident's needs. During an interview on 05/24/2024 at 03:06 PM with CNA C revealed, she worked on Resident #22's hall and Resident #22 was always incontinent of bowel and bladder. 675380 Page 7 of 24 675380 05/24/2024 Windsor Nursing and Rehabilitation Center of Segui 1219 Eastwood Dr Seguin, TX 78155

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 2. Record review of Resident #64's electronic face sheet dated 05/22/2024 reflected he was admitted to the facility on [DATE]. His diagnoses included: Alzheimer's disease (a type of dementia that affects memory, thinking and behaviors), Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), end stage renal disease (the final permanent stage of chronic kidney disease) and malignant neoplasm of prostate (prostate cancer that can grow and spread to other parts of the body). Record review of Resident #64's quarterly MDS assessment with an ARD of 04/09/2024 reflected he scored a 03 out of 15 on his BIMS which signified he was severely cognitively impaired. He could be understood and usually could understand. He required moderate to extensive assistance with his ADL's. He was always incontinent of bowel and bladder. Observation on 05/23/2024 at 2:22 PM of CNA D and CNA E perform incontinent care for Resident #64 revealed he was incontinent of bowel and bladder. Record review of Resident #64's comprehensive person-centered care plan revised on 01/31/2022 reflected has an ADL self-care performance deficit r/t Alzheimer's disease, Interventions, TOILET USE: The resident requires limited to extensive assistance x1-2 staff for toileting. Resident will need staff assistance on and off toilet and with peri care brief changes daily and as needed. The care plan did not reflect he was always incontinent of bowel and bladder. During an interview on 05/24/2024 at 1:27 p.m. with the DON, she stated Resident #64 was incontinent of bowel and bladder and that information needed to be updated in his care plan for him to receive the appropriate care needed. During an interview on 05/24/2024 at 2:50 PM with the MDS nurse she stated Resident #64 was always incontinent of bowel and bladder and she did not know why she missed updating the information in his care plan. She stated the care plan reflected the care required for residents. During an interview on 05/24/2024 at 03:06 PM with CNA C revealed, she worked on Resident #64's hall and stated he was always incontinent of bowel and bladder. Record review of the CMS Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.17.1, October 2019 reflected the comprehensive care plan is an interdisciplinary communication tool. It must include measurable objectives and time limits and must describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The care plan must be reviewed and revised periodically, and the services provided or arranged must be consistent with each resident's written plan of care. 675380 Page 8 of 24 675380 05/24/2024 Windsor Nursing and Rehabilitation Center of Segui 1219 Eastwood Dr Seguin, TX 78155

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents received adequate supervision to prevent accidents for 1 of 10 residents (Resident #29) reviewed for quality of care. On 05/17/2024, Resident #29 suffered a broken ankle when CNA C and CNA I used a sheet to transfer Resident #29 from a shower chair to a wheelchair. This failure could place residents at risk for serious injuries. The findings included: A record review of Resident #29's admission record dated 05/23/2024, revealed an admission date of 05/02/2022 with diagnoses which included disorder of bone density and structure, pain in knees, and muscle weakness. A record review of Resident #29's annual MDS assessment dated [DATE], revealed Resident #29 was an [AGE] year-old female admitted for long term care and assessed with an ability to hear, make herself understood with clear speech, and had impaired vision without eyeglasses. Resident #29 was assessed with a BIMS score of 09 out of a possible 15 which indicated moderate cognitive impairment. Resident #29 was assessed as Dependent - Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity for the following activities of daily life: toileting, bathing / showering, chair to bed transfers, and tub / shower transfers. A record review of Resident #29's care plan dated 05/21/2024 revealed Resident #29 was a 2-person assist for transfers and bathing / showering. A record review of Resident #29's Occupational Therapy Evaluation and Plan of treatment certification period 04/17/2024 - 05/15/2024, dated 05/14/2024, revealed Resident #29's PLOF (prior level of functioning) was total dependence with bathing, toileting, lower body dressing, functional mobility during ADLs (activities of daily living) and required maximum assistance with a Hoyer lift (a mechanical lift). Resident #29 was assessed as having pain with movement: intensity = 09/10 due to severe arthritis in joints .location bilateral knees . Resident #29 was assessed with risk factors, due to the documented physical impairments and associated functional deficits, the patient is at risk for: falls, further decline in function, muscle atrophy, decreased participation with functional tasks and decreased ability to return to prior living environment A record review of Resident #29's Facility's Investigation report dated 05/28/2024, revealed the Administrator investigated and concluded CNA C and CNA I on the evening of 05/17/2024 assisted Resident with a shower and when Resident #29 was transferred back into her wheelchair when her legs were under her and the wheelchair and thus felt pain which was assessed as an ankle fracture. During an interview on 05/21/2024 at 03:10 PM, Resident #29 stated she was bed bound and had pain in her knees. Resident #29 stated she preferred to be showered in a shower chair and CNA C and CNA I would transfer her with a bed sheet from her bed to her wheelchair and then to the shower room where she would be transferred from the wheelchair to a shower chair. Resident #29 stated she preferred 675380 Page 9 of 24 675380 05/24/2024 Windsor Nursing and Rehabilitation Center of Segui 1219 Eastwood Dr Seguin, TX 78155

