Health inspection·April 6, 2023

F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview ad record review the facility failed to ensure residents received services in the facility with reasonable accommodations of each resident's needs for 2 of 7 residents ( Resident #35 and Resident #59) reviewed for call lights in that: Residents Affected - Few Residents # 35, and # 59 were observed in their rooms with their call lights not within reach. This failure could affect all residents who needed assistance with activities of daily living and could result in needs not being met. Findings included: 1. Record review of Resident #35's admission record dated 04/04/23 documented a [AGE] year-old female admitted on [DATE]. Resident #35 documented diagnoses included: muscle wasting and atrophy (decrease in size and loss of skeletal muscle mass) , repeated falls, abnormalities of gait and mobility (deviation of normal walking), unsteadiness of feet, lack of coordination). Record review of Resident #35's quarterly MDS dated [DATE] revealed resident had a BIMS score of 14 indicating the resident was cognitively intact. The MDS also revealed the resident required extensive assistance in various areas of activities of daily living such as transfer, dressing, bed mobility, toilet use and personal hygiene. Record review or Resident #35's care plan dated 02/23/22 with a revision date of 05/19/22 revealed Resident #35 was at high risk for falls related to generalized weakness, left 5th toe fracture due to fall at home, history of falls, and repeated falls. Interventions included: be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed; the resident needed prompt response to all requests for assistance. Observation and interview of Resident #35 on 04/03/23 at 04:20 p.m. revealed her call light was on floor next to bed and not in her reach. Resident #35 stated she uses call light to call for help when she can access it. However, she stated that not being able to access her call light happened frequently. Resident #35 stated she will call out loudly into hall when she cannot access her call light or call the nurse's station by using her cell phone so that a nurse come to her aide. 2. Page 1 of 22 676125 676125 04/06/2023 Windsor Atrium 1814 Atrium Place Harlingen, TX 78550

F 0558 Level of Harm - Minimal harm or potential for actual harm Record review of Resident #59's admission record dated 04/04/23 documented a [AGE] year-old female admitted on [DATE]. Resident #59's diagnoses included: lack of coordination, muscle wasting and atrophy (decrease in size and loss of skeletal muscle mass), schizophrenia (serious mental disorder in which people interpret reality abnormally), repeated falls, Alzheimer's disease (progressive disease that destroys memory and other important mental functions). Residents Affected - Few Record review of Resident #59's quarterly MDS dated [DATE] revealed resident had a BIMS score of 03 indicating the resident had severe cognitive impairment. The MDS also revealed the resident required extensive assistance in various areas of activities of daily living such as transfer, dressing, bed mobility, toilet use and personal hygiene. Record review of Resident #59's care plan dated 08/09/22 with a revision date of 03/15/23 revealed Resident #59 was at risk for falls related to generalized weakness due to Alzheimer's. Interventions included: be sure the resident's call light is within reach and encourage the resident use it or assistance as needed; the residence needs prompt response to all requests for assistance; 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, slide fails as ordered, handrails on walls personal items within reach. Observation and interview of Resident #59 on 04/03/23 at 04:25 p.m. revealed resident was quarantined alone in her room due to COVID-19 infection. Further observation revealed call light was hanging over oxygen tank next to resident bed and not within her reach. Resident #59 stated she does not like to use call light for help all the time because she does not want to bother the nurses. Resident #59 stated she would rather wait until staff members come and check on her to request for assistance but she does have to wait a while before they do come and check on her. Observation and interview during a walkthrough of hall 100 with the DON on 04/03/23 at 04:40 p.m. revealed the DON was unaware the call lights were not within resident's reach. At this time, the DON observed call lights for # 35 on the floor and not within the resident's reach. Resident # 35 did use her call light and knew the resident could not reach it from the floor herself. Further observation revealed call light of Resident # 59 resting on top of her oxygen tank. At that time neither call lights were within the resident's reach. The DON stated Resident #59 did use her call light. She stated staff did round on resident but may not round on her as often as other residents because she was on droplet isolation precautions and therefore, resident should have call light within reach. The DON stated that not having the call lights within the resident's reach could lead to resident's not having their needs met. The DON stated that all staff who were responsible for patient care were responsible for making sure call lights were within the resident reach. The DON stated she was responsible for the oversight of all staff and making sure they were following facility policies and practices, including call light placement. An interview with LVN G on 04/24/23 at 09:25 a.m. revealed staff should work as a team to make sure call lights were within resident reach. LVN G stated CNAs needed continuous reminding because they were not being consistent, and it was her responsibility to make sure call lights were within resident reach. An interview with RN ADON on 04/24/23 at 09:35 a.m. revealed every resident was different. She stated some residents do not like call lights and will throw it or place it out of their reach. RN ADON stated staff must ensure call light dislike was in the resident's care plan because some residents may not like the call light. RN ADON stated she rounded at 09:30 to make sure call lights were within 676125 Page 2 of 22 676125 04/06/2023 Windsor Atrium 1814 Atrium Place Harlingen, TX 78550

F 0558 Level of Harm - Minimal harm or potential for actual harm residents reach. RN ADON stated it was the responsibility of the LVN or ADON to remind CNAs to make sure call lights were within resident reach and if the resident cannot reach the call light, the resident may not be able to call for assistance. RN ADON stated all staff were expected to round on residents every 2 hours or more often and ensure their call lights are within reach. She stated staff were in-serviced periodically on call lights and reminded of facility policy. Residents Affected - Few Record review of facility policy with an implemented date of 10/13/22 titled Call Lights: Accessibility and Timely Response, quoted in part, the purpose of the policy is to assure the facility is adequately equipped with a call light at each resident's bedside .to allow residents to call for assistance .call lights will directly relay to a staff member or centralized location to ensure appropriate response .staff will ensure the call light is within reach of resident and secure, as needed . the call system will be accessible to residents while in their bed or other sleeping accommodations within the resident's rooms. 676125 Page 3 of 22 676125 04/06/2023 Windsor Atrium 1814 Atrium Place Harlingen, TX 78550

