Consulate Health Care Of Windsor

F-F657: Comprehensive care plan prepared by an IDT and the resident and/or resident's representative.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 38 of 50 495347 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 495347 B. Wing 05/01/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Consulate Health Care of Windsor 23352 Courthouse Highway Windsor, VA 23487

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)

F 0725 4. During an interview on 05/01/25 at 4:34 PM, LPN 1 stated the scheduler would frequently ask her to be responsible for both the Peach Unit and Blue Unit. She stated she would never do that because it would put Level of Harm - Minimal harm or her license at risk. LPN 1 stated I can't be on one hall because I couldn't see the other hall. potential for actual harm 5. The facility failed to ensure residents received adequate supervision. Cross Reference

F-F689: Supervision. Residents Affected - Many

During an interview on 05/01/25 at 5:24 PM, the Administrator stated they had six open CNA positions, seven open LPN positions, and seven open Registered Nurse (RN) positions. The Administrator stated they did not have a Staffing Policy.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 39 of 50 495347 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 495347 B. Wing 05/01/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Consulate Health Care of Windsor 23352 Courthouse Highway Windsor, VA 23487

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)

F 0730 Observe each nurse aide's job performance and give regular training.

Level of Harm - Minimal harm or 35690 potential for actual harm Based on interviews and record reviews, the facility failed to ensure Certified Nurse Aides (CNA) received Residents Affected - Some performance reviews at least once every 12 months and regular in-service education based on the outcome of the reviews for four of five CNAs (CNA6, CNA9, CNA10, and CNA12) whose personnel files were reviewed. This had the potential to have a negative impact on resident care.

Findings include:

Review of CNA 6's personnel file revealed a start date of 02/02/23. There was no documented evidence in

the personnel file that CNA6 had a performance evaluation or in-service education based on the outcome of

the review.

Review of CNA 9's personnel file revealed a start date of 08/01/22. There was no documented evidence in

the personnel file that CNA9 had a performance evaluation or in-service education based on the outcome of

the review.

Review of CNA 10's personnel file revealed a start date of 09/20/23 There was no documented evidence in

the personnel file that CNA10 had a performance evaluation or in-service education based on the outcome of

the review.

Review of CNA 12's personnel file revealed a start date of 12/13/23. There was no documented evidence in

the personnel file that CNA12 had a performance evaluation or in-service education based on the outcome of

the review.

During an interview on 05/01/25 at 4:30 PM, CNA 1 stated she had not received a performance evaluation in many years. She stated she would like to have one because it is nice to be recognized and get feedback on how she is doing.

During an interview on 05/01/25 at 5:02 PM with CNA3 and CNA4, CNA 3 stated she had worked in the facility for one year. She stated she had not had a performance review and had not received any competency training since she started. CNA 4 stated he had worked at the facility for three years. He stated

he had had one performance review since he started and had never received competency training.

During an interview on 05/01/25 at 5:24 PM, the Administrator stated as a result of multiple changes in nurse management, competencies and performance evaluations had not been completed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 40 of 50 495347 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 495347 B. Wing 05/01/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Consulate Health Care of Windsor 23352 Courthouse Highway Windsor, VA 23487

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)

F 0760 Ensure that residents are free from significant medication errors.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 40026 potential for actual harm Based on observation, interview, clinical record review and facility documentation the facility staff failed to Residents Affected - Some ensure Residents were free from significant medication errors for 2 Residents (#87 & #94) in a survey sample of 55 Residents.

The findings included:

1. For Resident #87 the facility staff failed to ensure she received Risperdal Consta injections every 2 weeks as ordered by physician for Schizophrenia.

Resident # 87 was admitted to the facility on [DATE REDACTED] with diagnoses that included, but we're not limited to dementia, schizophrenia, anemia, hypertension, psychotic disorder with delusions due to unknown physiological condition, and cognitive communication deficit. Resident number 87's most recent minimum data set with an ARD (Assessment Reference Date) of 4/16/25 coded Resident # 87 as having a BIMS (Brief

Interview of Mental Status) score of 6 out of 15 indicating severe cognitive impairment. Resident number 87 could follow simple conversation.