F 0689 Level of Harm - Actual harm Residents Affected - Few the bed sheet transfer and would refuse to be transferred any other way. Resident #29 stated the Hoyer lift was uncomfortable. Resident #29 stated on 05/17/2024 when CNA C and CNA I transferred her from the shower chair to the wheelchair using a draw sheet, and she was put in the wheelchair while her legs went under her and felt pain to her right foot . Resident #29 stated she was assessed with a broken ankle; the x-ray showed my broken foot. Interview on 05/22/2024 at 01:30 PM with Resident #29 revealed she could not place weight on her feet. She stated the staff were good to her at the facility and what happened with her ankle was an accident. She stated the staff took her from the shower chair and placed her into the wheelchair, where her knee buckled, and she started sliding out of the chair and landed on her ankle. She stated she did not like the mechanical lift or gait belt, and the staff transferred her with a draw sheet which did not hurt her like the mechanical lift. During a joint interview on 05/23/24 at 03:32 PM CNA C and CNA I stated Resident #29 was not able to stand or walk and needed the assistance of 2 staff to transfer from a bed to a wheelchair. CNA C and CNA I stated Resident #29 would refuse transfer assistance with a Hoyer lift and would also usually refuse a bed bath. CNA C and CNA I stated Resident #29 preferred a shower in the shower chair and over the last months they had developed a rapport with Resident #29 and successfully transferred Resident #29 with a 2 person assist bed sheet transfer. CNA C and CNA I stated they used a bed sheet as a draw sheet and would place the sheet under Resident #29 then they would grasp the sheet and pick Resident #29 above the bed and over to the wheelchair. CNA C and CNA I stated on 05/17/2024 they transferred Resident #29, with the draw sheet from her bed to her wheelchair, to the shower room, to the shower chair, and afterwards transferred Resident #29 from the shower chair to the wheelchair. CNA C and CNA I stated when they used the draw sheet to pick up Resident #29 and transferred her to the wheelchair, they had not seen Resident #29 bend her knees and tucked them under her while they sat her down and thus Resident called out in pain. CNA C stated she used her strength to pick up the front wheels of Resident #29's wheelchair to allow Resident #29 to extend her legs from under the wheelchair. CNA C and CNA I stated Resident #29 was assessed by the nurse and then sent to the hospital where she was assessed with a broken right ankle. CNA C and CNA I stated Resident #29 had always had her legs extended straight out and they had never known Resident #29 had the ability to bend her knees therefore they never expected Resident #29 could bend her legs and have them under the wheelchair. During an interview on 05/23/24 at 04:30 PM, ADON K stated Resident #29 often preferred to stay in bed and was assessed as a 2 person assist for transfers. ADON K stated Resident #29 would refuse to be transferred with a gait belt and or a Hoyer mechanical lift . ADON K stated CNA C and CNA I were Resident #29's preferred staff and had developed a rapport and technique to transfer Resident #29 with a draw sheet. On 05/24/2024 at 10:00 AM, a facility policy regarding transfers was requested from the facility and a policy regarding Activities of Daily living was provided. A record review of the facility's Activities of Daily Living policy dated 05/26/2023 revealed, the facility will, based on the Resident's comprehensive assessment and consistent with the Resident's needs and choices, ensure a Resident's ability in activities of daily life do not deteriorate unless deterioration is unavoidable. Care and services will be provided for the following activities of daily living: bathing, dressing, grooming, and oral care; transfer and ambulation; toileting 675380 Page 10 of 24 675380 05/24/2024 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure its medication error rates were not 5% or greater. The facility had a medication error rate of 6.9%, based on 2 errors out of 29 opportunities which involved 2 of 6 residents (Resident #16 and #53) reviewed for medication administration and medication errors. Residents Affected - Some 1. Medication Aide J administered Resident #16's clonazepam, a drug used to treat panic disorder, 17 minutes late. 2. Medication Aide J administered Resident #53's gabapentin, a drug used to treat nerve pain, 30 minutes late. These deficient practices could place residents at risk for not receiving therapeutic effects of their medications and possible adverse reactions. The findings included: A record review of Resident #16's admission record dated 5/24/2024 revealed an admission date of 08/16/2024 with diagnoses which included anxiety, bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration), and malignant neoplasm of brain (brain cancer). A record review of Resident #16's admission MDS dated [DATE] revealed Resident #16 was a [AGE] year-old female admitted for long term care and was assessed with medically complex conditions which included non-traumatic brain dysfunction and cancer. Resident #16 was assessed with a BIMS score of 11 out of a possible 15 which indicated intact cognition. A record review of Resident #16's care plan dated 05/04/2024 revealed, (Resident #16) will exhibit indicators of depression, anxiety, or sad mood less than daily by review date .Administer medications as ordered. Monitor/document for side effects and effectiveness A record review