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 that included measurable objectives and time frames to meet, attain, and/or maintain the resident's highest practicable physical, mental, and psychosocial well-being for two residents (Resident #60 and Resident #83) of twelve residents reviewed for care plans. 1. The facility failed to revise Resident #60's comprehensive person-centered care plan to reflect resident's weight loss and dietary plan. 2. The facility failed to develop and implement a comprehensive person-centered care plan for Resident #83 to address physical therapy. This failure could affect residents who receive care at the facility and could result in missed or inadequate care. The findings were: 1. Record review of Resident #60's face sheet dated 04/05/2023, revealed a [AGE] year old female with an initial admission date of 11/28/2022 with diagnoses which included: Gout (a type of inflammatory arthritis that causes pain and swelling in joints), Acute Kidney Failure with tubular necrosis (a kidney disorder involving damage to the tiny ducts in the kidneys that help filter the blood when it passes through the kidneys), Urinary Tract Infection, Chronic Congestive Heart Failure (the heart cannot pump enough blood), moderate protein-calorie malnutrition, Gastro-Esophageal Reflux Disease (GERD - occurs when stomach acid repeatedly flows back into the tube connecting the mouth to the stomach). Record review of Resident #60's Quarterly MDS, dated [DATE], revealed a BIMS score of 06, which indicated moderate cognitive impairment. Record review of Resident #60's Care Plan, dated 02/26/2023, revealed no mention of nutritional status or dietary plan for weight loss. Record review of Resident #60's electronic clinical record, Weights, and Vitals, revealed on 12/01/2022, Resident #60's documented weight at admission was 166 pounds. On 03/02/2023, Resident #60's weight was documented as 144 pounds. On 03/07/2023 and 03/08/2023, Resident's documented weight was 144 pounds. Record review of Resident #60's electronic clinical record progress notes revealed on 03/22/2023, Dietician H's Dietary/Nutrition Note: wt. loss progress note: CBW 144lbs, current diet: Regular diet, mech soft texture, reg. liquids. po intake 25-50%. some wt. changes secondary to diuretic treatment. skin intact, meds: lasix, labs reviewed. estimated nutritional needs: 1307-1437kcal(msj 1.25AF x 1-1.1IF), protein needs: 65-79g(1-1.2g/kg), fluid needs: 1964ml(30ml/kg). rec. house shake BID with medications x 30 days. goal: po intake 50% all meals. will continue to monitor and follow up as needed. Record review of a nurse's progress note written by LVN E, dated 03/27/2023, revealed, Healthshakes 676125 Page 4 of 22 676125 04/06/2023 Windsor Atrium 1814 Atrium Place Harlingen, TX 78550

F 0656 BID x 30 days as per dietician recommendation. Level of Harm - Minimal harm or potential for actual harm In an interview on 04/05/23 at 10:06 a.m., DON stated residents were weighed monthly. Residents Affected - Few In an interview on 04/05/23 at 11:00 a.m., CNA A stated new admissions were weighed at the time of admission and every four weeks after from the date the resident gets there. CNA A stated if there were an order for weekly weights, the resident gets weighed weekly. CNA A continued saying the nurse gives the CNAs a list of residents who need to be weighed, the CNAs weigh them, the nurse gets the weights off the computer, and the CNAs also let the nurse know of weight changes. In an interview on 04/05/23 at 11:05 a.m., LVN E stated residents were weighed monthly from the time of admission or weighed once a week if there were orders and some residents had daily weights. LVN E stated Restorative Aides, CNAs or nurses weigh the residents. LVN E stated if a resident has changes in weight, whoever has weighed the resident, will let the nurse know. LVN E stated nurses also receive computer notification of changes in weight and if changes have occurred, the nurse notifies the provider. The nurse will investigate as to why there have been changes in the resident's weight. LVN E stated the Provider is notified and if orders are received, they are carried out. LVN E said family and DON are also notified, documentation is completed, and if there is an order for a dietary consult, the nurse notifies the dietician. In an interview on 04/05/23 at 02:25 a.m., the DON stated the MDS nurses were responsible for the care plans. In an interview on 04/05/23 at 03:36 p.m., LVN MDS F stated the dietician gives ADON recommendation he has made and the ADON puts the weight loss in the care plan. LVN MDS stated she does not put weight loss or dietary recommendations in the care plan. In an interview on 04/05/23 at 03:50 p.m., RN ADON G stated she would have to check Resident 60's chart for weight loss. RN ADON G stated anyone can update the care plan. She stated the negative outcome would be different for every resident. RN ADON G stated if it was not in the care plan, it does not mean it (whatever is not in the care plan) was not being done. Whatever it is, would be in the orders or somewhere else so the CNA or nurse can complete it. RN ADON G stated there should be orders and documentation. In an interview on 04/06/23 at 10:27 a.m., Resident #60 stated she had originally lost a lot of weight, but she was getting her appetite back. In an interview on 04/06/23 at 10:37 a.m., CNA A stated they weigh residents on admission and the last day of the month. CNA A stated they get the list of residents to be weighed monthly from DON. The nurses tell them when there is a new resident who needs to be weighed. Observation on 04/06/23 at 10:27 a.m., CNA A and CNA B weighed Resident #60. Resident 60's weight was 153.6 pounds using the weight chair. Review of the facility policy and procedure, undated, entitled Quick Reference Guide Weight System - A guide to assist the facility in obtaining and maintaining accurate Resident weights (undated) revealed 6. A licensed nurse must observe a re-weigh on any Resident demonstrating a 5-pound or more weight loss. 8. Documentation and interventions for all weights must be completed. 676125 Page 5 of 22 676125 04/06/2023 Windsor Atrium 1814 Atrium Place Harlingen, TX 78550

