Health inspection·December 3, 2025

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review, the facility failed to ensure that a resident who was incontinent of bladder with a suprapubic catheter (flexible tube inserted into the bladder through the abdomen to drain urine) received appropriate treatment and services to prevent urinary tract infections for 1 (Resident #27) of 1 resident reviewed for urinary catheters (a flexible tube used to empty the bladder and collect urine in a drainage bag). The facility failed to place Resident #27's urinary catheter drainage bag below the bladder. This failure could place residents with urinary catheters at risk for urinary tract infections. Record review of Resident #27's face sheet dated 12/03/25 revealed a [AGE] year-old male admitted on [DATE] with an original admission date of 02/02/25. Resident #27 had diagnoses of unspecified dementia, hypospadias (a congenital condition in males in which the opening of the urethra is on the underside of the penis), and neuromuscular disfunction of the bladder (the nerves that carry messages back and forth between the bladder and the spinal cord and brain don't work the way they should). Record review of Resident #27's Physician's Order dated 11/27/25 revealed SUPRAPUBIC CATHETER: Irrigate (procedure used to clear the bladder of mucus and debris) suprapubic catheter twice a day with 60ml NS two times a day. Record review of Resident #27's Quarterly MDS dated [DATE] revealed a BIMS score of 15 which indicated the resident's cognition was intact. Further review of section H - Bladder and Bowel, revealed Resident #27 had an indwelling catheter. Record review of Resident #27's comprehensive care plan initiated on 02/03/25 and revised on 06/12/25 revealed Resident #27 is at risk for urinary tract infection related to the Foley catheter. Observation on 12/01/25 at 9:02 am revealed Resident #27 was sitting in his wheelchair, and the Foley drainage bag was hooked onto a pocket located mid-back of his wheelchair. The Foley tubing was running through his legs, under the wheelchair and hooked to the back of the wheelchair. The Foley drainage bag rested above Resident #27's bladder. In an interview on 12/01/25 at 9:03 am revealed Resident #27 was unaware the catheter bag was hung to the back of his wheelchair. Resident #27 stated Oh, I didn't know it was back there. In an interview and observation on 12/01/25 at 9:18 am, RN L was informed and shown the catheter bag hanging from the mid back of Resident #27's wheelchair. RN L stated when residents sat in a wheelchair, the Foley drainage bag should be placed somewhere but did not know where to place it. RN L stated, I know it has to be below the bladder but I'm not sure of the placement in a wheelchair. RN L stated a negative outcome for the Foley drainage bag above the bladder was that the backflow of the urine could cause infection. RN L was observed placing the bag on a low metal bar of the wheelchair, but the Foley drainage bag touched the floor. RN L was observed again placing the Foley drainage bag on another metal bar higher on the wheelchair. The Foley drainage bag hung below Resident #27's bladder and did not touch the floor. In an interview on 12/03/25 at 6:58 am, LVN J stated the Foley drainage bag should be placed below the patient's abdomen. LVN J stated that when a resident is sitting in a (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 3 Event ID: 455662 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 455662 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Nursing and Rehabilitation Center of McAll 900 S 12th St McAllen, TX 78501 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)