of Resident #16's physician's orders dated 05/24/2024 revealed the physician prescribed Resident #16 clonazepam tablet 0.5mg three times a day, at 08:00 AM, 02:00 PM, and 08:00 PM, related to anxiety disorder. During an observation on 05/23/2024 at 09:17 AM revealed Med Aide J prepared and administered to Resident #16's her clonazepam. A record review of Resident #53's admission record revealed an admission date of 07/31/2022 with diagnoses which included type 2 diabetes mellitus (a disease that occurs when your blood glucose, also called blood sugar, is too high) with diabetic polyneuropathy (many nerves in pain). A record review of Resident #53's quarterly MDS assessment dated [DATE], revealed Resident #53 was a [AGE] year-old female admitted for long term care and assessed with medically complex diagnoses which included diabetes, and a BIMS score of 05 out of a possible of 15 which indicated severe cognitive impairment. 675380 Page 11 of 24 675380 05/24/2024 Windsor Nursing and Rehabilitation Center of Segui 1219 Eastwood Dr Seguin, TX 78155

F 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A record review of Resident #53's physician's orders dated 05/24/2024 revealed Resident #53 was prescribed Gabapentin 100mg 1 capsule three times a day, at 08:00 AM, 02:00 PM, and 08:00 PM, for diabetic polyneuropathy. A record review of Resident #53's care plan revealed Resident #53 had nerve pain related to the diabetes, (Resident #53) receives scheduled medications and has PRN (as needed) meds available as well During an observation on 05/23/2024 at 09:30 AM revealed Medication Aide J prepared and administered to Resident #53 her gabapentin. During an observation on 05/23/2024 at 09:35 AM Medication Aide J stated she administered Resident #16's clonazepam a few minutes late and administered Resident 53's gabapentin 30 minutes late. Medication Aide J stated she was running a little late due to preparing residents for their physicians' appointments earlier in the morning. Medication Aide J stated she had not reported to her supervisor she had a potential for administering medications late. During an interview on 05/24/2024 at 09:17 AM the DON stated nursing staff should administer medications on time as prescribed and staff are expected to communicate with their supervisor and or the DON if they have a potential to administer medications late. A record review of the facility's Medication Administration policy dated 10/01/2019, revealed, Policy: medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so . the facility has sufficient staff and a medication distribution system to ensure safe administration of medications without unnecessary interruptions .Procedure: . 10 rights of medication administration-whenever you are preparing to give someone medication, it is important to understand the 10 rights of medication administration. safety should be the first thing on your mind with medications. there is always a risk of giving the wrong pill, the wrong dose, or the wrong person's medication. If this happens, harm to the person can occur and some reactions can be deadly . In the past, you may have heard of the five rights of medication administration: right patient, right drug, right route, right time, and right dose. medical practices have changed to include a few more rights . right time- the time a medication is given is important. check the frequency of the ordered medication. double check that you are giving the ordered dose at the correct time. confirm when the last dose was given A record review of The Institute for Safe Medication Practices website, Guidelines for Timely Administration of Scheduled Medications (Acute) | Institute For Safe Medication Practices (ismp.org) , accessed 05/24/2024, titled, Guidelines for Timely Administration of Scheduled Medications revealed, .How to Use the Guidelines: These guidelines are applicable ONLY to scheduled medications (see definition section) . Definitions: 1. Scheduled medications include all maintenance doses administered according to a standard, repeated cycle of frequency (e.g., q4h, QID, TID, BID, daily, weekly, monthly, annually) . 2. Medications administered more frequently than daily but not more frequently than every 4 hours (e.g., BID, TID, q4h, q6h) Administer these medications within 1 hour before or after the scheduled time A record review of the National Library of Medicine's website, Nursing Rights of Medication Administration StatPearls - NCBI Bookshelf (nih.gov) , accessed 05/24/2024 titled Nursing Rights of Medication Administration updated 09/04/2023, revealed, Definition/Introduction: Nurses have a unique role and responsibility in medication administration, in that they are frequently the final person to check to see that the medication is correctly prescribed and dispensed before administration.[1] It 675380 Page 12 of 24 675380 05/24/2024 Windsor Nursing and Rehabilitation Center of Segui 1219 Eastwood Dr Seguin, TX 78155

F 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some is standard during nursing education to receive instruction on a guide to clinical medication administration and upholding patient safety known as the 'five rights' or 'five R's' of medication administration. These 'rights' came into being during an era in medicine in which the precedent was that an error committed by a provider was that provider's sole responsibility and patients did not have as much involvement in their own care.[2]; The five traditional rights in the traditional sequence include: . 'Right time' - administering medications at a time that was intended by the prescriber. Often, certain drugs have specific intervals or window periods during which another dose should be given to maintain a therapeutic effect or level. A guiding principle of this 'right' is that medications should be prescribed as closely to the time as possible, and nurses should not deviate from this time 675380 Page 13 of 24 675380 05/24/2024 Windsor Nursing and Rehabilitation Center of Segui 1219 Eastwood Dr Seguin, TX 78155