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the facility policy and procedure dated December 2017, titled Charting and Documentation revealed, All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Documentation in the medical record may be electronic, manual or a combination. 2. Record review of Resident #83's admission record dated 04/03/23 documented an [AGE] year-old female with an admission date of 03/01/23. Resident #83's diagnoses include: chronic diastolic congestive heart failure (condition in which the heart's main pumping chamber, left ventricle, becomes stiff and unable to fill properly), essential hypertension (condition in which the blood pressure is persistently elevated with no secondary cause identified), hyperlipidemia (condition in which the blood has too much fat or cholesterol/triglycerides), unspecified dementia (condition in which a person loses the ability to think, remember, learn, make decisions, and solve problems), unspecified hearing loss (bilateral) (condition of loss of hearing in both ears), pain in left knee, anorexia (an eating disorder characterized by low weight, food restriction, body image disturbance, fear of gaining weight associated with self-induced behaviors towards thinness). Record review of Resident #83's active physician orders dated 04/03/23 documented an order for PT (physical therapy) C/O (care of): initiate PT services 5x(times)/wk.(week) to address ICD-10 codes M62.59.59, R26.81, and R26.89 through therapeutic activities and exercise; gt (gait) training; and modalities PRN (as necessary) to increase overall functional status. One time only for Therapy Services for 4 weeks. Order for physical therapy dated 03/27/23 with a start date of 03/27/23 and an end date of 04/24/23. Further record review of Resident #83's active physician orders dated 04/03/23 also documented an order for PT (physical therapy) to EVAL (evaluate) and TX (treat) with an order date of 03/27/23. Record review of Resident #83's admission MDS dated [DATE] documented a BIMS score of 04 which indicated the resident had severe cognitive impairment. Record review of Resident #83's care plan with an admission date 03/01/23 and an initiated date 03/14/23 revealed no care plan including problems, goals, and interventions for physical therapy. Observation and interview on 04/03/23 at 03:10 pm in Resident #83's room revealed resident sitting in chair. Resident was awake, alert, and able to make needs known. Resident stated she liked going to the gym to get her exercise referring to the therapy she was receiving. In an interview on 04/05/23 at 03:40 p.m., with LVN MDS F recognized Resident #83 was receiving physical therapy and was not part of the care plan. LVN MDS F identified 03/01/23 as the date Resident #83 was admitted . LVN MDS F stated the care plan should have been completed based on the resident's admission date. LVN MDS F stated it was her responsibility to review the resident's care plan and she had up to 14 days to complete the care plan. LVN MDS F stated that regarding Resident #83's, she may have missed initiating the care plan for physical therapy. In an interview with RN ADON on 04/05/23 at 03:50 p.m. revealed any staff member involved in the resident's care could initiate a care plan. RN ADON mentioned that having a care plan should reflect the care of a resident and not having one could negatively affect a resident. RN ADON mentioned that a resident's problem should be in the care plan because if it was not, then there would be 676125 Page 6 of 22 676125 04/06/2023 Windsor Atrium 1814 Atrium Place Harlingen, TX 78550

F 0656 information missing regarding the resident that practitioners could use for their care. Level of Harm - Minimal harm or potential for actual harm In an interview with the Administrator on 04/06/23 at 09:10 a.m. revealed the facility has daily meetings with key staff members to review care plans. The Administrator mentioned all staff involved in the resident care were responsible for reviewing care plans. He mentioned care plans were important because they serve as a way of documentation of the resident's needs. Residents Affected - Few In an interview with the DON on 04/26/23 at 10:40 a.m. revealed care plans in the facility should be completed within 14 days. The DON outlined the process of developing a care plan in their facility beginning with receiving an order from a physician and developing a baseline care plan. The DON mentioned the MDS coordinator initiated a care plan within 7 days of completion of a MDS assessment. The DON mentioned care plans were addressed at their daily clinical meetings with staff members including the ADONs and the MDS coordinator. The DON mentioned she was unsure how the care plan for Resident #83 was missed. She stated we the clinical team would have been responsible for initiating the care plan. The DON mentioned the care plan was also reviewed during the family meeting and the team, including the MDS coordinator, missed initiating or reviewing the care plan at this meeting. The DON mentioned the individualized care plan was person centered and the facility used it to know the resident's needs or how to care for them. Record review of the facility's policy on Care Planning with a revision date of 12/2017 quoted in part, a baseline plan of care to meet the resident's immediate needs shall be developed for each resident within forty-eight (48) hours of admission .a comprehensive care plan for each resident is developed within seven (7) days of completion of resident assessment (MDS) . The care plan is based n the resident's comprehensive assessment and is developed by a Care Planning/Interdisciplinary Team which includes, but is not necessarily limited to the following personnel . 676125 Page 7 of 22 676125 04/06/2023 Windsor Atrium 1814 Atrium Place Harlingen, TX 78550

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range for 1 (Resident #60) of 6 residents whose records were reviewed for weight loss in that: Residents Affected - Few The facility did not monitor Resident #60's weight to identify a weight loss from 12/1/22 through 3/2/22. This failure could affect any resident and could result in residents' continued weight loss and decline in physical health. The findings were: Record review of Resident #60's face sheet dated 04/05/2023, revealed an initial admission date of 11/28/2022 with diagnoses which included: Gout (a type of inflammatory arthritis that causes pain and swelling in joints), Acute Kidney Failure with tubular necrosis (a kidney disorder involving damage to the tiny ducts in the kidneys that help filter the blood when it passes through the kidneys), Urinary Tract Infection, Chronic Congestive Heart Failure (the heart cannot pump enough blood), moderate protein-calorie malnutrition, Gastro-Esophageal Reflux Disease (GERD - occurs when stomach acid repeatedly flows back into the tube connecting the mouth to the stomach). Record review of Resident #60's Quarterly MDS, dated [DATE], revealed a BIMS score of 06, which indicated moderate cognitive impairment. No nutritional issues were coded in MDS. Record review of Resident #60's Care Plan, dated 02/26/2023, revealed no mention of nutritional status or dietary plan for weight loss. Record review of Resident's #60's Weights and Vitals revealed Resident #60's weight on 12/01/2022 as 166 pounds. The next weight for Resident#60's weight was on 03/02/2023 as 144 pounds. Weight was taken again on 03/07/2023 and 03/08/2023 documented at 144 pounds. No weights were documented from 12/01/2022 through 03/01/2023 or 03/09/2023 through 04/06/2023. Record review of Resident #60's electronic clinical record progress notes revealed on 03/22/2023, Dietician H's Dietary/Nutrition Note: wt. loss progress note: CBW 144lbs, current diet: Regular diet, mech soft texture, reg. liquids. po intake 25-50%. some wt. changes secondary to diuretic treatment. skin intact, meds: lasix, labs reviewed. estimated nutritional needs: 1307-1437kcal(msj 1.25AF x 1-1.1IF), protein needs: 65-79g(1-1.2g/kg), fluid needs: 1964ml(30ml/kg). rec. house shake BID with medications x 30 days. goal: po intake 50% all meals. will continue to monitor and follow up as needed. Record review of Resident #60's electronic clinical record progress note written by LVN E, dated 03/27/2023, revealed, Healthshakes BID x 30 days as per dietician recommendation. In an interview on 04/05/23 at 10:06 a.m., DON stated residents were weighed monthly. In an interview on 04/05/23 at 11:00 a.m., CNA A stated new admissions are weighed at the time of admission and every four weeks after from the date the resident gets there. CNA A stated if there is 676125 Page 8 of 22 676125 04/06/2023 Windsor Atrium 1814 Atrium Place Harlingen, TX 78550

