Health inspection·May 17, 2023

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure prompt efforts were made to resolve resident grievances for 2 of 6 residents reviewed for grievance resolution. (Resident # 1 and Resident #2) 1. There was no grievance available or evidence of resolution when Resident #1's family member alleged elder abuse. 2. The facility failed to investigate and resolve a grievance when Resident # 2 complained CNA A was rough during a turn, spanked his buttocks and said he was afraid of her. This failure could place all residents at risk of unresolved grievances, abuse, and decreased quality of life. Findings included: 1. Record review of Resident #1's electronic face sheet dated 12/12/2022 indicated an [AGE] year-old male admitted on [DATE] with the following diagnoses: unspecified paraplegia (paralysis of legs and lower body), disorder of peripheral nervous system (weakness, numbness, and pain from nerve damage, usually in the hands and feet), other specified depressive episodes, pressure ulcer of right buttock, and hypertensive heart disease without heart failure (high blood pressure). Resident #1 was discharged to an ALF in another state on 12/12/2022. Record review of an MDS dated [DATE] indicated Resident #1 was cognitively intact, was understood by others and was able to understand others. Record review of a voice recording dated 9/11/2022 at an unknown time indicated Resident #1's family member alleged elder abuse to the ADM. The family member said an unknown female nurse was rough and man-handled Resident #1's legs while providing care. Record review of a progress note dated 9/11/22 at 6:30 p.m., completed by LVN D, indicated Resident #1 said he felt as if he was being neglected. The DON and ADM were made aware of the situation. [Family member] was spoken to as well. Record review of a progress note dated 9/12/22 at 10:03 a.m., completed by RN B, indicated RN B talked to Resident #1 about the complaint from a family member about his catheter not being changed for several hours on 9/10/22. Resident #1 told RN B he felt RN C was rude when repositioning his legs when she inserted his foley catheter. Page 1 of 13 675415 675415 05/17/2023 Windsor Las Palmas Nursing and Rehabilitation Cent 1301 E Quebec Ave McAllen, TX 78503

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Grievance book indicated there were no grievances available prior to 12/12/22 available for review. During an interview on 4/5/23 at 10:58 a.m., the ADM said the facility was taken over by a new company on 12/15/22. She said the previous company took all the grievances and she did not have any available prior to 12/15/22. During an interview on 5/15/23 at 8:40 p.m., RN C said she was currently employed in the facility as an RN and had worked the 10 p.m. to 6:30 a.m. shift (Overnight) for the last 10 years. RN C said she remember Resident #1 with foley catheter and had to change his catheter sometime in September 2022. RN C said she did not remember the exact details when she changed Resident #1's catheter or the circumstances surrounding the event. RN C denied any allegation of physical abuse or mistreatment to Resident #1 or to any of the residents she provided care. RN C acknowledged she was trained on ANE prevention and added she would report any cases of abuse or neglect even suspicion of, to the administrator immediately. She said she was never told not to go into Resident #1's room, but instead to take another person with her when she provided care. 2. Record review of an admission record face sheet dated 4/5/23 indicated Resident #2 was admitted [DATE], was an [AGE] year-old male and had diagnoses including Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors), hypertension (high blood pressure), history of falling, muscle weakness, and need for assistance with personal care. Record review of an MDS dated [DATE] indicated Resident #2 was cognitively intact. He was able to understand others and others were able to understand him. Resident #2 required extensive assistance of one person for bed mobility. Record review of Resident #2's care plan indicated he was discharged home on 2/12/2023. Record review of a grievance dated 12/28/22 indicated Resident #2 told the DOR CNA A caused rib pain when she turned him. When CNA A was finished, she spanked his butt, and he did not like it. Resident #2 complained of rib pain and said he was afraid of CNA A. There was no documentation of facility follow-up or resolution of the grievance. Record review of additional grievances from December 2022 through April 2023 indicated no other complaints about CNA A. During an interview on 4/5/23 at 10:58 a.m., the administrator said she was not aware Resident #2 had been afraid of anyone. She said she had not seen the grievance, or she would have acted on it. During an interview on 4/5/22 at 11:52 a.m., the ADM said it was the facility's fault the allegation of abuse for Resident #2 was not reported or investigated. In December it was the interim DON who was responsible for the grievance folder because she was out with COVID. The ADM said she was still responsible and missed the abuse allegation. During an interview on 4/5/23 at 11:57 a.m., the DOR said she saw Resident #2 in therapy and was working on wheelchair mobility. When it was time to stand, she said he did not want to stand due to rib pain. Resident #2 said CNA A had turned him and hurt him, spanked, and was afraid of her. She said they had just started with the new company and had been told to complete the grievance forms. She said she could not remember if she gave the form to someone or just put it in the grievance book. 675415 Page 2 of 13 675415 05/17/2023 Windsor Las Palmas Nursing and Rehabilitation Cent 1301 E Quebec Ave McAllen, TX 78503

