Health inspection·October 11, 2024

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that all alleged violations involving neglect, were reported immediately to the State Survey Agency, not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, for 1 of 3 residents (Resident #1) reviewed for abuse/neglect. The facility failed to report Resident #1's unwitnessed fall with injury where Resident #1 sustained a 6 cm laceration to the left side of her eyebrow which required 12 stitches to close to State Survey Agency within 24 hours. The incident occurred on 05/10/2024 at 5:34 p.m. The facility emailed the report on 05/13/2024. This failure could place all residents at increased risk for potential abuse to unreported allegations of abuse and neglect. The findings included: Record review of Resident #1's admission Record dated 10/10/24, revealed a [AGE] year-old female, admitted to the facility on [DATE]. Her diagnoses included: Dementia (a general term for a group of diseases that cause a loss of cognitive functioning, such as thinking, remembering, and reasoning, to the point that it interferes with daily life), and type 2 diabetes mellitus, repeated falls, and unsteadiness on feet. Record review of Resident #1's Medicare 5-Day MDS assessment dated [DATE] revealed a BIMS score of 01, indicating severe impaired cognition. Record review of Resident #1's Care Plan dated 11/19/21, revealed: FOCUS: o CANCELLED: The resident has had an actual fall Date Initiated: 06/07/2024 Revision on: 06/25/2024 Cancelled Date: 06/25/2024 GOAL: o RESOLVED: The resident will resume usual activities without further incident through the review date. Date Initiated: 01/17/2023 Revision on: 08/14/2023 Target Date: 07/02/2024 Resolved Date: 08/14/2023 o CANCELLED: The resident's head injury will resolve without complication by review date. Date Initiated: 04/03/2024 Revision on: 06/25/2024 Target Date: 07/02/2024 Cancelled Date: 06/25/2024 INTERVENTIONS/TASKS: o CANCELLED: 3/27/24 resident returned: pt/ot/st and discontinue aspirin Date Page 1 of 5 675475 675475 10/11/2024 Windsor Nursing and Rehabilitation Center of Raymo 1700 S Expressway 77 Raymondville, TX 78580