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few an order for weekly weights, the resident gets weighed weekly. CNA A said the nurse gives the CNAs a list of residents who need to be weighed, the CNAs weigh them, the nurse gets the weights off the computer, and CNAs also let the nurse know of weight changes. In an interview on 04/05/23 at 11:05 a.m., LVN E stated residents are weighed monthly from the time of admission or weighed once a week if there are orders and some residents have daily weights. LVN E stated Restorative Aides, CNAs or nurses weigh the residents. LVN E stated if a resident has changes in weight, whoever has weighed the resident, will let the nurse know. LVN E stated nurses also receive computer notification of changes in weight, if changes have occurred, the nurse notifies the provider. LVN E stated the nurse will investigate as to why there have been changes in the resident's weight, the Provider is notified, and if orders are received, they are carried out. LVN E stated family and DON are also notified, documentation is completed, and if there is an order for a dietary consult, the nurse notifies the dietician. In an interview on 04/05/23 at 03:50 p.m., RN ADON G stated she would have to check Resident 60's chart for weight loss. RN ADON G stated anyone can update the care plan. She stated the negative outcome would be different for every resident. RN ADON G stated there should be orders and documentation. In an interview on 04/06/23 at 10:27 a.m., Resident #60 stated she had originally lost a lot of weight, but she was getting her appetite back. In an interview on 04/06/23 at 10:37 a.m., CNA A stated they weigh residents on admission and the last day of the month. CNA A stated they get the list of residents to be weighed monthly from DON. The nurses tell them when there is a new resident who needs to be weighed. Observation on 04/06/23 at 10:27 a.m., CNA A and CNA B weighed Resident #60. Resident 60's weight was 153.6 pounds using the weight chair. Review of the facility policy and procedure, entitled Quick Reference Guide Weight System - A guide to assist the facility in obtaining and maintaining accurate Resident weights (not dated) revealed: 6. A licensed nurse must observe a re-weigh on any Resident demonstrating a 5-pound or more weight loss. 8. Documentation and interventions for all weights must be completed. Review of the facility policy and procedure dated December 2017, titled Charting and Documentation revealed, All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Documentation in the medical record may be electronic, manual or a combination. 676125 Page 9 of 22 676125 04/06/2023 Windsor Atrium 1814 Atrium Place Harlingen, TX 78550

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record reviews the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each Resident for 1 (Resident #13) of 5 residents reviewed medications, in that: The facility failed to clarify parameters for administering a blood pressure medication. This failure could place residents at risk for not receiving the therapeutic effects of the medications prescribed and/or received adverse effects from the medication. The findings included: A record review of Resident #13's admission record dated 04/04/2022, revealed an admission date of 12/22/2022, with diagnoses which included dementia (a condition characterize by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain), Alzheimer's disease (progressive mental deterioration that can occur in middle or old age, due to generalized degeneration of the brain), hypertension (high blood pressure), peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), presence of a cardiac pacemaker, and type 2 diabetes mellitus. A record review of Resident #13's quarterly MDS dated [DATE] revealed Resident #13 was an [AGE] year-old female with severe cognitive impairment. A record review of Resident #13's medication order, dated 12/22/2022, revealed Resident #13 was to receive the medication Lisinopril Tablet 40mg Give 1 tablet by mouth two times a day for HTN (hypertension) MONITOR IF SBP (systolic blood pressure) <100 or SBP (systolic blood pressure) <60 and Hold med if continues to decrease notify MD. During medication pass observation on 04/04/2023 at 07:55 a.m., MA C was dispensing medication to Resident #13. MA C took Resident #13's blood pressure prior to administration. Resident #13's blood pressure reading was 120/53 and heart rate was 64. MA C held Lisinopril Tablet 40mg and notified her nurse (LVN D). In an interview on 04/04/23 at 08:17 a.m., LVN D stated the order for Lisinopril was confusing (MONITOR IF SBP (systolic blood pressure) <100 or SBP (systolic blood pressure) <60 and Hold med if continues to decrease notify MD). LVN D stated he would give the Lisinopril. MA C stated she was not going to give it. She did not feel comfortable doing that. In an interview and observation on 04/04/23 at 08:24 a.m., revealed RN ADON G read Lisinopril order. RN ADON G stated she was going to clarify the order with the doctor and MA C was to hold the medication until there was clarification. In an interview on 04/04/23 at 08:29 AM, the DON stated the order (for Resident #13 Lisinopril 40mg tablet - to MONITOR IF SBP <100 or SBP <60) was not right . The DON stated the negative 676125 Page 10 of 22 676125 04/06/2023 Windsor Atrium 1814 Atrium Place Harlingen, TX 78550

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few outcome would depend on the resident and how they break down the medication. The DON stated to hold the Lisinopril. The DON stated she was going to call the doctor and pharmacy to check the order. In an interview on 04/04/23 at 08:37 a.m., RN ADON G stated she was on the phone holding for the doctor to clarify the order. RN ADON G stated she would correct the order and if the resident was to get the Lisinopril, she would get it and if it were to be held, it would be held. In an interview on 04/04/23 at 09:01 a.m., RN ADON G stated she had spoken with the doctor and he said to recheck the BP on Resident #13, and he gave a new order for SBP < 90 or DBP < 40. Record Review of Receiving/Recording Physician Orders Supervision by a Physician NPP - Medications (rev 07/15), revealed: 4. Physician Orders/Progress Notes should be signed and dated every thirty (30) days for SNF residents. (Note: This may be changed to every sixty (60) days after initial ninety (90) days of the resident's admission.) 676125 Page 11 of 22 676125 04/06/2023 Windsor Atrium 1814 Atrium Place Harlingen, TX 78550