On 4/29/25 a review of the clinical record revealed that Resident #87 had the following orders:

Risperdal Consta Intramuscular Suspension Reconstituted ER 25 MG Inject 25 mg intramuscularly one time

a day every 14 day(s) for schizophrenia due to noncompliance with oral tablets/worsening behaviors.

A review of the MAR revealed that Resident #87 was started on Risperdal Consta due to refusal of oral medications. She received her first dose on 1/3/25 however did not get another dose until 2/3/25 and then a third dose on 2/17/25 followed by a missed dose on 3/3/25, and given a dose on 3/19, followed by 2 missed doses in April finally getting a dose on 4/30/25.

A review of the clinical record revealed the following notes about the injections not being available:

3/3/25 5:09 p.m. - Risperdal Consta Intramuscular Suspension Reconstituted ER 25 MG Inject 25 mg intramuscularly one time a day every 14 day(s) for schizophrenia due to noncompliance with oral tablets/worsening behaviors Medication will be delivered tonight

**There was no follow up indicating the Resident received this dose. **

4/2/25 5:55 p.m. - Risperdal Consta Intramuscular Suspension Reconstituted ER 25 MG Inject 25 mg intramuscularly one time a day every 14 day(s) for schizophrenia due to noncompliance with oral tablets/worsening behaviors Not Available, Pharmacy Made aware

Note from psychiatric provider on 4/10/25 read:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 41 of 50 495347 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 495347 B. Wing 05/01/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Consulate Health Care of Windsor 23352 Courthouse Highway Windsor, VA 23487

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)

F 0760 Date of Service: 04/10/2025 - Schizophrenia: No reported delusions or hallucination, the patient is on Risperdal Consta [NAME] 25 mg every 14 days for schizophrenia because of noncompliance with oral Level of Harm - Minimal harm or medication. Recommend continuing the current medications. potential for actual harm 4/16/25 4:46 p.m. - Risperdal Consta Intramuscular Suspension Reconstituted ER 25 MG - Inject 25 mg Residents Affected - Some intramuscularly one time a day every 14 day(s) for schizophrenia due to noncompliance with oral tablets/worsening behaviors not available [sic] pharmacy made aware

On 4/28/25 at 11:00 a.m. an interview was conducted with LPN #6 who was asked what the procedure is if you do not have a medication for your Resident, she stated that they look in Omnicell (stat meds), and if it is not there, we notify the pharmacy, and they usually get it on the next run. When asked about documenting

she stated that they should document what they have done to try and obtain the medication and who they have notified. When asked who they should notify she stated the physician, pharmacy, resident or representative, and the DON or Unit Manager. When asked if Resident #87 was receiving any oral antipsychotics she stated that she was not. When asked if her psychiatric provider was made aware of the lack of consistent administration of this medication, she stated that the NP is notified. When asked if the NP is managing Schizophrenia and medications like Risperdal Consta or is the psychiatrist, she stated that she was not sure.

4/30/25 at 10:20 a.m. spoke with LPN #7 the unit manager and we went to the medication refrigerator on the unit and discovered that Resident #87's Risperdal Consta was unopened, and it was dated as sent from the pharmacy on 4/16/25.

On 5/1/25 a review of the clinical record revealed the following note:

4/30/25 at 7:22 p.m. - Resident was given injection in left upper arm per her request.

According to Johnson & Johnson the manufacturer of Risperdal Consta:

Managing missed doses

The appropriate strategy for patients who have missed a dose or doses of RISPERDAL CONSTA will depend on whether a steady-state plasma concentration of RISPERDAL CONSTA has been reached. Generally, steady-state plasma concentrations are achieved after 4 consecutive injections.

