Health inspection·August 11, 2025

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 interviews and record reviews, the facility failed to ensure all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported 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 not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (which included to the State Survey Agency) in accordance with State law through established procedures for 1 of 4 residents (Resident #1) reviewed for reporting alleged allegation of abuse. CNA A failed to report an allegation of abuse to the Administrator involving Resident #1 being tucked into bed with a blanket tucked behind her shoulders sometime in March of 2025. This failure could place residents at risk for undetected abuse and neglect, and a decline in feelings of safety and well-being. The findings included: 1. Record review of Resident #1's face sheet, dated 08/22/25, revealed the resident was a [AGE] year-old female who was initially admitted to the facility on [DATE] with diagnoses that included: Alzheimer's disease (progressive brain disorder that gradually destroys memory and thinking skills) unspecified dementia (a group of thinking an social symptoms that interferes with daily functioning), unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety and need for assistance with personal care (ADLs) Record review of Resident #1's annual MDS assessment, dated 06/05/25, revealed Resident #1 had a BIMS score of 00, indicating her cognition was severely impaired. Resident #1's MDS reflected she had unclear speech, was rarely/never understood, and rarely/never understood others. Resident #1's MDS reflected she required supervision or touching assistance to roll left or right in bed, to go from lying to sitting on the side of the bed, to sit to stand and to complete chair/bed to chair transfers. Record review of Resident #1's care plan with an initiation date of 11/21/19 reflected a problems of [Resident #1] has an ADL self -care performance deficit r/t Alzheimer's, impaired balance. Requires a lot of encouragement and guidance to complete a task. With an initiation date of 08/03/23 and intervention of, BED MOBILITY: The resident requires assistance by 1 staff to monitor for safety in bed as necessary. and TRANSFER: The resident requires assistance by 1 staff to move between surfaces necessary. with an initiation date of 08/03/23. During an attempted interview with Resident #1 on 08/06/25 at 2:35pm, she would not respond to any introduction or question. Record review of Resident #1's medical chart from March to May did not reveal any verbiage related to the allegation of Resident #1 being tucked in except for a note written by the DON on 06/18/25 when the facility received a compliance call that mentioned the incident with Resident #1. The note written by the DON stated, A head to toe assessment was performed with no open areas noted. Resident was noted to have red scratch marked to right buttock and right upper thigh with no broken skin. During n interview with CNA A on 08/08/25 at 3:31pm, he said he was Page 1 of 4 675475 675475 08/11/2025 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 no longer employed at the facility as of July, 2025. CNA A stated that sometime in March of 2025 around 3:00am or 4:00am, he was completing his rounds and noticed that Resident #1 was asleep and had 3 or 4 blankets in use and was restrained with some type of blanket. CNA A initially stated it was a blanket with a knot and then stated it was not a knot, but two ends of the blanket were tied, and the blanket was on top of Resident #1's shoulders with the corners crossed in back of her on her back but not in a knot just crossed. CNA A stated the blanket was tucked behind her shoulder blades. CNA A stated, at the time he found Resident #1, he removed the blanket. CNA A stated he did not know who placed the blanket like that and did not know if there was anyone else working with Resident #1 at that time. CNA A stated he never showed a photo of Resident #1 and never had a photo of Resident #1. CNA A stated he had completed 2 prior rounds on her during his shift and had checked her brief each time and did not see a blanket tucked behind her shoulder blades during those rounds. CNA A stated Resident #1 would not have been able to remove the blanket and stated his initial thought was that Resident #1 looked restrained. CNA A stated he considered restraints as a form of abuse. CNA A stated after he removed the blanket from Resident #1, he reported it to LVN B as a safety precaution. CNA A stated he did not report to the Administrator because he did not have her number. CNA A stated he had previously been trained over immediately reporting allegations of abuse to the abuse coordinator who was the Administrator but could not recall who provided him with that training or when. CNA A stated the facility policy stated he needed to report allegations like this one to the administrator immediately, and stated he felt he did not follow the