Windsor Nursing and Rehabilitation Center of Segui

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure the MDS assessment accurately reflected the resident's status for two residents (#8 and #94) of thirty-two residents reviewed for MDSs. 1. Facility failed to note on Resident #8's annual MDS, dated [DATE], the resident was taking CPAP (Continuous Positive Airway Pressure) at hours of sleep. 2. Facility failed to note on Resident #94's annual MDS, dated [DATE], she was taking a hypoglycemic medication. This deficient practice affects residents who receive care and could result in missed or inappropriate care.

Inspectors wroteBased on interviews and record review, the facility failed to identify a diagnosis of mental illness on the preadmission screening and resident review (PASRR) assessment for 1 of 8 residents (Resident #55) whose records were reviewed for PASRR services. The facility failed to recognize on the Level I PASRR screening that Resident #55 had the mental illness diagnoses of depression, delusional disorder and bipolar disorder which would qualify Resident #55 for a PASRR evaluation. This deficient practice could place residents with mental illness at risk for not obtaining the services needed to treat their mental health diagnoses.

Inspectors wroteBased on interviews and record review, the facility failed to review and revise resident care plans after each assessment for 1 of 26 residents (Resident #8) reviewed for care plan revision/timing. The facility failed to ensure Resident #8's care plan addressed changes in his smoking status regarding the resident did not need a smoking apron while smoking because he was very safe smoker after smoking assessment, dated 06/20/2025. This deficient practice could affect residents' care and services and may cause a delay in treatment and/or decline in health.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 (Resident #7) of 4 residents reviewed for incontinence care. CNA A after he retracted Resident #7's foreskin of his penis did not pull it forward after incontinent care and CNA B did not clean the left buttock and scrotal area of Resident #7 when they turned him over to complete his incontinent care. This failure could place residents who required incontinence care at risk for cross contamination and the development of urinary tract infections.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) for 2 (north nursing cart and south nursing cart) of 3 med carts and 1 (Resident #11) of 26 residents reviewed for pharmacy services. 1. There was one individual pack of Remedy - Intensive skin therapy Hydragurd-D dimethicone cream to protect skin from the drying effects that expired 05/2025 found in north nursing cart and seven individual packs found in south nursing cart on 07/30/2025. 2. Resident #11's insulin Flasp (Insulin aspart) for diabetes had open date of 06/26/2025, found inside the south nursing cart on 07/30/2025. Per the label of the insulin said, Discard 28 days after date opened, which was on 07/24/2025. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen. The facility failed to ensure the Robot Coupe that was being used to prepare altered texture diets was clean and free from contaminates prior to using. These failures could place residents who received meals and/or snacks from the kitchen at risk for food borne illness.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases and infections for 1 (Resident #90) of 7 residents reviewed for infection control practices during medication administrations. MA-D did not sanitize or wash her hands and did not clean a blood pressure cuff when administering medications and measuring blood pressure to Resident #90. This deficient practice could place residents at risk for cross contamination and infections.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents received adequate supervision to prevent accidents for 1 of 10 residents (Resident #29) reviewed for quality of care. On 05/17/2024, Resident #29 suffered a broken ankle when CNA C and CNA I used a sheet to transfer Resident #29 from a shower chair to a wheelchair. This failure could place residents at risk for serious injuries.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure its medication error rates were not 5% or greater. The facility had a medication error rate of 6.9%, based on 2 errors out of 29 opportunities which involved 2 of 6 residents (Resident #16 and #53) reviewed for medication administration and medication errors. 1. Medication Aide J administered Resident #16's clonazepam, a drug used to treat panic disorder, 17 minutes late. 2. Medication Aide J administered Resident #53's gabapentin, a drug used to treat nerve pain, 30 minutes late. These deficient practices could place residents at risk for not receiving therapeutic effects of their medications and possible adverse reactions.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys for 1 medication cart and 1 Treatment cart of 2 carts observed for secure biologicals and drugs. 1. LVN F left the medication cart unsecured on 200 Hallway while administering medications. 2. The Treatment Nurse left the treatment cart unsecured on 05/22/2024 on the 100 Hallway, and on 05/23/2024 on the 300 Hallway prior to wound care for a resident. These deficient practices could place residents at risk for misappropriation, misuse or tampering of medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen. 1. The facility failed to ensure pre-packaged chicken salad was discarded after the use by date. 2. The facility failed to ensure beverage machines dispenser gun with dispenser buttons was clean and properly stored. 3. The facility failed to ensure staff with facial hair was covered by a hair restraint. 4. The facility failed to ensure refrigerated items were dated and properly sealed. 5. The facility failed to ensure puree carrots were prepared in a sanitary fashion. These failures could place residents who received meals and/or snacks from the kitchen at risk for food borne illness.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases and infections for 3 residents (Residents #3, #102 and #308) of 24 residents reviewed for infection control. 1. Resident #3 had an opened wound and received treatment but was not on EBP. 2. Resident #102's urinary drainage bag was on the floor wedged between the low bed frame and the floor. 3. Resident #308 had a Stage II pressure ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed) to her sacrum, received treatment and was not on EBP. [...]