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Initiated: 04/03/2024 Revision on: 06/25/2024 Cancelled Date: 06/25/2024 06/25/2024 o CANCELLED: 3/28/24 Siderails as enabler Date Initiated: 04/03/2024 Revision on: 06/25/2024 Cancelled Date: 06/25/2024 06/25/2024 o CANCELLED: 4/22/24 Resident continues on Restorative Services Date Initiated: 05/17/2024 Revision on: 06/25/2024 Cancelled Date: 06/25/2024 06/25/2024 o RESOLVED: 4/28/23 neuros, physical therapy, and foam to foot board of bed. Date Initiated: 04/28/2023 Revision on: 08/14/2023 Resolved Date: 08/14/2023 08/14/2023 o CANCELLED: 4/6/24 Continues on PT/OT services Date Initiated: 05/17/2024 Revision on: 06/25/2024 Cancelled Date: 06/25/2024 06/25/2024 o CANCELLED: 5/17/24 Order for ENT due to history of falls. Date Initiated: 05/17/2024 Revision on: 06/25/2024 Cancelled Date: 06/25/2024 06/25/2024 o RESOLVED: Check range of motion (Specify #) times daily. Date Initiated: 01/17/2023 Revision on: 08/14/2023 Resolved Date: 08/14/2023 LN RN 08/14/2023 o RESOLVED: Continue interventions on the at-risk plan. Date Initiated: 01/17/2023 LN RN 08/14/2023 Revision on: 08/14/2023 Resolved Date: 08/14/2023 o CANCELLED: helmet at all times as tolerated Date Initiated: 04/03/2024 Revision on: 06/25/2024 Cancelled Date: 06/25/2024 DEN 06/25/2024 o CANCELLED: Monitor/document /report PRN x 72h to MD for s/sx: Pain, bruises, Change in mental status, New onset: confusion, sleepiness, inability to maintain posture, agitation. Date Initiated: 04/03/2024 Revision on: 06/25/2024 Cancelled Date: 06/25/2024 LN RN 06/25/2024 o CANCELLED: Neuro-checks as needed. monitor head injury for any changes in condition. Date Initiated: 04/03/2024 Revision on: 06/25/2024 Cancelled Date: 06/25/2024 LN RN 06/25/2024 o CANCELLED: PT/OT to evaluate and treat due to multiple falls Date Initiated: 06/09/2024 Revision on: 06/25/2024 Cancelled Date: 06/25/2024 LN 06/25/2024 o CANCELLED: remove floor mats Date Initiated: 06/09/2024 Revision on: 06/25/2024 Cancelled Date: 06/25/2024 CNA LN 06/25/2024 o CANCELLED: send to hospital for evaluation and treatment Date Initiated: 04/03/2024 Revision on: 06/25/2024 Cancelled Date: 06/25/2024 06/25/2024 o CANCELLED: Vital signs as needed and ordered. Take BP lying/sitting/standing x1 in first 24hr. Date Initiated: 04/03/2024 Revision on: 06/25/2024 Cancelled Date: 06/25/2024 CNA LN RN 06/25/2024 FOCUS: o CANCELLED: is at risk for falls and at risk for bumping into things. r/t TRAUMATIC HEMORRHAGE OF CEREBRUM, ANXIETY DISORDER, DEMENTIA, FRONTOTEMPORAL NEUROCOGNITIVE DISORDER, TRANSIENT CEREBRAL ISCHEMIC ATTACK Confusion, TYPE 2 DIABETES MELLITUS, CHRONIC KIDNEY DISEASE, DISORDER OF BONE DENSITY/STRUCTURE, HYPERTENSION, MALIGNANT NEOPLASM OF BREAST, Unaware of safety needs, Wandering. Date Initiated: 04/03/2024 Revision on: 06/25/2024 Cancelled Date: 06/25/2024 GOALS: o CANCELLED: The resident will not sustain serious injury through the review date. Date Initiated: 04/03/2024 Revision on: 06/25/2024 Target Date: 07/02/2024 Cancelled Date: 06/25/2024 o CANCELLED: The resident will be free of falls through the review date. Date Initiated: 04/03/2024 Revision on: 06/25/2024 Target Date: 07/02/2024 Cancelled Date: 06/25/2024 INTERVENTIONS/TASKS: o CANCELLED: 9/19/23 place a bell in the room and the bathroom Date Initiated: 04/03/2024 Revision on: 06/25/2024 Cancelled Date: 06/25/2024 06/25/2024 o CANCELLED: Anticipate and Meet The resident's needs. Date Initiated: 04/03/2024 Revision on: 06/25/2024 Cancelled Date: 06/25/2024 CNA LN RN 06/25/2024 o CANCELLED: Be sure The resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Date Initiated: 04/03/2024 Revision on: 06/25/2024 Cancelled Date: 06/25/2024 CNA LN RN 06/25/2024 o CANCELLED: Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs. Date Initiated: 04/03/2024 Revision on: 06/25/2024 Cancelled Date: 06/25/2024 LN RN 06/25/2024 o CANCELLED: Ensure that The resident is wearing appropriate footwear when ambulating or mobilizing in w/c. Date Initiated: 04/03/2024 Revision on: 06/25/2024 Cancelled Date: 06/25/2024 ACTA CNA LN RN 06/25/2024 o CANCELLED: Follow facility fall protocol. Date Initiated: 04/03/2024 Revision on: 06/25/2024 Cancelled Date: 06/25/2024 ACTA CNA LN RN 06/25/2024 o CANCELLED: 675475 Page 2 of 5 675475 10/11/2024 Windsor Nursing and Rehabilitation Center of Raymo 1700 S Expressway 77 Raymondville, TX 78580