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 4/5/2023 at 12:27 p.m., CNA A said she was assigned to the hall where Resident #2 resided. She did not recall any incidents with Resident #2. She said she did not slap or hit him. She said she was trained on reporting abuse/neglect to the administrator. Record review of the Resident and Family Grievances implemented 8/15/22 indicated 2. The Grievance Official is responsible for overseeing the grievance process; receiving and tracking grievances through to their conclusion; leading any necessary investigations by the facility; maintaining the confidentiality of all information associated with grievances; issuing written grievance decisions to the resident; and coordinating with state and federal agencies as necessary I light of specific allegations. 675415 Page 3 of 13 675415 05/17/2023 Windsor Las Palmas Nursing and Rehabilitation Cent 1301 E Quebec Ave McAllen, TX 78503

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, 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 not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, to the Administrator and the State Survey Agency, for 2 (Resident #1 and Resident #2) of 10 residents reviewed for abuse. An allegation of abuse was not reported to the State Survey Agency within two hours of being made by Resident #2 or a family member of Resident #1. This failure could place the residents at risk of abuse and neglect. Findings included: 1. Record review of Resident #1's electronic face sheet dated 12/12/2022 indicated an [AGE] year-old male admitted on [DATE] with the following diagnoses: unspecified paraplegia (paralysis of legs and lower body), disorder of peripheral nervous system (weakness, numbness, and pain from nerve damage, usually in the hands and feet), other specified depressive episodes, pressure ulcer of right buttock, and hypertensive heart disease without heart failure (high blood pressure). Resident #1 was discharged to an ALF out of state on 12/12/22. Record review of an MDS dated [DATE] indicated Resident #1 was cognitively intact, was understood by others and was able to understand others. Record review of a voice recording dated 9/11/2022 at an unknown time indicated Resident #1's family member alleged elder abuse to the ADM. The family member said an unknown female nurse was rough and man-handled Resident #1's legs while providing care. During an interview on 5/15/2023 at 12:08 p.m., the ADM said she had not reported the allegation of elder abuse to the State Agency. She was not able to give a reason as to why the allegation was not reported. She said she did investigate the allegation for Resident #1 and was not able to substantiate any abuse. She said the alleged perpetrator was RN C. During an interview on 5/15/23 at 8:40 p.m., RN C said she was currently employed in the facility as an RN and had worked the 10 p.m. to 6:30 a.m. shift (Overnight) for the last 10 years. RN C said she remember Resident #1 with foley catheter and had to change his catheter sometime in September 2022. RN C said she did not remember the exact details when she changed Resident #1's catheter or the circumstances surrounding the event. RN C denied any allegation of physical abuse or mistreatment to Resident #1 or to any of the residents she provided care. RN C acknowledged she was trained on ANE prevention and added she would report any cases of abuse or neglect even suspicion of, to the administrator immediately. During an interview on 5/17/2023 at 9:40 a.m., LVN D acknowledged that on 9/11/2022, 2:00 p.m. to 10:00 p.m. shift she provided care to Resident #1. LVN D said Resident #1 did not verbalize to her that he had been neglected but said Resident #'1's daughter alleged neglect when she called facility. 675415 Page 4 of 13 675415 05/17/2023 Windsor Las Palmas Nursing and Rehabilitation Cent 1301 E Quebec Ave McAllen, TX 78503