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to ensure the MDS assessment must accurately reflect the resident's status for 1 (Resident #3) of 24 residents reviewed for assessments. Resident #3 was ordered an RCS diet with pureed texture and fortified foods, and her annual MDS assessment with an ARD of 05/03/2024 did not reflect she was on a therapeutic diet. This deficient practice affects residents with specialized care and could result in inaccurate or missed care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental, and psychosocial needs that were identified in the comprehensive assessment, for 1 of 24 residents (Residents #3) reviewed for care plans. Resident #3 had compression stockings ordered to be on in AM and off in PM which was not reflected in her person-centered care plan. This deficient practice affected residents who require assistance with ADL's and could result in missed or inadequate care.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments for 2 (Residents #22 and #64) of 24 residents reviewed for care plans. 1. Resident #22's comprehensive person-centered care plan was not revised after her quarterly MDS assessment with an ARD of 05/09/24 to reflect she was incontinent of bladder. 2. Resident #64's comprehensive person-centered care plan was not revised after his quarterly MDS assessment with an ARD of 04/09/2024 to reflect he was always incontinent of bowel and bladder. This deficient practice affects residents who require assistance with ADL's and could place residents at risk of missing required care.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure residents were free from significant medication errors for 3 of 6 residents (Residents #31, #34, and #104) reviewed for significant medication errors. 1. On 05/23/2024 at 09:42 AM, Medication Aide J administered sodium chloride (salt; is an important mineral that helps balance the amount of fluid (water) in your body. It also helps your nerves and muscles to work properly. When the salt level in your blood is too low, extra water moves into your cells and makes them swell. This can be dangerous, especially in the brain where there is not a lot of room to expand) to Resident #104 late by 42 minutes. 2. On 05/23/2024 at 09:43 AM, Medication Aide J administered buspirone (primarily used to treat generalized anxiety) 10 mg to Resident #31 late by 43 minutes. 3. [...]

Inspectors wroteBased on observations and interviews, the facility failed to post, in a place readily accessible to residents, family members, and legal representatives of residents, the results of the most recent survey of the facility for 1 of 1 facility reviewed for resident rights. The facility did not have the survey results available and accessible to residents and visitors without having to ask for them on 5/21/24, 5/22/24, and 5/23/24 during the survey period. This failure resulted in residents, family members, and legal representatives of residents having a lack of knowledge of the facility's past inspections, violating resident rights.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the resident environment was as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents for 2 of 9 residents (Residents #1 and #2) reviewed for accidents and hazards. 1. The facility failed to ensure Resident #1 did not elope from the facility. Resident #1 eloped to a busy street on 12/18/23. 2. The facility failed to ensure staff were adequately trained on the elopement process, which included not training the therapy department after 12/18/23 elopement incident. 3. The facility failed to ensure interventions for elopement were updated and appropriate to prevent elopements for Resident #1 and #2. Resident #1 successfully eloped 12/18/23. An Immediate Jeopardy (IJ) situation was identified on 04/19/24 at 03:28 PM. [...]

Inspectors wroteBased on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 3 of 12 residents (Residents #2, #4 and #5) reviewed for care plans. The facility failed to develop person-centered care plan to include interventions to prevent elopement for Residents #2, #4 and #5. This failure could place residents at risk of not having their needs met.

Inspectors wroteBased on interviews and record reviews the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property were reported immediately, but no later than 2 hours after the allegation was made, in events that caused the allegation involved abuse or resulted in serious bodily injury to the Administrator of the facility and other officials, which included to the State Survey Agency, for 1 of 9 residents (Resident #3) reviewed for reporting abuse and neglect. LVN F failed to report to the administrator and HHSC an allegation of sexual abuse made by Resident #3 on 02/05/24. This failure could place residents at risk for harm to include neglect, a diminished quality of life, and possible death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen, in that: 1.a. Food items were not sealed, dated in the kitchen refrigerator. b. Two fryer baskets on a cookie tray, were dirty. 2. The chlorine sanitizer in the dish machine was not at the required concentration to sanitize the dishes and utensils. The daily dish machine temperature and sanitizer log were not completed for February/March 2023. The facility was utilizing expired chlorine testing strips to test the chlorine level of the dish machine. This deficient practice could place residents who received meals and/or snacks from the kitchen at risk for food borne illness.

