Inspection·September 19, 2024

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 record review and interview the facility failed to develop and implement a comprehensive person-centered care plan that included measurable objectives and time frames to meet the residents psychosocial needs for one (Resident#11) of two residents reviewed for comprehensive person centered care plan. The facility did not have interventions in place for Resident #11's behavior of removing peg tube. Resident #11 had removed his peg tube on 2 separate occasions and was sent to hospital. This failure could affect residents and place them at risk of not receiving appropriate interventions. The findings were: Record review of Resident 11's admission Record dated 09/19/24 revealed a [AGE] year-old male with an original admission date of 06/07/24 and diagnoses of Alzheimer's Disease Unspecified (brain disorder that slowly destroys memory and thinking skills), Gastrostomy Status (surgical procedure that creates an opening in the abdomen & into the stomach to provide nutritional support), Displacement of other gastrointestinal (organs that process food and liquid) Prosthetic Devices (device designed to make a part of the body work better), Chronic Kidney Disease Stage 5, Anxiety Disorder Unspecified, Restlessness and Agitation, and Muscle Wasting and Atrophy. Record review of Resident #11's Quarterly MDS dated [DATE] revealed Resident #11 was severely impaired in cognitive skills, rarely/never makes self-understood, rarely/never understands others. Resident #11 was also coded as having a peg tube in place as a nutritional approach. Record review of Resident #11's Care plan dated 06/28/24 revealed Resident #11 requires tube feeding r/t Dysphagia. Record review of Resident #11's progress note dated 07/26/24 documented by LVN D revealed facility nurse had found Resident #11 had removed his peg tube and was sent to the hospital for reinsertion. Record review of Resident #11's progress note dated 09/13/24 documented by LVN C revealed that Resident #11 had pulled out his peg tube and was sent out to hospital for reinsertion. Record review of Resident #11's Care plan dated 09/03/24 found no documentation of interventions for Resident #11's behavior of removing peg tube. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 675414 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675414 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Nursing and Rehabilitation Center of Edinb 1505 S Closner Edinburg, TX 78539 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)