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to assure that drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, for 1 (Resident #13) of 5 residents reviewed for labeling and storage, in that: The pharmacy label for Resident #13's prescription showed incorrect parameters for blood pressure. This failure could affect residents prescribed medications in the facility and place them at risk for not receiving the correct medications at the correct times. The findings were: A record review of Resident #13's admission record dated 04/04/2022, revealed an admission date of 12/22/2022, diagnoses which included dementia (a condition characterize by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain), Alzheimer's disease (progressive mental deterioration that can occur in middle or old age, due to generalized degeneration of the brain), hypertension (high blood pressure), peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), presence of a cardiac pacemaker, and type 2 diabetes mellitus. A record review of Resident #13's quarterly MDS dated [DATE] revealed Resident #13 was a [AGE] year-old female with severe cognitive impairment. A record review of Resident #13's medication order, dated 12/22/2022, revealed Resident #13 was to receive the medication Lisinopril Tablet 40mg Give 1 tablet by mouth two times a day for HTN (hypertension) MONITOR IF SBP (systolic blood pressure) <100 or SBP (systolic blood pressure) <60 and Hold med if continues to decrease notify MD. During medication pass observation on 04/04/2023 at 07:55 a.m., MA C was dispensing medication to Resident #13. MA C took Resident #13's blood pressure prior to administration. Resident #13's blood pressure reading was 120/53 and heart rate was 64. MA C held Lisinopril Tablet 40mg and notified her nurse (LVN D). The label on the medication packet and the doctor's order had the same parameters of MONITOR IF SBP (systolic blood pressure) <100 or SBP (systolic blood pressure) <60 and Hold med if continues to decrease notify MD. The order on the label and the physician's order were the same. In an interview on 04/04/23 at 08:17 a.m., LVN D stated the order for Lisinopril was confusing. LVN D stated he would give the Lisinopril. MA C stated she was not going to give it. She did not feel comfortable doing that. (Order: Lisinopril Tablet 40mg Give 1 tablet by mouth two times a day for HTN MONITOR IF SBP <100 or SBP <60) In an interview on 04/04/23 at 08:24 a.m., RN ADON G read Lisinopril order. RN ADON G stated she was going to clarify the order with the doctor and MA C was to hold the medication until there was clarification. 676125 Page 12 of 22 676125 04/06/2023 Windsor Atrium 1814 Atrium Place Harlingen, TX 78550

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few In an interview on 04/04/23 at 08:29 AM DON stated the order was not right (MONITOR IF SBP <100 or SBP <60). DON stated the negative outcome would depend on the resident and how they break down the medication. DON stated to hold the Lisinopril. DON stated she was going to call the doctor and pharmacy to check the order. In an interview on 04/04/23 at 08:37 a.m., RN ADON G stated she was on the phone holding for the doctor to clarify the order. RN ADON G stated she would correct the order and if the resident was to get the Lisinopril, she would get it and if it were to be held, it would be held. In an interview on 04/04/23 at 09:01 a.m., RN ADON G stated she had spoken with the doctor and he said to recheck the BP on Resident #13, and he gave a new order for SBP < 90 or DBP < 40. Record review of Regency Integrated Health Services policy NPP - Medications (rev 07/15) revealed, Recording Orders: When recording any physician orders, verify resident's allergies prior to ordering or administering medication. 1. Medication Orders: When recording orders for medication, specify: a. The type, route, dosage, frequency, and strength of the medication ordered (i.e., Dilantin 100mg 1cap p.o. t.i.d.). 676125 Page 13 of 22 676125 04/06/2023 Windsor Atrium 1814 Atrium Place Harlingen, TX 78550

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 by professional standards for food service safety for 2 of 2 nutrition/supply rooms reviewed in that: Residents Affected - Some There was unlabeled and undated food and beverages in both nutrition room refrigerators. The refrigerator temperature logs for both nutrition rooms were missing data. The room temperature logs for both nutrition rooms were missing data. These failures could place residents at serious risk for complications from food contamination, and/or foodborne illness. Findings included: Observation of the Long Term Care supply/nutrition room on 04/04/23 at 10:37 AM revealed an unlabeled and undated 8 oz. container of an unidentified white substance, an open and half full, unlabeled pint of ice cream with an expiration date of 04/07/22, and an open, unlabeled 2.85 oz. bag of jerky in the freezer. There was a paper plate covered with foil that had dried food on it and was unlabeled and not dated, an undated and unlabeled sandwich wrapped in foil, a 6oz. container of yogurt that expired 01/09/23, and a half-full liter of bottled water in a plastic bag that was not labeled or dated-the contents of the bag were also not dated or labeled in any way. The supply/nutrition room temperature log for 2023 was missing documentation for 10 days in January, all days in February, and 23 days in March, and had no entries for April. The thermometer on the wall and a thermometer on a shelf both showed 80F. The wall thermometer was marked at 78F, to indicate the proper temperature the room should be at. An interview with the DON on 04/04/23 at 11:05 AM stated the unlabeled/updated food comes from residents' families. They are supposed to have a resident's name and date. The individual who received the items should have labeled and dated those items. The DON stated housekeeping was responsible for cleaning out the refrigerator and freezer and she will have to check if the housekeepers knew to look for expired and/or unlabeled items to dispose of. The DON stated the refrigerator log was not complete and the nurses were responsible for filling in the log. The DON stated the room temperature log was missing data and was not complete. The room temperature was supposed to be 78F. This information was not on the logs. For out-of-range temperatures, maintenance would be notified by calling the Maintenance Director, who was in the hospital at this time, so the administration should be notified. The DON stated the facility also utilized an electronic log system in which anyone can enter items for maintenance repair or service. Observation of the Transitional Care Unit supply/nutrition room and Interview with the DON on 04/04/23 at 11:22 AM revealed the 2023 refrigerator was missing data-16 days in March and no entries for April. The room temperature logs were missing data-20 days in March and no entries for April. A thermometer on the wall next to the room temperature log was marked at 78F, indicating the acceptable temperature. The refrigerator had 3, 12oz. cans of an energy drink, unlabeled and undated, a 15oz. container of a green substance that was unlabeled, undated, and expired 02/23/23, an open 8 oz. container of tube feeding unlabeled, undated, and expired 01/09/22, an unlabeled and undated container of 676125 Page 14 of 22 676125 04/06/2023 Windsor Atrium 1814 Atrium Place Harlingen, TX 78550