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure residents were free from significant medication errors for 3 of 6 residents (Residents #31, #34, and #104) reviewed for significant medication errors. Residents Affected - Few 1. On 05/23/2024 at 09:42 AM, Medication Aide J administered sodium chloride (salt; is an important mineral that helps balance the amount of fluid (water) in your body. It also helps your nerves and muscles to work properly. When the salt level in your blood is too low, extra water moves into your cells and makes them swell. This can be dangerous, especially in the brain where there is not a lot of room to expand) to Resident #104 late by 42 minutes. 2. On 05/23/2024 at 09:43 AM, Medication Aide J administered buspirone (primarily used to treat generalized anxiety) 10 mg to Resident #31 late by 43 minutes. 3. On 05/23/2024 at 09:48 AM, Medication Aide J administered carbidopa- levodopa (a combination medications used to treat symptoms of Parkinson's disease or Parkinson-like symptoms, such as: shakiness, stiffness, and difficulty moving) to Resident #34 late by 48 minutes. These deficient practices placed residents at risk for not receiving the therapeutic effects of their prescribed medications. The findings include: 1. A record review of Resident #104's admission record dated 5/24/2024 revealed an admission date of 03/28/2024 with diagnoses which included cerebral infarction (stroke) and hypo-osmolality (a condition where the levels of electrolytes, proteins, and nutrients in the blood are lower than normal) and hyponatremia (a condition that occurs when the level of sodium in the blood is too low). A record review of Resident #104's MDS assessment dated [DATE] revealed Resident #104 was a [AGE] year-old male admitted for long term care and was assessed with medically complex conditions which included low blood sodium. Resident #104 was assessed with a BIMS score of 03 out of a possible 15 which indicated severe cognition impairment. A record review of Resident #104's care plan dated 05/04/2024 revealed, (Resident #104) has had a cerebral vascular accident, causing weakness, aphasia (difficulty speaking), dysphagia (difficulty swallowing), and impaired cognition .Give medications as ordered by the physician. Monitor/document side effects and effectiveness A record review of Resident #104's physician's orders dated 05/24/2024 revealed the physician prescribed Resident #104 sodium chloride 1 gram, three times a day, at 08:00 AM, 02:00 PM, and 08:00 PM, related to low salt in his blood. A record review of Resident #104's Medication Adim Audit Report dated 05/24/2024 revealed Medication Aide J administered to Resident #104 his sodium at 09:42 AM when it was scheduled at 08:00 AM, 42 minutes late. 675380 Page 14 of 24 675380 05/24/2024 Windsor Nursing and Rehabilitation Center of Segui 1219 Eastwood Dr Seguin, TX 78155

F 0760 2. Level of Harm - Minimal harm or potential for actual harm A record review of Resident #31's admission record dated 05/24/2024 revealed an admission date of 09/26/2022 with diagnoses which included generalized anxiety disorder. Residents Affected - Few A record review of Resident #31's quarterly MDS assessment dated [DATE], revealed Resident #31 was a [AGE] year-old female admitted for long term care and assessed with medically complex diagnoses which included generalized anxiety and a BIMS score of 07 out of a possible of 15 which indicated severe cognitive impairment. A record review of Resident #31's care plan revealed, (Resident #31) uses anti-anxiety medications r/t (related to) anxiety . Administer anti-anxiety medications as ordered by physician. Monitor for side effects and effectiveness Q-SHIFT (every shift) A record review of Resident #31's physician's orders dated 05/24/2024 revealed Resident #31 was prescribed buspirone 10mg three times a day, at 08:00 AM, 02:00 PM, and 08:00 PM, for generalized anxiety. A record review of Resident #31's Medication Adimn Audit Report dated 05/24/2024 revealed Medication Aide J administered to Resident #31 her buspirone at 09:43 AM when it was scheduled at 08:00 AM, 43 minutes late. 3. A record review of Resident #34's admission record dated 05/24/2024 revealed an admission date of 02/16/2018 with diagnoses which included dementia (not a specific disease but is rather a general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities) and Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination). A record review of Resident #34's quarterly MDS assessment dated [DATE], revealed Resident #34 was a [AGE] year-old male admitted for long term care and assessed with medically complex diagnoses which included Parkinson's disease and a BIMS score of 08 out of a possible of 15 which indicated moderate cognitive impairment. A record review of Resident #34's physician's orders dated 05/24/2024 revealed Resident #34 was prescribed carbidopa-levodopa 10-100mg three times a day, at 08:00 AM, 02:00 PM, and 08:00 PM, for Parkinson's disease. A record review of Resident #34's care plan revealed, (Resident #34) is at risk for pain r/t Parkinson's disease . Notify physician if interventions are unsuccessful or if current complaint is a significant change from residents past experience of pain A record review of Resident #34's Medication Adimn Audit Report dated 05/24/2024 revealed Medication Aide J administered to Resident #34 his carbidopa-levodopa at 09:48 AM when it was scheduled at 08:00 AM, 48 minutes late. During an observation and interview on 05/23/2024 at 09:35 AM revealed Med Aide J at her medication cart with the electronic medication administration record displayed which revealed a red 675380 Page 15 of 24 675380 05/24/2024 Windsor Nursing and Rehabilitation Center of Segui 1219 Eastwood Dr Seguin, TX 78155

