Windsor Quail Valley Post-Acute Healthcare

Inspectors wroteBased on observation, interview and record review, the facility failed to coordinate assessments with the pre-admission screening and resident review program (PASARR) to the maximum extent practicable to avoid duplicative testing and effort for 1 of 1 (Resident #2) reviewed for PASARR. The facility failed to ensure Resident #2 who had a diagnosis of mental illness, received a positive PASARR Level I and PASARR Level II screening. This failure could place residents at risk of not receiving needed care and services, causing a possible decline in mental health.

Inspectors wroteBased on observations, 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 of 3 residents (Residents #21) and 1 of 3 (CMA Q) staff observed during medication administration. The facility failed to ensure staff clarified the order for Resident #21's Miralax prior to administering the medication on 05/13/2026. The failure could place residents at risk of not receiving the intended therapeutic benefit.

Inspectors wroteBased on observations, interviews and record reviews 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 diseases and infections for 1 of 1 (WCN) staff observed for infection control practices. The facility failed to ensure WCN followed proper infection control procedures after she completed a wound care procedure on 05/14/2026. The failure could place residents and staff at risk of infections.

Inspectors wroteBased on observation, interview and record review, the facility failed to dispose of garbage and refused properly for trash bins A and B reviewed for garbage disposal. - The facility failed to ensure the dumpster doors were secured on trash bin. - The facility failed to ensure trash bags were off the ground and in dumpster trash bins. This failure could place residents at risk of infections, pests and rodents from improperly disposed garbage.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide pharmaceutical services including procedures to accurately administer medications to meet the needs of each resident 1 (Resident #1) of 6 reviewed for pharmacy services. -RN A instructed CNA B to administer Resident #1's medication Eliquis. This failure placed residents at risk for medication errors.

Inspectors wroteBased on observation, interview and record review the facility failed to provide the necessary services to maintain personal care for one of seven residents (Resident #19) reviewed for ADL care in that: -Resident #19 waited over an hour to receive incontinent care. -The call light activator switch was placed out of reach. -During that hour, three staff entered and exited the room without assisting the resident with incontinent care. -One staff turned off the call light and left the room. The deficient practice could cause residents at risk of not receiving the care as needed and place them at higher risk for skin breakdown.

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and 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 diseases and infections for 1 resident (Resident #19) of 7 residents reviewed for infeciton control. -Staff provided incontinent care for the resident and did not practice hand hygiene prior to repositioning the resident and arranging the linens. The deficient practice placed the residents at risk for infection.

Inspectors wroteBased on interviews and records reviewed, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promoteds maintenance or enhancement of his or her quality of life, for 1 (Resident #1) of 6 residents reviewed for resident rights. -The facility failed to allow Resident #1 to exercise his right to choose that CNA B not provide him care. This failure could place residents at risk for decreased feelings of self-worth and dignity.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure residents received care, consistent with professional standards of practice to identify, prevent pressure ulcers from developing and promote healing for 1 (Resident CR# 1) of 9 residents reviewed for pressure ulcers. The facility failed to prevent, identify, and treat pressure sores on Resident CR#1's right buttock and right hip. CR #1 was sent to the hospital after family intervention, and there it was determined she had an unstageable wound to her buttocks and a stage 3 wound to her hip. The noncompliance was identified as Past Non-Compliant. The IJ began on 07/13/2024 and ended on 07/16/2024. The facility corrected the non-compliance before the survey began. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary services to maintain grooming and personal care for 1 of 5 residents (Resident #1) reviewed for ADL care. 1. The facility failed to ensure Resident #1 received proper grooming, including hair washing, three times a week (Monday, Wednesday and Friday) as per her bed bath and shower schedule. 2. The facility failed to address Resident#1's refusal to have her hair washed with FM on 3/6/2024. These failures could place Residents at risk for skin breakdown, infection, and loss of self-esteem. Findings Included: [...]

Inspectors wroteAbbreviations: ADMIN - Administrator ADON-Assistant Director of Nursing AS-Agency Staff BIMS-Brief Interview for Mental Status MA- Medical Aides CNA-Certified Nursing Assistant CR-Closed Record CW-Confidential Witness DON - Director of Nursing DORC - Director of Resident Care ED - Executive Director ERN - emergency room Nurse EMS-Emergency Medical Services EMT-Emergency Medical Technician FM-Family Member HHSC-Health and Human Services Commission IJ-Immediate Jeopardy IT-Immediate Threat LE-Law Enforcement LVN-Licensed Vocational Nurse PD- Police Dept MD-Medical Doctor MT - Resident Med Tech NP- Nurse Practitioner R-Resident RA-Resident Assistant RN-Registered Nurse RP-Responsible Party Based on observations, interviews, and record review, the facility failed to ensure residents were free from abuse for 1 resident (CR#1) of 5 residents reviewed for abuse. [...]

Inspectors wroteBased on Interview, and record review, the facility failed to implement abuse and neglect policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents for 1 (CR#1) of 5 residents reviewed for abuse by not implementing their abuse policy to prohibit and prevent abuse by conducting an investigation immediately; thus, failing to protect resident when there is a warranted suspicion of abuse and identifying staff responsible for the investigation. The facility failed to ensure each resident was free from abuse when CR#1 was physically abused by CNA C on 2/20/2024 around 6:30am, which was the time CNA A started her morning shift and observed the bruising to CR#1's face. These failures placed residents at risk of physical harm, emotional distress, mental anguish and death from possible abuse and neglect. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to have evidence that all alleged violations of abuse were thoroughly investigated, to prevent further potential abuse or mistreatment while the investigation was in progress, and report the result of all investigations to other officials in accordance with State law, including to the State Survey Agency within 5 working days of the incident for 1 of 5 residents (CR #1) reviewed for abuse. The facility failed to complete the investigation of the allegation of abuse, report the results of the investigation to HHSC within 5 days, and prevent further potential abuse while the investigation was in progress when CR #1 was found with suspicious injuries of unknown origin. An Immediate Jeopardy (IJ) was identified on 02/26/2024 at 1:48pm. [...]

Inspectors wroteTag:842 S/S= D Surveyor Name(s): [NAME] Immediate Supervisor: [NAME] Based on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 1 of 5 Residents (CR#1) reviewed for clinical records accuracy, there was only one progress note Record Review of the Progress Notes for CR#1: There was only one progress note entered since 1/3/2024; then, on 2/21/2024 at 16:17 (4:17pm), there was a note which was titled Admin Note and stated the Administrator notified FM of the HHSC investigation on 2/21/2024 with allegations of abuse. The facility failed to maintain an accurate record by indicating CR #1's unexplained or unknown eye injury, what medical staff did after observing the injury, who they called and the type of assessment completed. [...]

Inspectors wroteBased on interviews and record review the facility did not provide, in writing, a bed-hold notice upon transfer at the time of transfer of a resident to a hospital or for therapeutic leave, for 1 of 3 residents (CR#1) reviewed for transfers and discharge. -The facility failed to provide bed-hold notifications to CR#1 when she was transferred to the hospital. This failure could place residents at risk for not receiving notice of the facility's bed hold policy before being transferred.