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some an unknown substance, 4 slices of white bread, 4 slices of what appeared to be cheese, a bag of deli meat with an expiration date of 04/03/23, a second bag of deli meat, 5 other type slices of bread, a 16oz can of beans, a 20 oz. bottle of an electrolyte drink, a store-bought sandwich that expired 03/27/23, a 1.5 oz. bag of pepperoni expired 03/29/23, a half-full 64 oz. bottle of apple juice expired 09/11/22, a different 64 oz., full bottle of juice expired 12/17/22, a 64oz. bottle of chocolate milk expired 03/01/23, a personal drink with a pink fluid in it, and 4 near empty containers of various unidentified food. All of the items listed above were unlabeled and undated. There were 2, 8oz cans of tube feeding expired 09/21/21, 7, 8oz bottles of hand sanitizer expired 08/07/22, and 24 bottles of 8oz hand sanitizer expired 07/25/22 in the supply closet. The DON stated the unlabeled/updated food comes from residents' families. They were supposed to have a resident's name and date. The individual who received the items should have labeled and dated those items. The DON stated housekeeping was responsible for cleaning out the refrigerator and freezer and she will have to check if the housekeepers knew to look for expired and/or unlabeled items to dispose of. The DON stated the refrigerator log was not complete and the nurses were responsible for filling in the log. The DON stated the room temperature log was missing data and was not complete and the room temperature was supposed to be 78F. After removing several undated, unlabeled, and/or expired items from the refrigerator, the DON stated, You already have a solid Tag, do you HAVE to continue? Interview with ES on 04/06/23 at 08:31 AM, the ES stated housekeeping was supposed to go into the nutrition rooms and clean the refrigerators daily. The ES stated the housekeepers were supposed to remove any food or anything that did not have a visitor/resident name and expiration dates and they throw it (away). The ES stated the ADM mentioned the refrigerators to her and told her to be sure the housekeepers were checking the dates and following the protocol for cleaning the refrigerators. An Interview with the DON on 04/06/23 at 02:55 PM, she stated the facility did not have a refrigerator and room temperature logs policy. Record review of the facility policy, Potluck Meals and Foods from Home dated 12/18/17 documented under Guidelines: 1) When outside foods are brought into the facility by resident family or friends, it must be labeled to clearly distinguish it from the food purchased or prepared by the facility and stored separately from the facility's food by placing on a distinguished shelf, labeled bag, or in a bin labeled resident food with the resident name on the items. Foods must be dated with food safety guidelines followed. 676125 Page 15 of 22 676125 04/06/2023 Windsor Atrium 1814 Atrium Place Harlingen, TX 78550

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to maintain medical records on each resident that are complete and accurately documented for 1 (Resident #13) of 5 Residents reviewed for complete and accurate medication administration records, in that: The facility did not document physician ordered blood pressure readings for medication administration for Resident #13. This failure could place residents at risk for not receiving care and services and their medications as prescribed. The findings included: A record review of Resident #13's admission record dated 04/04/2023, revealed an admission date of 12/22/2022 with diagnoses which included dementia (a condition characterize by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain), Alzheimer's disease (progressive mental deterioration that can occur in middle or old age, due to generalized degeneration of the brain), hypertension (high blood pressure), peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), presence of a cardiac pacemaker, and type 2 diabetes mellitus. A record review of Resident #13's quarterly MDS dated [DATE] revealed Resident #13 was an [AGE] year-old female with severe cognitive impairment. A record review of Resident #13's physician's order, dated 12/22/2022, revealed Resident #13 was to receive the medication Lisinopril Tablet 40mg Give 1 tablet by mouth two times a day for HTN (hypertension) MONITOR IF SBP (systolic blood pressure) <100 or SBP (systolic blood pressure) <60 and Hold med if continues to decrease notify MD. A record review of Resident #13's Medication Administration Record dated 03/01/2023 through 03/31/2023 had no blood pressure or pulse reading documented for the twice a day administration of Lisinopril Tablet 40mg two times a day for hypertension. In an interview on 04/05/23 at 10:06 a.m., concerning the blood pressure readings not being documented on Resident 13's MAR (Medication Administration Record), DON stated nurses and medication aides were supposed to check and put blood pressure readings in MAR when giving blood pressure medications. The DON stated the negative outcome would be different for each resident since each resident breaks down medication differently. The DON also stated that if a blood pressure medication were held and the blood pressure was not documented, no one would know what the reading was and why it was held. In an interview on 04/05/23 at 11:05 a.m., LVN E stated when blood pressure medications were given, blood pressure readings were put in the computer and blood pressure readings were put in the MAR. If blood pressure was not put in the computer, a resident could be receiving blood pressure medication when it is not called for. Resident could have low blood pressure and blood pressure medication could lower it more. 676125 Page 16 of 22 676125 04/06/2023 Windsor Atrium 1814 Atrium Place Harlingen, TX 78550

F 0842 Record review of the facility's Integrated Health Services Level of Harm - Minimal harm or potential for actual harm Charting and Documentation (rev 07/15) revealed, All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Residents Affected - Few 676125 Page 17 of 22 676125 04/06/2023 Windsor Atrium 1814 Atrium Place Harlingen, TX 78550

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of infections, hand hand hygiene procedures, and for establishing a process to make every visiitor entering the facility aware of suspected or confiremd SARS-COV-@2 infection for 1 of 1 staff (ADON) and one of four residents, (Resident #71) reviewed for infection control, in that: Residents Affected - Few 1. The ADON removed sterile packing from its container with bare fingers. The ADON used non-sterile scissors to cut the packing. The ADON applied wound cleanser to sterile gauze in a non-sterile plastic cup. The ADON utilized non-sterile wooden spoons to apply ointments to an open surgical wound. 2. The facility failed to ensure CNA I sanitized her hands between glove changes in a manner that promoted cleanliness and prevented infection while providing incontinent care to Resident #71. 3. The facility failed to ensure there was proper signage posted on all main entrances to ensure everyone including guests and visitors were aware of suspected or confirmed SARS-CoV2 infection and the recommended infection prevention and control (IPC) practices in the facility. These failures could place residents at risk for cross-contamination and/or the spread of infection. The findings were: 1. Resident #242 was a [AGE] year-old male with diagnoses of osteomyelitis (bone infection), aorto and coranary bypass grafts (heart surgery), diabetes, high cholesterol, high blood pressure, and heart disease. Record review of Resident #242's history and physical from the hospital dated 03/04/23 documented purulent discharge and pain from a coronary artery bypass graph (CABG) performed on 02/01/23. Record review of the physician orders for Resident #242 dated 03/22/23: Cleanse sternum with wound cleanser, pat dry with gauze, apply topical and antibiotic to wound, pack with packing gauze; cover with dry dressing one time a day for SX (surgical) wound and as needed for SX wound. May change dressing when wet, soiled, or dislodged. Observation of wound care for Resident #242 on 04/05/23 at 02:00 PM with the ADON, who performed the dressing change. Resident #242's bedside table was sanitized, and non-sterile wax paper was placed on it to receive supplies. Reusable scissors were sanitized. Wound cleanser was applied to sterile gauze that was in a non-sterile plastic cup. The ADON removed sterile packing was removed from its original container with bare fingers. The packing was cut with sanitized scissors. An antibiotic was placed on a non-sterile wooden spoon and placed in a non-sterile plastic medicine cup. Sterile gloves were not utilized throughout wound care. 676125 Page 18 of 22 676125 04/06/2023 Windsor Atrium 1814 Atrium Place Harlingen, TX 78550