F 0760 Level of Harm - Minimal harm or potential for actual harm highlighted medication for Resident 31, Resident #34, and Resident #104. Medication Aide J stated she had yet to administer 08:00 AM scheduled medications for residents #31, #34, and #104 due to her running a little late earlier in the morning. Medication Aide J stated she had to assist a couple of residents prepare for their physicians' appointments. Medication Aide J stated she had not reported the potential late medication administrations to her supervisor or the DON. Residents Affected - Few During an interview on 05/24/2024 at 09:17 AM the DON stated nursing staff should administer medications on time as prescribed and staff were expected to communicate with their supervisor and or the DON if they had a potential to administer medications late. A record review of the facility's Medication Administration policy dated 10/01/2019, revealed, Policy: medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so . the facility has sufficient staff and a medication distribution system to ensure safe administration of medications without unnecessary interruptions .Procedure: . 10 rights of medication administration-whenever you are preparing to give someone medication, it is important to understand the 10 rights of medication administration. safety should be the first thing on your mind with medications. there is always a risk of giving the wrong pill, the wrong dose, or the wrong person's medication. If this happens, harm to the person can occur and some reactions can be deadly . In the past, you may have heard of the five rights of medication administration: right patient, right drug, right route, right time, and right dose. medical practices have changed to include a few more rights . right time- the time a medication is given is important. check the frequency of the ordered medication. double check that you are giving the ordered dose at the correct time. confirm when the last dose was given A record review of The Institute for Safe Medication Practices website, Guidelines for Timely Administration of Scheduled Medications (Acute) | Institute For Safe Medication Practices (ismp.org) , accessed 05/24/2024, titled, Guidelines for Timely Administration of Scheduled Medications revealed, .How to Use the Guidelines: These guidelines are applicable ONLY to scheduled medications (see definition section) . Definitions: 1. Scheduled medications include all maintenance doses administered according to a standard, repeated cycle of frequency (e.g., q4h, QID, TID, BID, daily, weekly, monthly, annually) . 2. Medications administered more frequently than daily but not more frequently than every 4 hours (e.g., BID, TID, q4h, q6h) Administer these medications within 1 hour before or after the scheduled time A record review of the National Library of Medicine's website, Nursing Rights of Medication Administration StatPearls - NCBI Bookshelf (nih.gov) , accessed 05/24/2024 titled Nursing Rights of Medication Administration updated 09/04/2023, revealed, Definition/Introduction: Nurses have a unique role and responsibility in medication administration, in that they are frequently the final person to check to see that the medication is correctly prescribed and dispensed before administration.[1] It is standard during nursing education to receive instruction on a guide to clinical medication administration and upholding patient safety known as the 'five rights' or 'five R's' of medication administration. These 'rights' came into being during an era in medicine in which the precedent was that an error committed by a provider was that provider's sole responsibility and patients did not have as much involvement in their own care.[2]; The five traditional rights in the traditional sequence include: . 'Right time' - administering medications at a time that was intended by the prescriber. Often, certain drugs have specific intervals or window periods during which another dose should be given to maintain a therapeutic effect or level. A guiding principle of this 'right' is that medications should be prescribed as closely to the time as possible, and nurses should not deviate from this time 675380 Page 16 of 24 675380 05/24/2024 Windsor Nursing and Rehabilitation Center of Segui 1219 Eastwood Dr Seguin, TX 78155

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observations, interviews, and record review, the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys for 1 medication cart and 1 Treatment cart of 2 carts observed for secure biologicals and drugs. 1.LVN F left the medication cart unsecured on 200 Hallway while administering medications. 2.The Treatment Nurse left the treatment cart unsecured on 05/22/2024 on the 100 Hallway, and on 05/23/2024 on the 300 Hallway prior to wound care for a resident. These deficient practices could place residents at risk for misappropriation, misuse or tampering of medications. The findings included: Observation on 05/22/2024 at 08:29 a.m. on the 200 Hall revealed the medication cart was left unattended and not locked. During an interview on 05/22/2024 at 08:30 with LVN F, who returned to the unlocked cart from a resident's room, she stated she had not left the medication cart unlocked before and did not know why she did. She stated she was focused on checking a resident and did not secure the cart. She stated she knew she should have secured the medication cart because there were resident medications on the cart to include insulin. She stated misappropriation, misuse, and harm could happen if someone were to get into the cart and acquire something they should not have. Observation on 05/24/2024 at 08:40 am on 100 Hall revealed the treatment cart was left unlocked and unattended. Inside were solutions and ointments