Steady-state plasma concentration achieved

The next dose of RISPERDAL CONSTA should be given as soon as possible if steady-state concentrations of RISPERDAL CONSTA have been achieved and only 3-6 weeks have passed since the last injection. Clinicians should monitor symptom recurrence. If more than 6 weeks have elapsed since the last injection, risperidone long-acting should be initiated as soon as possible and 3 weeks of coverage with an oral antipsychotic should be given.

Steady-state plasma concentration not achieved (<4 consecutive injections)

RISPERDAL CONSTA should be reinitiated as soon as possible, and oral antipsychotic coverage for 3 weeks should be given.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 42 of 50 495347 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 495347 B. Wing 05/01/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Consulate Health Care of Windsor 23352 Courthouse Highway Windsor, VA 23487

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)

F 0760 A review of the MAR revealed no oral coverage was being administered.

Level of Harm - Minimal harm or On 5/1/25 during the end of day meeting the Administrator was made aware of the findings and no further potential for actual harm information was provided.

Residents Affected - Some 2. For Resident #94 the facility staff failed to ensure Midodrine was given as prescribed by the physician according to the parameters in the order.

Resident number 94 was admitted to the facility on one/22/24 with diagnoses that included but we're not limited to alcohol abuse anemia, hypertension, muscle weakness was Wernicke's encephalopathy, cognitive communication deficit, insomnia, and signs and symptoms involving cognitive functions and awareness.

On 4/28/25 a review of the clinical record revealed the following orders:

Midodrine HCl oral tablet 2.5 mg give one tablet by mouth three times a day for low blood pressure hold for systolic >110

A review of the MAR (Medication Administration Record) for April 2025, revealed that in the following days and times the proper assessment, and parameters were not followed with regard to the Midodrine administration order:

Blood pressure not assessed, and medication not given:

2 p.m. - 4/5, 4/12, 4/16, 4/20

9 p.m. - 4/ 2/, 4/9, 4/11, 4/18, 4/21, 4/22, 4/25, 4/28

The following dates blood pressure was not assessed, and medications were given:

9 p.m. - 4/3, 4/8, 4/16, 4/22, 4/23, 4/26, 4/27

The following dates blood pressures were assessed out of parameters and meds given anyway.

8 a.m. - 4/14/25 - 140/77

9 pm - 4/4/24 - 122/62, 4/14/25 - 116/74

2p.m. - 4/28/25 - 114/78

A review of the previous MAR's for February and March revealed the same errors.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 43 of 50 495347 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 495347 B. Wing 05/01/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Consulate Health Care of Windsor 23352 Courthouse Highway Windsor, VA 23487

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)

F 0760 On 4/30/25 at approximately 3:00 pm an interview was conducted with the Unit Manager about the administration of Midodrine and parameters. When asked what Midodrine was used for she stated keeping Level of Harm - Minimal harm or your blood pressure up, when asked why the use of parameters with Midodrine, and she stated so that you potential for actual harm don't use it and make the blood pressure too high. When asked if the order has parameters should a nurse ever give it without first checking the blood pressure, she stated they should not. When asked if the nurse Residents Affected - Some should hold the medication if the blood pressure was not taken, she stated that there would be no reason to hold it if you don't know the blood pressure. When asked if a nurse checks the blood pressure and it is above

the parameters, she should give the medication she stated that she should not. When asked if the blood pressure assessment, and parameters ordered in Resident #94's chart were followed and she stated that

they were not.

On 5/1/25 during the end of day meeting the Administrator was made aware of the findings and no further information was provided.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 44 of 50 495347 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 495347 B. Wing 05/01/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Consulate Health Care of Windsor 23352 Courthouse Highway Windsor, VA 23487

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)

F 0761 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 Level of Harm - Minimal harm or locked, compartments for controlled drugs. potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 40824 Residents Affected - Few Based on observation, interview, and facility policy review, the facility failed to ensure medications were stored and labeled for three of four medication carts observed and one of two medication rooms observed.