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some LVN D said that Resident #1 complained about everything including colostomy care and catheter care but never mentioned the words neglect. She reported the allegation to the ADM 2. Record review of an admission record face sheet dated 4/5/23 indicated Resident #2 was admitted [DATE], was an [AGE] year-old male and had diagnoses including Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors), hypertension (high blood pressure), history of falling, muscle weakness, and need for assistance with personal care. Record review of an MDS dated [DATE] indicated Resident #2 was cognitively intact. He was able to understand others and others were able to understand him. Resident #2 required extensive assistance of one person for bed mobility. Record review of Resident #2's care plan indicated he was discharged home on 2/12/2023. Record review of a grievance dated 12/28/22 indicated Resident #2 told the DOR CNA A caused rib pain when she turned him. When CNA A was finished, she spanked his butt, and said he did not like it. Resident #2 complained of rib pain and said he was afraid of CNA A. There was no documentation of facility follow-up or resolution of the grievance. During an interview on 4/5/23 at 10:58 a.m., the administrator said she was not aware Resident #2 had been afraid of anyone. She said she had not seen the grievance, or she would have acted on it. During an interview on 4/5/22 at 11:52 a.m., the ADM said it was the facility's fault the allegation of abuse for Resident #2 was not reported or investigated. In December it was the interim DON who was responsible for the grievance folder because she was out with COVID. The ADM said she was still responsible and missed the abuse allegation. During an interview on 4/5/23 at 11:57 a.m., the DOR said she saw Resident #2 in therapy and was working on wheelchair mobility. When it was time to stand, she said he did not want to stand due to rib pain. Resident #2 said CNA A had turned him and hurt him, spanked, and was afraid of her. She said they had just started with the new company and had been told to complete the grievance forms. She said she could not remember if she gave the form to someone or just put it in the book. During an interview on 4/5/2023 at 12:27 p.m., CNA A said she was assigned to the hall where Resident #2 resided. She did not recall any incidents with Resident #2. She said she did not slap or hit him. She said she was trained on reporting abuse/neglect to the administrator. Record review of the facility's Abuse & Neglect Prohibition policy revised May 2022 indicated 1. a. If the events that caused the allegation involve abuse or result in serious bodily injury, a report is made not later than 2 hours after the center is notified of the allegation. 675415 Page 5 of 13 675415 05/17/2023 Windsor Las Palmas Nursing and Rehabilitation Cent 1301 E Quebec Ave McAllen, TX 78503

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to have evidence that all allegations of abuse were thoroughly investigated for 1 (Resident #2) of 5 residents reviewed for abuse. Residents Affected - Few The facility did not investigate an allegation of abuse when Resident #2 complained CNA A was abusive during care. This failure could place residents at risk for abuse. Findings included: Record review of an admission record face sheet dated 4/5/23 indicated Resident #2 was admitted [DATE], was an [AGE] year-old male and had diagnoses including Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors), hypertension (high blood pressure), history of falling, muscle weakness, and need for assistance with personal care. Record review of an MDS dated [DATE] indicated Resident #2 was cognitively intact. He was able to understand others and others were able to understand him. Resident #2 required extensive assistance of one person for bed mobility. Record review of Resident #2's care plan indicated he was discharged home on 2/12/2023. Record review of a grievance dated 12/28/22 indicated Resident #2 told the DOR CNA A caused rib pain when she turned him. When CNA A was finished, she spanked his butt and said he did not like it. Resident #2 complained of rib pain and said he was afraid of CNA A. There was no documentation of facility follow-up or resolution of the grievance. During an interview on 4/5/22 at 11:52 a.m., the ADM said it was the facility's fault the allegation of abuse for Resident #2 was not investigated. In December it was the interim DON who was responsible for the grievance folder because she was out with COVID. The ADM said she was still responsible and missed the abuse allegation. During an interview on 4/5/23 at 11:57 a.m., the DOR said she saw Resident #2 in therapy and was working on wheelchair mobility. When it was time to stand, she said he did not want to stand due to rib pain. Resident #2 said CNA A had turned him and hurt him, spanked, and was afraid of her. She said they had just started with the new company and had been told to complete the grievance forms. She said she could not remember if she gave the form to someone or just put it in the book. Record review of the facility's Abuse and Neglect Prohibition policy revised May 2022 indicated 1. The center will timely conduct an investigation of any alleged abuse/neglect, exploitation, mistreatment, injuries of unknown origin, or misappropriation of resident property in accordance with state law. 675415 Page 6 of 13 675415 05/17/2023 Windsor Las Palmas Nursing and Rehabilitation Cent 1301 E Quebec Ave McAllen, TX 78503