for wound care, dressings, and other supplies. During an interview on 05/24/2024 at 08:45 a.m. with the Treatment Nurse, she stated she had never left the cart unlocked and unattended. She stated residents and others could have access to the cart, take items, or use them and be harmed. Observation on 05/24/2024 at 11:09 a.m., before going to observe a treatment for a resident, the Treatment Nurse gathered her supplies and went into the resident's room. She motioned for the surveyor to follow. The treatment cart was left unlocked. The surveyor lingered to see if the Treatment Nurse would come back to the cart, but she did not. The surveyor stepped inside the resident's room halfway and motioned for the Treatment Nurse to check her cart. During an interview on 05/24/2024 at 11:15 a.m. with the Treatment Nurse, she stated she could not believe she left the treatment cart unlocked and unattended again. She stated she did not know why she left the cart unlocked twice in one morning. During an interview on 05/24/2024 at 1:27 p.m. with the DON, she stated LVN F and the Treatment Nurse were two of her nurses who had worked at the facility the longest, and she could not understand how both could have forgotten to lock the carts. She stated nurses and medication aides were trained 675380 Page 17 of 24 675380 05/24/2024 Windsor Nursing and Rehabilitation Center of Segui 1219 Eastwood Dr Seguin, TX 78155

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some to keep the medication carts secure when not in use because of the potential of misappropriation and harm if someone took medications they were not prescribed. Record review of the facility's policy and procedure titled Medication Carts and Supplies for Administering Meds revised 10/01/19 reflected The facility maintains equipment and supplies necessary for the preparation and administration of medications to residents. The mobile medication cart will be used to facilitate administration of medications to residents. The purpose of the mobile medication system is to ensure appropriate control and surveillance of resident assigned medications. Procedure, only a licensed nurse or certified medical aide may carry keys to the medication cart, the medication cart is locked at all times when not in use, do not leave the medication cart unlocked or unattended in the resident care areas. 675380 Page 18 of 24 675380 05/24/2024 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. Residents Affected - Some 1. The facility failed to ensure pre-packaged chicken salad was discarded after the use by date. 2. The facility failed to ensure beverage machines dispenser gun with dispenser buttons was clean and properly stored. 3. The facility failed to ensure staff with facial hair was covered by a hair restraint. 4. The facility failed to ensure refrigerated items were dated and properly sealed. 5. The facility failed to ensure puree carrots were prepared in a sanitary fashion. These failures could place residents who received meals and/or snacks from the kitchen at risk for food borne illness. The findings included: Observation on 05/21/2024 at 9:46 a.m. during the initial tour of the kitchen walk in refrigerator revealed pre-packaged chicken salad in producer container with less than ¼ of the container left, dated use by 05/09/2024 and received date 04/20/2024. The beverage machine dispenser guns with dispenser buttons were hanging down over the side of the counter with beverage build up on them. During an interview on 05/21/2024 at 10:00 a.m. the DM stated the beverage machine dispenser guns should have been placed in the holders next to the machine and needed to be cleaned due to risk of cross contamination. The DM further stated the chicken salad had last been used to make sandwiches for residents on Monday (05/20/2024). The DM stated the chicken salad was expired and it should have been thrown out. The DM further stated the chicken salad could have made the resident's sick due to possibility of being spoiled. Observation on 05/22/2024 at 10:20 a.m. DA L was observed with a mustache and thin beard not wearing a facial hair restraint while washing dishes and using the dish washing machine. Observation and interview on 05/22/2024 at 11:27 a.m. DA L was observed to still be washing dishes with a mustache and thin beard not restrained by facial hair restraint. DA L stated he had just started 3 days ago and did not believe he needed to wear a beard restrain in the dish room, but knew he was supposed to wear one when handling food. During an interview on 05/22/2024 at 11:33 a.m. the dietician stated DA L should have been wearing a facial hair restraint to his beard. The dietician further stated by wearing the restraint it would prevent hair from getting in the food and contaminating it. The dietician then instructed DA L to get a hair net and use it over his beard and mustache. Observation on 05/23/2024 at 11:07 a.m. the walk- in refrigerator revealed a tray of cranberry 675380 Page 19 of 24 675380 05/24/2024 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 juices, and a tray of milk covered but not dated, along with a tray with 8 glasses of apple juice not covered or dated. During an interview on 05/23/2024 at 11:12 a.m. DA A stated the apple juices should have been covered so nothing could fall in them and dated so staff would know when they were prepared. Residents Affected - Some During an interview on 05/23/2024 at 11:14 a.m. DA B stated she had put the juices and milk in the fridge and had forgotten to date them. DA B further stated it was important to date drinks so staff would know how long they had been in the fridge. DA B stated she did not want to give someone something old they could get sick. Observation on 05/23/2024 at 3:20 p.m. the [NAME] was observed during puree prep of carrots. When she finished completing the puree of the