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Frequent checks to ensure safety. Date Initiated: 04/03/2024 Revision on: 06/25/2024 Cancelled Date: 06/25/2024 06/25/2024 o CANCELLED: Frequent monitoring. Try to keep her in dining/living area. Date Initiated: 04/03/2024 06/25/2024 Revision on: 06/25/2024 Cancelled Date: 06/25/2024 o CANCELLED: Has foam to footboard of bed Date Initiated: 04/03/2024 Revision on: 06/25/2024 Cancelled Date: 06/25/2024 06/25/2024 o CANCELLED: Pt evaluate and treat as ordered or PRN. Date Initiated: 04/03/2024 Revision on: 06/25/2024 Cancelled Date: 06/25/2024 LN RN THR 06/25/2024 o CANCELLED: Review information on past falls and attempt to determine cause of falls. Record possible root causes. Alter remove any potential causes if possible. Educate resident/family/caregivers/IDT as to causes. Date Initiated: 04/03/2024 Revision on: 06/25/2024 Cancelled Date: 06/25/2024 LN RN 06/25/2024 o CANCELLED: The resident needs a safe environment with even floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, the bed in low position at night; Side Rails as ordered, handrails on walls, personal items within reach Date Initiated: 04/03/2024 Revision on: 06/25/2024 Cancelled Date: 06/25/2024 CNA LN RN 06/25/2024 . Record review of Resident #1's progress notes written on 05/10/24 05:34 PM by RN A revealed Late Entry: Note Text: pt (Resident #1) noted to be laying on floor on back, laceration noted to left side forehead and skin tear present to left cheek. no LOC noted . Hips midline centered with no deficits noted, leg length equal, pt able to perform ROM denies pain/ discomfort pt noted wearing non-slip socks at time of fall. blanket bundled next to pt, when asked pt states I was folding my blanket. NP made aware. pt sent to (hospital) for eval and tx. Record review of Resident #1's progress notes written on 05/11/24 at 12:58 AM LVN B revealed Note Text: Resident arrived via stretcher accompanied by 2 EMS personnel. Alert and oriented to self. Was taken to room and assisted to bed. Made comfortable. Educated resident on use of call light and return demonstration. Bed to lowest position and call light within reach. Record review of Resident #1's progress notes written on 05/11/24 at 02:25 AM by LVN revealed Late Entry: Note Text: The measurements for resident's stitches to left side of forehead measured (6cm X 0.1cm). Record review of Resident #1's progress notes written on 05/11/24 at 05:36 PM Nurse Note written by RN A: Late Entry: Note Text: resident in dining room area watching television, laceration to forehead clean and dry. sutures intact with no drainage noted pt denies pain / discomfort. Record review of Resident #1's on 04/22/24 Fall Risk Evaluation revealed 17.0 high risk for falls. Record review of Resident #1's on 05/10/24 Fall Risk Evaluation revealed 10.0 high risk for falls. Record review of Resident #1's on 05/10/24 Fall Risk Evaluation revealed 12.0 high risk for falls. Record review of Resident #1's on 06/07/24 Fall Risk Evaluation revealed 16.0 high risk for falls. Record review of Resident #1's on 06/08/24 Fall Risk Evaluation revealed 15.0 high risk for falls. Record review of Resident #1's 05/16/24 Weekly Skin Evaluation, revealed, laceration to left side of forehead measures 5cm x 0.1cm w/ 12 noted stitches in place. In an interview on 04/30/24 at 04:11 PM, the DON stated allegations of abuse or neglect, injuries of unknown origin, certain resident-to resident altercations, misappropriation of property, and 675475 Page 3 of 5 675475 10/11/2024 Windsor Nursing and Rehabilitation Center of Raymo 1700 S Expressway 77 Raymondville, TX 78580

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few elopement were reportable. The DON stated the Administrator always took the lead and reported to State. The DON stated she was notified of all falls (witnessed and unwitnessed). The DON stated she would go over all falls or incidences with the Administrator and he would decide whether it was reportable or not. In an interview on 10/11/24 at 03:51 PM, ADON C stated Resident #1 was his family member. He stated he was not in the unit when she fell 05/10/24. ADON C stated a BIMS of 01 was not enough for Resident #1 to tell how she fell. He said she was severely cognitively impaired with a BIMS of 01. In an interview on 10/11/24 at 05:20 PM, LVN D stated she worked there for a year and four months. LVN D stated she worked back in the secure unit. LVN D stated she worked with Resident #1 when she fell around shift change in May 2024. LVN D stated she was the one who sent Resident #1 out to the hospital. LVN D stated the wound on the left side of Resident #1's head was deep and bleeding. LVN D stated she was not the nurse who assessed Resident #1. Attempted a telephone interview on 10/11/24 at 06:16 PM with CNA F. No answer. Voicemail left. Attempted telephone interview on 10/11/24 at 06:20 PM with RN A. Wrong number. Unable to leave voicemail. An attempted telephone interview on 10/11/24 06:22 PM with LVN H. No answer. Voicemail left. In an interview on 10/11/24 at 06:24 PM, the DON stated she started working at the facility late July 2024. The DON stated she was notified of all falls. The DON stated if a resident has a BIMS of 01, they would not be able to explain what happened or why. The DON stated when she was notified of falls or any incident, she tried to get information. The DON stated she immediately started her investigation. The DON stated the Administrator was the one who reported to State. The DON stated both she and the Administrator were notified on any allegations of abuse or neglect. The DON stated she read about the incident with Resident #1's unwitnessed fall. In an interview on 10/11/24 at 06:38 PM, the Administrator stated she had worked at the facility since August, 1, 2024. The Administrator stated she was notified of all allegations of abuse and neglect and all falls. The Administrator stated when she was notified, she would get with the consultants and file a report. The Administrator stated her DON made sure all protocol was adhered to and followed. Review of facility's Abuse, Neglect, Exploitation policy, not dated, revealed: VII. Reporting/Response A. The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: 675475 Page 4 of 5 675475 10/11/2024 Windsor Nursing and Rehabilitation Center of Raymo 1700 S Expressway 77 Raymondville, TX 78580

F 0609 a. Level of Harm - Minimal harm or potential for actual harm Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or Residents Affected - Few b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. 675475 Page 5 of 5