facility policy. CNA A stated not reporting allegations of abuse or restraints to the Administrator could negatively impact residents mentally and could be considered neglect. Record review of a written statement dated 08/08/25 by the DON revealed, This statement is regarding a concern voiced in March. The resident in question was assessed by a licensed nurse who based on their professional experience, voiced that after his thorough assessment, the resident did not have any indication of abuse or neglect as defined by THHS. According to the Licensed Nurse, the resident was not in any immediate danger, her safety was in no way at risk, and the resident was noted to freely move all extremities along with being noted to get out of bed without any form of resistance or signs of distress. During an interview with LVN B on 08/11/25 at 12:43pm, he stated he didn't remember when, but thought maybe in April or May 2025 at around 5:00am in the morning, he was called over by CNA A and LVN C and was shown an undated photo without timestamp that CNA A had of Resident #1. LVN B stated Resident #1 appeared to be tucked in but was not tied. LVN B stated with the way Resident #1 was tucked in she would have been able to break out of and remove. LVN B stated CNA A did not say anything about Resident #1 being restrained or tucked in, and stated he told CNA for them to go look at Resident #1. LVN B stated he went back to see Resident #1 and found her sitting in bed with a smile with blankets at her feet. LVN B stated Resident #1 did not have any markings or signs of abuse or anything. LVN B stated he did not know if CNA A had removed the blankets from Resident #1 prior to him seeing her. LVN B stated Resident #1 had problems with mobility and would have been able to get the blanket off of her without any problems and stated when he saw the photo of Resident #1, she was smiling and had the blanket up to her chest and it was tied or wrapped it was lightly pushed in on the sides. LVN B stated he did not see any abuse or neglect, did not see anything wrong with Resident #1. LVN B stated he had nothing to report, and he did not document anything because there was nothing to document. LVN B stated he had called the DON about an hour after he was shown the photo of Resident #1, and stated she did not call him back until a little later but was not sure what time. LVN B stated at that time, he let the DON know that he was shown an undated, photo without a timestamp of Resident #1, but when he went to check her, he found her 675475 Page 2 of 4 675475 08/11/2025 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 with her blankets at her feet and stated she was smiling and was unable to tell him what happened. LVN B stated he didn't think he needed to tell the Administrator because there was nothing there, he did not know when the photo was taken, and he did not see anything or suspect any abuse or neglect . LVN B stated he thought telling the DON was good. LVN B stated he had been trained over abuse and reporting requirements on their annual trainings and monthly trainings, and stated if he suspected or witnessed abuse, he had to report to the abuse coordinator, who was the Administrator, immediately. LVN B stated the Administration was responsible for reporting any allegation of abuse to HHSC and they only had 2 hours to report. LVN B stated he did not consider tucking in a resident as abuse, but if they were wrapped like a burrito, then yes, he would. LVN B stated the facility policy stated they had to report allegation of abuse to their abuse coordinator, and he did not suspect abuse from the photo he saw of Resident #1. LVN B stated he followed the facility's policy and felt like he did what needed to be done at that time. LVN B stated not reporting allegation of abuse to the Administrator, and not reporting to HHSC within the appropriate time frame, could negatively impact the residents because whatever type of abuse could be happening, could also be happening to other residents. During an interview with the DON on 08/11/25 at 3:08pm, she stated the Administrator was the abuse coordinator and responsible for reporting allegation of abuse to HHSC. The DON stated the Administrator provided monthly in-services to staff over abuse which included examples of abuse and what was considered abuse. The DON stated staff were educated on reporting to the Administrator, herself, and the ADON, if they suspected or witnessed any abuse. The DON stated, sometime in March, LVN B had gotten word from CNA A that Resident #1 was tucked in bed, but according to his assessment, she was freely able to move around and get out of bed and he did see anything impeding her from getting out of bed. The DON stated LVN B stated Resident #1 was not scared or afraid, and had no signs that would warn him that something had occurred. The DON stated she was not made aware until a couple days later, when LVN B called her at 7:00am or 8:00am a couple days after to notify her of what he had been told