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few An interview with the ADON on 04/05/23 at 2:15 PM,: the ADON stated since her hands were clean, she felt it was ok to remove the sterile packing from the container it was in. The ADON stated she did not know of another method to remove the sterile packing. An interview with the DON on 04/05/23 at 02:50 PM revealed she did not know what procedure the facility had to remove sterile packing from the container it was in. The DON stated she was not a wound care nurse but when she did wound care in the past, she always used sterile tweezers to remove sterile packing from the container it was in. Record review of the facility's policy, Wound Care, revised 07/2015 revealed, #7. Use the no-touch technique . (see below) Record review of the Classification of Surgical Site Infections (SSI), Summarized from the CDC/NHSN Surveillance Definitions for Specific Types of Infections was as follows: .Deep incisional SSI: infection must occur within 30 or 90 days after the operative procedure and involve deep soft tissues of the incision and the patient must also have at least one of the following: Purulent drainage from the deep incision, a deep incision that spontaneously dehisces (comes apart), is re-opened by a surgeon, and the organism is identified by a biologic testing method, and fever and/or pain, and/or tenderness, an abscess or other evidence of infection .Indicating Resident #242's wound was a surgical wound infection to the sternum (osteomyelitis=bone infection) that occurred within 30 days. References: CDC-Centers for Disease Control, NHSN-National Healthcare Safety Network, J.AmAcadOrthopSurgGlobResRev. 2017 Jun; 1(3): e022 Published online 2017 Jun 13. doi: 10.5435/JAAOSGlobal-D-17-00022 ncbi.nlm.nih.gov Record review of Lippincott's Procedures for surgical wound care documents for best practices: Dressing a surgical wound calls for a sterile no-touch technique and sterile supplies to prevent contamination. Adherence to standard precautions set by the Centers for Disease Control and Prevention is always necessary when providing wound care. Equipment: gloves, sterile gloves, sterile gauze pads, prescribed antiseptic cleaning agent, a dressing, soap and water, sterile drape. Optional: pain medication, gown, mask, goggles, mask with face shield, adhesive remover, sterile normal saline, prescribed topical medication(s), sterile container, wound irrigation, and supplies, sterile cotton-tipped applicators, protective skin barrier, sterile forceps, or tweezers. Caring for the wound: Perform hand hygiene, establish a sterile field with all needed supplies, open and prepare the supplies, perform hand hygiene, put on sterile gloves, and clean the wound using a new pad for each swipe .If ordered, pack the wound with sterile strips folded to fit using sterile forceps . Reference: https://www.facs.org/~/media?files/education/patient%20ed/wound_surgical.ashx 2. Record review of Resident # 71's admission record dated 04/06/23 revealed an admission date 02/10/23 with primary diagnoses including: sepsis (condition that arises as a result of the body's response to an severe infection that can cause injury to its own organs and tissues), urinary tract infection (UTI) (infection to any part of the urinary tract system), pneumonia (an inflammatory condition of the lung affecting the small air sacs known as the alveoli), acute and chronic respiratory failure with hypoxia (condition in which the level of oxygen in the blood becomes dangerously low or the level of carbon dioxide in the blood becomes dangerously high), encephalopathy (condition that affects brain structure or function causing dysfunction) , nontraumatic intracranial hemorrhage (non-traumatic internal bleeding of the brain). 676125 Page 19 of 22 676125 04/06/2023 Windsor Atrium 1814 Atrium Place Harlingen, TX 78550

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of Resident # 71's Quarterly MDS assessment, dated 02/10/22, revealed Resident # 71 was unable to obtain responses to questions regarding cognition and recall. The MDS also revealed Resident #71 required extensive assistance in various areas of activities of daily living such as transfer, dressing, bed mobility, and personal hygiene. Record review of Resident #71's care plan dated 08/24/22 with a revision date of 10/05/22 revealed Resident #71 had bowel incontinence and bladder incontinence related to limited mobility problems. Interventions included provide peri care after each incontinent episode and clean peri-area with each incontinence episode. Observation on 04/06/23 at 01:45 p.m. revealed Resident #71 was in bed and positioned in a low-semi-Fowler's position (on her back with her legs apart) and uncovered exposing her perineal area. Her adult brief was then unsecured, and CNA I wiped across the resident's pubic area using one wipe, one swipe. CNA I then wiped the resident's external genitalia each side in a downward motion using one wipe one swipe. CNA I then wiped the resident's urethral area in a downward motion using one wipe, one swipe three separate times. CNA I then removed her soiled gloves and donned new gloves without sanitizing her hands between glove changes. CNA I then wiped the foley catheter tube with 1 wipe in a downward motion two separate times. The resident was then turned to her left side. CNA I removed her soiled gloves, sanitized her hands, and donned new gloves. CNA I proceeded to wipe front to back using three different wipes, three times . CNA I then removed soiled adult brief and wiped the resident one-time front to back. CNA I removed her soiled gloves, sanitized her hands, and donned new gloves. She proceeded to push the draw sheet under the resident and place a new draw sheet and new adult brief under the resident. The resident was then turned onto her right side. MA J removed her soiled gloves and donned new gloves without sanitizing her hands between glove change. MA J pulled soiled draw sheet from under resident. MA J pulled new draw sheet and adult brief from under resident and resident was repositioned onto her back. MA J removed soiled gloves and donned new gloves failing to sanitize her hands between glove change. Resident was repositioned, trash and linen were removed from bedside, and gloves were doffed. In an interview on 04/06/23 at 02:00 p.m., with CNA I revealed she failed to sanitize her hands between changing her gloves. She stated she did not sanitize her hands between glove changes because she does not have the accessibility to always carry hand sanitizer in her pocket because of missing supplies. She stated she has brought this up to her ADON and DON. In an interview on 04/06/23 at 02:10 p.m., with MA J revealed she does not carry hand sanitizer because it was not supplied to her. She stated hand sanitizer on the walls was sometimes not accessible either because the liquid is out, and she has placed a work order for hall 200. MA J stated she had told maintenance about the hand sanitizer liquid being out and not being accessible, but it had not been addressed . MA J stated gloves were changed frequently but even those supplies were hard to find and must share the boxes of gloves amongst the staff in the hall. MA J stated staff do not always have enough supplies for residents including adult briefs. MA J stated it was important to have gloves and hand sanitizer for infection control for both residents and staff. MA J stated failing to perform adequate hand hygiene could cause residents to get infection especially those with weak immune system. In an interview on 04/06/23 at 02:25 p.m., with LVN H revealed performing proper hand hygiene was important to prevent transmission of infection. LVN H stated it was important to use hand sanitizer between glove changes up to three times for infection control. She stated that residents can get an infection or spread infection to other residents if proper hand hygiene was not used. LVN H stated 676125 Page 20 of 22 676125 04/06/2023 Windsor Atrium 1814 Atrium Place Harlingen, TX 78550