This had the potential for misappropriation of medications and possible unsafe medication administration.

Findings include:

Review of the facility policy titled Storage and Expiration Dating of Medications and Biologicals revised [DATE REDACTED] revealed, .Facility should ensure medications and biologicals are stored in an orderly manner in cabinets, drawers, carts, refrigerators/freezers of sufficient size to prevent crowding .Facility should ensure external use medications and biologicals are stored separately from internal use medications and biologicals . Facility should ensure all controlled substances are stored in a manner that maintains their integrity and security .Facility should ensure medications and biologicals for expired or discharged or hospitalized residents are stored separately, away from use, until destroyed or returned to the provider .Facility should destroy or return all discontinued, outdated/expired, or deteriorated medications or biologicals in accordance with pharmacy return/destruction guidelines and other applicable law .Facility personnel should inspect nursing station storage areas for proper storage compliance on a regularly scheduled basis .

1. During an observation and interview on [DATE REDACTED] at 6:20 AM of the Blue Unit medication cart, revealed in

the second drawer there were eight solid tablets laying loose, six partial/broken tablets, and one capsule loose in the drawer; the third drawer had one loose capsule. The Administrator was present and confirmed

the loose medications and stated that it was the expectation of the facility for loose medications to immediately be removed from the cart. Licensed Practical Nurse (LPN) 10 was also present and stated that

she normally would discard the loose medications in the sharps container. Staff confirmed that they did not know what the medications were or to whom they belonged.

2. During an observation and interview on [DATE REDACTED] at 6:50 AM with LPN5 of the medication cart on the [NAME] Unit revealed in the fourth drawer was a resident's cipro (antibiotic) 250 milligram (mg) with a pharmacy dispense date of [DATE REDACTED], there were five tablets remaining. One tablet of pyridium (pain reliever for urinary tract infections)100mg was in the fourth drawer with a dispense date of [DATE REDACTED]. LPN5 stated that

the cipro had been discontinued and no longer in use. LPN5 was unable to locate the start and stop date of

the medication in the EMR. LPN5 stated that the medication should not have been in the drawer and should have been placed in the medication storage room until the pharmacy could pick up the medications and dispose of them. Additionally, there was a narcotic blister pack with two tablets taped closed. LPN5 confirmed that the tablets should not be taped in the blister pack and should have been disposed of. The sixth drawer contained two and a half tablets and one capsule that were loose. LPN5 was unable to determine what the loose medications were or to whom they belonged. There was a card of cephalexin (antibiotic) 500 mg capsules with one capsule remaining. LPN5 stated that the medication had been completed. The third drawer had eight tablets and three half tablets loose in the third drawer, and the second drawer had 44 solid tablets, one capsule, and 13 partial tablets loose in the drawer. LPN5 stated that all nurses should maintain the medication carts.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 45 of 50 495347 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 495347 B. Wing 05/01/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Consulate Health Care of Windsor 23352 Courthouse Highway Windsor, VA 23487

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)

F 0761 3. During an observation and interview on [DATE REDACTED] at 7:25 AM with LPN5 of the [NAME] Unit medication storage room included a blister pack for a resident dated [DATE REDACTED] for cipro HCL 250 mg tablets with three Level of Harm - Minimal harm or tablets remaining in the pack. LPN5 stated that normally the Unit Manager disposes of any discontinued potential for actual harm medications, and she was not sure why this pack was propped up against the wall behind intravenous supplies. Residents Affected - Few 4. During an observation and interview on [DATE REDACTED] at 8:45 AM with LPN11 of the Peach Unit revealed the second drawer had 22 tablets, two capsules, and eight half tablets that were loose in the drawer. The third drawer had five partial pills loose; fourth drawer had one tablet loose; and the eighth drawer had a bottle of alcohol and wound cleanser spray stored with a resident's permethrin 5% cream dispensed by the pharmacy

on [DATE REDACTED]. Additionally, a resident's ammonium lactate 12% cream was with other resident's oral medications. The narcotic drawer had one loose solid tablet and eight partial/broken tablets. LPN11 stated that when they find loose pills the protocol was for them to put them in the sharps container. LPN11 confirmed that the resident's permethrin cream had been discontinued and should have been put in the medication storage room for return to the pharmacy and that all topical medications should be kept separate from oral medications. LPN11 was not able to identify the loose tablets.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 46 of 50 495347 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 495347 B. Wing 05/01/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Consulate Health Care of Windsor 23352 Courthouse Highway Windsor, VA 23487