Inspectors wroteBased on interview and record review, the facility failed to develop, implement, and maintain annually an effective training program for individuals providing services under a contractual arrangement, consistent with their expected roles, that included but are not limited to the mandatory training topics of communication, resident rights, abuse and neglect, QAPI, infection control, compliance and ethics, and behavioral health for 3 of 3 contract employees (PT P, OT Q and ST R) reviewed for training, in that: The facility failed to ensure required trainings were provided for PT P, OT Q and ST R working in the therapy department at the facility under a contractual agreement for the review period of March 2022 to March 2023. This failure could place residents at risk of being cared for by staff who have been insufficiently trained.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents' right to formulate an advance directive for 1 of 4 residents (Resident #85) reviewed for advanced directives, in that: The facility failed to ensure the completed OOH-DNR was in the facility for Resident #85. This failure could place residents at-risk of having their end of life wishes dishonored, and of having CPR performed against their wishes. Record review of Resident #85's face sheet, dated [DATE], revealed an admission date of [DATE] with diagnoses that included: [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure personal privacy during medical treatment and personal care for two of five residents (#41 and #68) observed for medication observation. A. LVN G did not ensure residents personal health information was protected during medication administration for Resident #41. B. CMA F did not provide privacy during administration of Resident #68's Lidocaine Patch to his lower back. This failure could affect all residents in the facility that received care where privacy is required and could result in embarassment for the residents.

Inspectors wroteBased on observation, interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. for 1 of 8 (#102) residents reviewed for care plans, in that: Resident #102 did not have care plan for smoking. This could affect residents with care plans and could result in residents not provided care by staff.

Inspectors wroteBased on observation, interview and record review revealed the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good personal hygiene for 1 of 8 residents (Resident #71) reviewed for ADL care, in that: The facility failed to assist Resident #71 maintain personal hygiene. This failure could place residents at risk of feelings of poor self-esteem and loss of dignity.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the resident environment remained as free of accident hazards as was possible and that each resident received adequate supervision to prevent accidents for 1 of 1 resident (Resident #102) and for 1 of 5 halls (Hall 500) observed for accidents/supervision, in that: 1. Resident #102 was missing his initial and quarterly assessments for smoking. 2. A dirty dish cart with sanitizing cleaner was left unattended on Hall 500 (secured unit) to which 7 residents had direct access. These failures could place residents at risk of living in an unsafe environment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 6 resident (Resident #36) reviewed for incontinent care, in that: While providing incontinent care for Resident #36, CNA A made multiple pass with the same wipe and used a back to front motion to clean Resident #36's genitals. CNA did not clean Resident #36's buttocks. This deficient practice could place residents at-risk for infection and skin break down due to improper care practices.

Inspectors wroteBased 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 and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise; was offered sufficient fluid intake to maintain proper hydration and health; or was offered a therapeutic diet when there is a nutritional problem and the health care provider orders a therapeutic diet for 1 of 8 residents (Resident #50) reviewed for assisted nutrition and hydration, in that: Resident #50 did not receive her supplement, ice cream during lunch service. This failure could affect residents with therapeutic diets and could result in residents weight loss.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure medication error rates are not 5 percent or greater during observation of two CMAs, one LVN, and one RN administering medication to one of five residents (#19). There were seven errors in 31 opportunities for errors, resulting in a 22 percent medication error rate. Resident #19's 09:00 a.m. medications were not administered within one hour before or one hour after the scheduled time by CMA E. This failure could affect residents who receive medication and could result in residents not receiving the highest possible therapeutic outcome for the medication regimen.

Inspectors wroteBased on observation, interview and record review the facility failed to dispose of garbage and refuse properly for 1 of 1 facility in that: The one dumpster side door was open, a trash bag was on the ground near the dumpster and trash was scatted on the ground near the dumpster. This could affect all residents and could result in pest in the facility.

Inspectors wroteBased on interview and record review the facility failed to designate a member of the facility's interdisciplinary team who is responsible for working with hospice representatives to coordinate care to the resident provided by the LTC facility staff and hospice staff and obtain the required information for 2 of 3 (Resident #70 and #87) residents reviewed for hospice services, in that: 1. The facility failed to obtain Resident #70's most recent hospice plan of care, names and contact information for hospice personnel involved in hospice care of each resident, documentation by specific interdisciplinary hospice staff providing services. 2. The facility failed to obtain Resident #87's most recent hospice plan of care, names and contact information for hospice personnel involved in hospice care of each resident, documentation by specific interdisciplinary hospice staff providing services. [...]

Inspectors wroteBased 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 and to help prevent the development and transmission of communicable disease and infection for 2 of 6 residents (Residents #36 and, #59) reviewed for infection control, in that: 1. While providing incontinent care for Resident #36 CNA A did not wash or sanitize her hands between change of gloves. 2. While providing incontinent care for Resident #59 CNA C and CNA D cross contaminated the clean brief of the resident with the soiled incontinent pad. These deficient practices could place residents at-risk for infection due to improper care practices.