carrots, she grabbed the spatula from the counter by the spatula side not the handle with her bare hand she had been using to push buttons on food processor, worn oven mitts, and handled the pans. The [NAME] then proceeded to scrape the carrots from the processor into the pan. The [NAME] covered the carrots and placed carrots in oven to warm. During an interview on 05/24/2024 at 3:23 p.m. the [NAME] stated by touching the spatula end instead of the handle she could have caused the food to be contaminated. During an interview on 05/24/2024 at 3:28 p.m. the DM stated when items were stored in the refrigerator they should covered to prevent bugs and things from getting in them to avoid cross contamination. The DM further stated items stored in the refrigerator should have been dated so items were not stored in the refrigerator too long. The DM stated the pre-poured drinks should have been used the same day. The DM stated the [NAME] should have washed the spatula prior to using it after she grabbed the wrong end due to by her touching it with her hand, she caused it to be contaminated. The DM further stated by touching the spatula with her hand and using it in the food it could cause the residents to get sick. Review of facility's policy Food Storage, date approved 10/1/20218 and revised 06/01/2019, read Policy: To ensure that all food served by the facility is of good quality and safe for consumption, all food will be stored according to the state, federal and US Food Codes and HACCP guidelines., Procedure: 2. Refrigerators: d. Date, label and tightly seal all refrigerated foods using clean, non-absorbent, covered containers that are approved for food storage. e. Use all leftovers within 72 hours. Discard items that are over 72 hours old. Review of facility's policy Employee Sanitation, date approved October 1, 2018, read Policy: The Nutrition & Food service employees of the facility will practice good sanitation practices in accordance with the state and US Food Codes in order to minimize the risk of infection and food borne illness., Procedure: 3. Employee Cleanliness Requirements, b. Hairnets, headbands, caps, beard coverings or other effective hair restraints must be worn to keep hair from food and food-contact surfaces. Review of the Food Code , U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed, 3-305.11, Food Storage, (A) Food shall be protected from contamination by storing the food: (1) in a clean, dry location; (2) Where it is not exposited to splash, dust, or other contamination. Review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed, 2-402 Hair Restraints, 2-402.11, Effectiveness., (A) Except as provided in paragraph (B) of this section, FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, beard 675380 Page 20 of 24 675380 05/24/2024 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 restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES. Residents Affected - Some 675380 Page 21 of 24 675380 05/24/2024 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 observations, interviews, and record reviews, the facility failed to establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases and infections for 3 residents (Residents #3, #102 and #308) of 24 residents reviewed for infection control. Residents Affected - Some 1.Resident #3 had an opened wound and received treatment but was not on EBP. 2. Resident #102's urinary drainage bag was on the floor wedged between the low bed frame and the floor. 3. Resident #308 had a Stage II pressure ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed) to her sacrum, received treatment and was not on EBP. These deficient practices affect residents who require assistance treatments and indwelling catheters and could place residents at risk for cross contamination and infections. The findings included: 1. Record review of Resident #3's electronic face sheet dated 05/22/2024 reflected she was admitted to the facility on [DATE]. Her diagnoses included: Alzheimer's disease (a type of dementia that affects memory, thinking and behaviors), chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs), diabetes mellitus (a disease in which the body does not control the amount of glucose (a type of sugar) in the blood and the kidneys make a large amount of urine) and anxiety (a feeling of worry, nervousness and unease). Record review of Resident #3's annual MDS assessment with an ARD of 05/03/2024 reflected she scored a 03 out of 15 on her BIMS which signified she was severely cognitively impaired. She was dependent on staff for ADLs, and had an open cancerous lesion. Record review of Resident #3's comprehensive person-centered care plan dated revised on 03/05/2024 reflected Resident's left lateral breast has an area of hardness and has some clear drainage noted, Interventions, clean with skin wound cleanser and apply triple antibiotic ointment and cover with a nonstick dressing QD until resolved. Further review reflected, has an open wound #2 to the medial aspect of the left breast 05/07/2024 merged into one wound, Interventions, clean with skin wound cleanser and apply triple antibiotic ointment and cover with nonstick dressing QD until resolved. Record review of Resident #3's Active Orders as of: 05/23/2024 reflected Wound to left breast each day shift cleanse with skin wound cleanser and apply triple antibiotic ointment and cover with nonstick dressing until resolved, start date 05/17/2024. During an interview on 05/23/2024 at 10:30 AM with the Treatment Nurse, she stated Resident #3 had breast cancer and her lesions were open and received treatment each day. Record review of facility training titled Enhanced Barrier Precautions dated 04/29/2024 revealed 35 staff members were signed off as trained. 