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)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 40711 potential for actual harm Based on observation, resident interview, staff interview, clinical record review, and review of facility Residents Affected - Few documents, the facility's staff failed to ensure a resident visually impaired resident received training and assistance on infection prevention measures were followed while providing urinary catheter care self care for 1 of 55 residents (Resident #43), in the survey sample.

The findings included:

Resident #43 was originally admitted to the facility 11/05/22 and readmitted [DATE REDACTED] after an acute care hospital stay. The resident has never been discharged from the facility. The current diagnoses included; Neuromuscular Dysfunction of the Bladder.

The quarterly revision, Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 1/22/25 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of

a possible 15. This indicated Resident #43 cognitive abilities for daily decision making were intact.

In section B (Hearing, Speech and Vision) the resident was coded moderately impaired with vision and coded Yes, for corrective lenses.

In sectionGG(Functional Abilities Goals) the resident was coded as requiring set-up help with eating and oral hygiene. Resident coded as dependent with toileting hygiene. Requiring substantial/maximal assistance with shower/bathe self. Requiring partial/moderate assistance with personal hygiene. (Functional Limitations in Range of Motion) Resident coded as no impairment for upper extremity. Resident coded as impairment on both sides for lower extremities. (Mobility Devices) Resident coded as requiring a wheelchair. (Mobility) Resident coded as independent with rolling left and right. Requires supervision or touching assistance with sit to lying and lying to sitting. Resident coded as a dependent chair to bed.

In Section H (Bladder and Bowel) the resident was coded as having an indwelling, external catheter.

The April 2025 Physicians Order Summary (POS) read:

Catheter care every shift and as needed every shift for Foley catheter -Start Date- 11/08/2024 7:00 pm.

The person-centered care plan dated 3/08/23 read that Resident #43 has impaired visual function r/t Diabetes, Glaucoma R eye severe impairment, L eye adequate. (Revised on 3/08/23). The Goals for Resident #43 are the resident will maintain optimal quality of life within limitation imposed by visual function through the review date and the resident will have no indications of acute eye problems through the target date of 4/22/25. The interventions for Resident #43 are Arrange consultation with eye care practitioner as required (3/08/23). Monitor/document/report PRN any s/sx of acute eye problems (3/08/23).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 47 of 50 495347 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 495347 B. Wing 05/01/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Consulate Health Care of Windsor 23352 Courthouse Highway Windsor, VA 23487

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)

F 0880 The person-centered care plan dated 10/30/23 read that Resident #43 has an indwelling foley catheter as well as a colostomy r/t diabetes, BPH, and dx of other obstructive and reflux uropathy. The Goals for Level of Harm - Minimal harm or Resident #43 are the resident will The resident will show no s/sx of Urinary infection through review date and potential for actual harm the resident will be/remain free from catheter-related trauma through review date (4/22/25). The interventions for Resident #43 are to monitor/document for pain/discomfort due to catheter and Monitor/record/report to Residents Affected - Few MD for s/sx UTI (Urinary Tract Infection).

On 04/30/25 at approximately 10:17 am, a brief interview was conducted with Resident #43. Resident #43 said that he had an enlarged prostate a few years ago that's why I have a foley. I have had infections (Urinary Tract Infections/UTI's), I see the Urologist one a month to get my foley changed. Resident #43 was asked if the staff performs daily catheter care. Resident #43 stated, I do my own (foley) catheter care. Permission was granted from resident to be observed performing his foley catheter care.