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few every single employee was responsible for performing hand hygiene. She stated staff were in-serviced on proper hand hygiene every 1-2 months by the RN, ADON or the DON. In an interview on 04/06/23 at 03:00 p.m., with RN ADON revealed that proper hand hygiene was important to prevent transmission of infection. RN ADON stated that proper hand hygiene included sanitizing hands between changing gloves. RN ADON stated that not performing proper hand hygiene can cause a resident to be contaminated or transmitted with infection. She stated that every staff member who performed peri care was responsible for performing proper hand hygiene. RN ADON stated that CNAs were not expected to go into the hall while providing peri care to get hand sanitizer and were provided hand sanitizers to carry with them. In an interview on 04/06/23 at 03:30 p.m. with the DON revealed proper hand hygiene during peri care was important to not contaminate from dirty to clean. The DON stated staff need to hand wash prior to and after peri care and hand sanitizing during peri care. The DON stated that by not washing or performing proper hand hygiene, there was a potential to have transmitting germs. She stated that every staff member providing peri-care was responsible for performing proper hand hygiene. The DON further went on to stated that in-services on peri care or handwashing were performed by herself or one of the ADONs assigned to the units were done regularly. Record review of facility in-service training report dated 03/21/23 revealed CNA I received competency for hand hygiene. Record review of facility policy and practices titled Perineal Care with a implemented date 10/24/22, quoted in part, It is the practice of this facility to provide perineal care to all incontinent residents during routine bath and as needed in order to promote cleanliness and comfort, prevent infection to the extent possible, and to prevent and assess for skin breakdown .perform hand hygiene and put on gloves .remove gloves and discard .perform hand hygiene . Record review of facility policy and practices titled Catheter Care with a revised date of 07/15, quoted in part, The purpose of this procedure is to prevent infection of the resident's urinary tract .remove gloves and discard into the designated container .9. wash and dry your hands thoroughly . 10. put on clean gloves .19. Discard disposable items into designated containers. Remove gloves and discard into designated container. Wash and dry your hands thoroughly. Record review of CDC Morbid and Mortality Weekly Report, Guideline for Hand Hygiene in Health-Care Settings, 2002, RR5116-Front Cover.p65 (cdc.gov), quoted in part, Indications for handwashing and hand antisepsis . Decontaminate hands if moving from a contaminated-body site to a clean-body site during patient care . Change gloves during patient care if moving from a contaminated body site to a clean body site. 3. Observation of main entrances of the facility on 04/03/23 at 09:00 a.m. revealed entrances were missing signage that alerted guests and visitors of suspected or confirmed SARS-CoV2 infection and the recommended infection prevention and control (IPC) practices in the facility. Observation and interview with staff on 04/03/23 at 04:40 p.m. revealed resident in room [ROOM NUMBER]-A was on droplet precautions for COVID-19 . Staff were observed donning PPE outside resident room prior to entering room. Interview on 04/03/23 at 09:20 a.m. with DON revealed facility had two residents who were positive 676125 Page 21 of 22 676125 04/06/2023 Windsor Atrium 1814 Atrium Place Harlingen, TX 78550

F 0880 for COVID-19 and were on droplet precautions. Level of Harm - Minimal harm or potential for actual harm Interview on 04/03/23 at 10:15 a.m. with RN ADON revealed resident in room [ROOM NUMBER]-A was on droplet precautions for COVID-19. Residents Affected - Few Observation and interview on 04/04/23 at 03:45 p.m. with Housekeeper revealed resident in room [ROOM NUMBER] was on droplet precautions for COVID-19. Housekeeper was observed doffing PPE outside resident room. Observation and interview on 04/05/23 at 08:50 a.m. with DON of facility main entrances revealed missing signage to inform guests and visitors of suspected or confirmed SARS-CoV2 infection and the recommended infection prevention and control (IPC) practices in the facility was not there. The DON stated she was not sure why and since when the signage was missing. The DON stated facility should have signage posted due to confirmed cases of COVID in the facility and she would make sure the signage was posted on the main entrances. Interview on 04/05/23 at 11:15 a.m. with RN ADON/IP revealed she was unsure how other visitors were informed of COVID related exposure other than posting signage at the main entrances. She stated that signage was not posted until surveyors brought it up to the DON. Interview on 04/06/23 at 09:10 a.m. with the Administrator revealed signage notifying guests on main entrances of suspected or confirmed SARS-CoV2 infection and the recommended infection prevention and control (IPC) practices in the facility was missing. The Administrator stated he was not sure why and since when the signage was missing. The Administrator stated the signage was initially posted outside of the door and could have been blown away due to the weather. The Administrator stated residents and immediate family members were notified of COVID-19 related exposure through mass text message. The Administrator stated guests and visitors other than immediate family members had no means of knowing of COVID-19 related exposure other than signage at the main entrances. The Administrator stated the DON made sure the signage was now posted on the main entrances on the inside of the doors visible to guests and visitors. Record review of facility policy and practices titled Coronavirus Prevention and Response without a revised or implementation date, quoted in part, This facility will respond promptly upon suspicion of illness associated with a SARS-CoV-2 infection in efforts to identify, treat, and prevent the spread of the virus .the facility will establish a process to identify and manage individuals with suspected or confirmed SARS-CoV-2 infection to include: ensuring that everyone is aware of the recommended IPC practices in the facility by posting visual alerts (e.g., signs, posters) at the entrance and in strategic places to include instructions about current IPC recommendations. Record review of CDC Healthcare Workers, Infection Control Guidance, titled, COVID-19 Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, 9/27/22, Infection Control: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), quoted in part, Establish a process to make everyone entering the facility aware of recommended actions to prevent transmission to others if they have any of the following three criteria .a positive viral test for SARS-CoV-2, symptoms of COVID-19 or close contact with someone with SARS-CoV-2 infection (for patients and visitors) . provide guidance (e.g., posted signs at entrances) . about recommended actions for patients and visitors who have any of the above three criteria. 676125 Page 22 of 22