675380 Page 22 of 24 675380 05/24/2024 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 Residents Affected - Some Record review of the EBP sign on Residents doors who were identified to need EBP reflected STOP, EVERYONE MUST: Clean their hands, including before entering and when leaving the room. Wear gloves and a gown for the following High-Contact Resident Care Activities .Changing briefs and assisting with toileting .Wound Care: Any skin opening requiring a dressing. During an interview on 05/24/2024 at 1:27 p.m. with the DON, she stated Resident #3 had an open wound area and should have been placed on EBP. She stated it was important to reduce the potential of cross contamination and infection and to reduce transmission of multidrug-resistant organisms. She stated staff were trained on EBP and residents would get EBP in their physician orders. 2. Record review of Resident #102's electronic face sheet dated 05/23/2024 reflected he was admitted to the facility on [DATE]. His diagnoses included: acute respiratory failure with hypoxia (a condition where there is not enough oxygen in the tissues in the body), diabetes mellitus (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), neuromuscular dysfunction of bladder (lack of bladder control due to brain, spinal cord, or nerve problems) and dysphagia (difficulty or discomfort in swallowing). Record review of Resident #102's significant change MDS assessment dated [DATE] reflected he was not a candidate for a BIMS which signified he was severely cognitively impaired. He could usually understand and usually be understood. He was dependent on staff for his ADL care. He had an indwelling urinary catheter. Record review of Resident #102's comprehensive person-centered care plan revised 05/22/2024 reflected Problem, has a need for Enhanced Barrier Precautions due to foley catheter, G-tube status, Interventions place on Enhanced Barrier Precautions. Observation on 05/23/2024 at 03:15 PM of MA G and CNA H perform catheter care for Resident #102 reflected they gowned, sanitized hands, and put on clean gloves. Resident #102's bed was in a low position, to the floor, and his indwelling urinary catheter bag was lying on the floor wedged between the floor and the bed frame. In an interview on 05/23/2024 at 3:20 PM with CNA H, she stated Resident #102's drainage bag was in a basin earlier and not on the floor. She stated someone must have placed his bed in the low position. She stated the drainage bag should not be on the floor because of cross contamination. During an interview on 05/24/2024 at 1:27 p.m. with the DON, she stated Resident #102's urinary drainage bag should not have been on the floor, but in a basin. She stated cross contamination could occur and give the resident an infection. 3. Record review of Resident #308's electronic face sheet dated 05/21/2024 reflected she was admitted to the facility on [DATE]. Her diagnoses included: hydrocephalus (fluid accumulates in the brain, enlarging the head and sometimes causing brain damage), severe protein-calorie malnutrition (significant muscle wasting and loss of subcutaneous fat), Down syndrome (genetic disorder caused when abnormal cell division results in extra genetic material from chromosome 21 and causes a distinct facial appearance, intellectual disability, and developmental delays), and Alzheimer's disease (a progressive disease that destroys memory and other important mental functions). Record review of Resident #308's admission MDS assessment dated [DATE] reflected she was not a candidate for BIMS which signified she was severely cognitively impaired. She could usually understand 675380 Page 23 of 24 675380 05/24/2024 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 Residents Affected - Some and usually be understood. She was dependent on staff for her ADL care. She had a Stage II pressure ulcer. Record review of Resident #308's comprehensive person-centered care plan revised 05/16/2024 reflected Problem, has a stage II pressure injury to the sacrum. Always stays on back while in bed with head of bed up, over scar tissue. Record review of Resident #308's Wound Care Notes dated 04/25/2024 reflected Assessments: 1. Pressure ulcer of sacral region, Stage II. Record review of Resident #308's Wound Care Notes dated 05/08/2024 reflected Assessments: 1. Pressure ulcer of sacral region, Stage II. Record review of Resident #308's weekly skin assessments dated 04/22/2024, 04/29/2024, 5/11/2024 and 5/13/2024 reflected she had a Stage II pressure injury to her sacrum. Observation on 05/23/2024 at 11:09 a.m. of the Treatment Nurse provide incontinent care and wound care for Resident #308 reflected she had a Stage II pressure sore which was open to her sacral area. She was not on EBP. Interview on 05/23/2024 at 11:20 a.m. with the Treatment Nurse, she stated Resident #308's stage II pressure sore was recurring and she had the open sore now for weeks. When asked why Resident #308 was not on EBP, she stated she did not know, but the resident should have been. During an interview on 05/24/2024 at 1:27 p.m. with the DON, she stated Resident #308 had an open pressure sore and should have been placed on EBP. She stated it was important to reduce the potential of cross contamination and infection and to reduce transmission of multidrug-resistant organisms. She stated staff were trained on EBP and residents would get EBP in their physician orders. Record review of the facility's policy and procedure titled Enhanced Barrier Precautions dated 04/05/2024 reflected An order for Enhanced Barrier Precautions will be obtained for residents with any of the following, wounds, diabetic foot ulcers, unhealed surgical wounds, chronic venous stasis ulcers). Record review of CDC presentation titled Indwelling Urinary Catheter Insertion and Maintenance undated https://www.cdc.gov/infection-control/media/pdfs/Strive-CAUTI104-508.pdf reflected Maintain Unobstructed Urine Flow .Keep the urine bag off the floor. 675380 Page 24 of 24