by CNA A. She stated she told LVN B to notify staff of doing things how they should be done with residents, and they completed an In-service with whatever staff was available at that time. The DON stated they did not document or do any investigation at that time, but did complete an in-service. The DON stated they did not do an investigation, because based on LVN B's clinical judgment ,Resident #1 was fine, and LVN B stated there was nothing to report because Resident #1 was free to move around and was safe with no signs or symptoms of abuse. The DON stated if a resident was tucked in tightly to where they could not move or get themselves out, then it would be considered restraints, and restraints would be consider abuse. The DON stated after LVN B reported to her, she called the Administrator who had also just been made aware, and after they spoke about it, there was nothing to report because LVN B said there were no signs or symptoms of abuse that was noted. The DON stated CNA A and LVN B should have reported these allegations to the Administrator at the time they occurred. The DON stated they had a 2-hour time frame to report to HHSC, but did not report anything until they received a compliance call in June 2025 that mentioned the incident. The DON stated the facility's policy stated they had to make a report to the state within 2 hours if they were told of any abuse. The DON stated herself and staff followed the facility's policy and they went by the information they received from the nurses, what they saw, and the findings on their assessments. The DON stated not reporting allegations of abuse to the Administrator, or HHSC within 2 hours, could negatively impact residents with harm if there was actual abuse. The DON stated, in this case, there was nothing. During an interview with the Administrator on 08/11/25 at 4:37pm, she stated she was not aware of the exact date or time that CNA A notified LVN B of Resident #1 being tucked in, but stated CNA A asked 675475 Page 3 of 4 675475 08/11/2025 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 LVN B if he could go look at Resident #1 and see how she was tucked in. The Administrator stated LVN B went to assess Resident #1, did not see any signs or symptoms of abuse or anything, and as per his clinical judgement, felt it was nothing to be concerned about. The Administrator stated the DON notified her, she did not remember at what date or time she was notified ,but it was later that same morning. The Administrator stated they did not do anything else in response and did not report it because based on the information provided to them from LVN B, Resident was stable, there was nothing to report, and had not been reported as abuse. The Administrator stated CNA A could have reported to her, but he felt safe with LVN B so he reported to him, the Administrator stated LVN B did not report to her and could have so that she could have been aware as to what was going on. The Administrator stated If LVN B had found something then he should have reported to it to her. The Administrator stated she was the abuse coordinator and was responsible for reporting any allegation of abuse to HHSC. The Administrator stated herself and staff had been trained over reporting abuse at least monthly, and staff should report to her as soon as possible because she only had 2 hours to report. The Administrator stated she considered restraints as abuse, but with being tucked in, it depended. The Administrator stated their facility's policy stated if staff saw, suspected, or even if they were not sure of it, they had to report any abuse to her. She stated, in this situation, she felt her and the staff followed that policy. The Administrator stated they monitored facility incidents to ensure they identified reportables and their appropriate time frame by reviewing documentation, rounding, and providing in-services to staff on what should be reported. The Administrator stated not reporting allegations of abuse to the Administrator and HHSC within a 2-hour time frame could negatively impact the residents because they would not be investigating or following protocols, and if they were not aware, then they were not doing interventions. Record review of the facility's in-service dated 02/13/25 that was provided by the Administrator covered abuse and neglect, and the 3 R's (recognize, remove, report) revealed CNA A, LVN B and the DON had received the training. Record review of the facility's policy with an implemented date of 07/11/25 and titled, Abuse, Neglect and Exploitation included a section titled, V. Investigation of Alleged Abuse, Neglect, and Exploitation that included verbiage stating, An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. VII. Reporting/Response.1.Reporting of all alleged violation to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: a. Immediately, but not later than 2 hour after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or 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 4 of 4