A review of the resident's medical records read that he's had several Urinary Tract Infections last year (2025).

On 4/30/25 at approximately 11:00 am., foley catheter self care was observed. Certified Nursing Assistant (CNA) #14. CNA #14 was observed setting up one basin, placing 2 wash cloths inside with a bar of soap.

The steps were as follows: CNA #14 washed Resident's back, used wash cloth placed back into the basin with clean wash cloth, resident reached for clean wash cloth in the basin, rung it out, washed his left and right groin and perineal area, placed wash cloth in basin and rung out cloth again, took wash cloth out of the basin, wipe his foley catheter moving downward and placed wash cloth inside basin.

On 4/30/25 at approximately 11:15 AM., a brief interview was conducted with CNA #14 concerning Resident #43s catheter care. CNA #4 said that she realized that she should have provided 2 basins, 1 basin with soap water and the other with rinse water.

On 05/01/25 at approximately 1:45 pm., a brief interview was conducted with Certified Nursing Assistant (CNA) #14. CNA #14 said that she was never informed to assist the resident with catheter care other than emptying his foley.

On 05/01/25 at approximately 12:13 pm., an interview was conducted with Licensed Practical Nurse (LPN) #10. LPN #10 said that the CNAs do the catheter care as part of the (Activity of Daily Living) ADLs.

On 05/01/25 at approximately 11:08 am., a brief interview was conducted with the Assistant Director of Nursing (ADON). The ADON said that the CNAs should help with foley catheter care. We will educate the resident on proper foley care.

Policy: Effective Date: 11/30/2014. Revised Date: 9/05/17. Catheter Care, Urinary

Assemble the following: Towel and wash cloth, soap, basin of warm water, disposable gloves, hand hygiene, remove catheter securement device, wash perineal area with soap and water from front to back, rinse and dry, clean catheter tubing with soap and water, reattach securement device, perform hand hygiene.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 48 of 50 495347 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 495347 B. Wing 05/01/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Consulate Health Care of Windsor 23352 Courthouse Highway Windsor, VA 23487

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)

F 0880 On 5/01/25 at approximately 7:00 p.m., during the pre-exit the above findings were shared with the Administrator, Director of Nursing and Corporate Consultant and [NAME] President of Operations. An Level of Harm - Minimal harm or opportunity was offered to the facility's staff to present additional information, but no additional information potential for actual harm was provided.

Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 49 of 50 495347 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 495347 B. Wing 05/01/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Consulate Health Care of Windsor 23352 Courthouse Highway Windsor, VA 23487

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)

F 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 49916 potential for actual harm Based on clinical record review and staff interviews, the facility staff failed to maintain an effective pest Residents Affected - Few control program for 1 of 55 residents (Resident #65), in the survey sample.

Resident #65 was admitted to the facility on [DATE REDACTED] with diagnoses of but not limited to hemiplegia and hemiparesis of right-side cerebral infarct, dysphagia, chronic congestive heart failure, and dementia.

The most recent Minimum Data Set (MDS) was a Quarterly Assessment with an Assessment Reference Date (ARD) of 04/24/25. Resident # 65's BIMS (Brief Interview for Mental Status) Score was a 15 out of 15, indicating no cognitive impairment. Resident #65 required assistance with all ADL's (Activities of Daily Living).

On 4/29/2025 during the initial tour, Resident # 65's room was observed with a bag sitting in a folding chair beside the bed with a large number of ants crawling in around and on the bag, chair and wall. Resident # 65 stated she did not know what exactly was in the bag or that it had ants. The CNA (Certified Nursing Assistant) #3, came in to clean the bag out and added Resident #65's room to the focus pest control log for 04/30/2025.

A review of the facility pest control log revealed that Resident #65's room was treated on 04/30/2025.

On 04/30/2025 during the end of day meeting, the Administrator and Director of Nursing were informed of the findings. No additional documentation provided.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 50 of 50 495347