Inspection·June 26, 2025

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for 1 of 3 residents (Resident #1) reviewed for wound care. Residents Affected - Few LVN A failed to communicate and provide treatment for the Resident #1's skin tear. This failure could place residents at risk for not receiving the appropriate care and services to maintain their health and safety. Finding included: Record review of Resident #1's face sheet dated 07/3/25 indicated Resident #1 was a [AGE] year-old female and admitted on [DATE] with diagnoses including diabetes mellitus type 2 (a chronic metabolic disorder where the body either doesn't produce enough insulin or can't effectively use the insulin it produces, leading to high blood sugar levels), essential hypertension (a condition where blood pressure is consistently elevated without a known underlying medical cause). Record review of Resident #1's MDS assessment dated [DATE] revealed a BIMS score of 5 (indicates a severe cognitive impairment). Record review of Resident #1's care plan initiated dated 05/21/24 indicated Resident #1 had limited mobility related to weakness, interventions revealed Monitor/Document/Report as needed any signs and symptoms of immobility: contractures forming or worsening, thrombus formation, skin-breakdown, fall related injury. During an interview and observation on 06/19/25 at 10:42 a.m., Resident #1 was lying in her bed with the call light in her hand. Resident #1 was not able to recall this incident. During an interview on 6/29/25 at 2:50 p.m. CNA B stated that she showered Resident #1 and resident didn't have a skin tear during the shower. CNA B said that the Resident's family member was putting lotion and told her that Resident #1 had a skin tear. CNA B stated that she told LVN A that Resident #1 had a skin tear. During a phone interview on 6/19/25 at 3:20 p.m. LVN A stated that CNA B told him that Resident #1 had a skin tear. LVN A stated that she went to Resident's #1 room and cleansed the skin tear and he forgot to call the doctor because he got busy with another resident. LVN A said that a negative outcome could be the skin tear could get infected. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 676125 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676125 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Atrium 1814 Atrium Place Harlingen, TX 78550 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)