F 0622 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the appropriate discharge information, for 1 of 3 residents (Residents #1) reviewed for discharge. The facility did not communicate a change in Resident #1's wound status to the receiving ALF to ensure the ALF was able to meet the needs of Resident #1. This failure placed residents who are discharged at risk of not getting the necessary care and services in a new facility to meet their physical and psychological needs. Findings included: Record review of Resident #1's electronic face sheet dated 12/12/2022 indicated an [AGE] year-old male admitted on [DATE] with the following diagnoses: unspecified paraplegia (paralysis of legs and lower body), disorder of peripheral nervous system (Weakness, numbness, and pain from nerve damage, usually in the hands and feet), other specified depressive episodes, pressure ulcer of right buttock, and hypertensive heart disease without heart failure (high blood pressure). Record review of Resident #1's nursing progress note dated 7/29/2022, completed by LVN A indicated resident arrived via ambulance, alert, and oriented x 4, discolorations to bilateral upper extremities due to intravenous lines and blood draws at hospital. Resident with stage II (the loss of soft tissue involving the full thickness layers of the skin up to the subcutaneous layer) wound to sacrum and right heel pressure ulcer (no stage given). Record review of Resident #1's health assessment, for the receiving ALF, dated 12/2/2022 performed by NP A indicated no pressure sores. Record review of Resident #1's nursing progress notes dated 12/6/2022, completed by RN A indicated Resident #1 was lying in bed with both legs tucked under himself. RN A noticed a dark purple discoloration to Resident #1's right heel with open area, light serous drainage. Some edema noted to right foot. No odor. Notified wound care physician of change. Further review of resident #1's progress notes and electronic clinical records indicated no evidence of active skin breakdown or wound to his right heel 1 week prior to 12/6/2022. Record review of a fax transmittal form dated 12/9/2022 indicated the health assessment completed by NP A on 12/2/22 was faxed to the receiving ALF in another state. There was no indication of an updated assessment sent informing the ALF of Resident #1's pressure ulcer found on 12/6/22. Record review of a Nursing Discharge Plan and Summary dated 12/12/2023, completed by LVN C, indicated Resident #1 had moisture associated dermatitis (MASD) to bilateral buttocks and a vascular ulcer on his right heel. Record review of Resident #1's Skin Assessment record from the assisted living facility dated 12/12/2022, completed by the ED indicated Resident (#1) arrived at [Facility Name] in the afternoon. Resident presented with an unstageable ulcer (a full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough or eschar in the wound bed) on his right heel. Resident also 675415 Page 7 of 13 675415 05/17/2023 Windsor Las Palmas Nursing and Rehabilitation Cent 1301 E Quebec Ave McAllen, TX 78503

F 0622 presented with raw but unopened buttock. Resident was sent to Hospital for treatment of wounds. Level of Harm - Minimal harm or potential for actual harm During an interview on 4/4/23 at 4:45 p.m., the ADM said she did not realize there had been a change in condition. She thought the other facility should have seen the diagnoses which included the pressure wounds and should have asked more questions. Residents Affected - Few During an interview on 4/5/2023 at 12:27 pm with DON regarding resident transfers and discharge to another facility. DON said resident's clinical records were supposed to be forwarded or faxed to the receiving facility in addition to verbal communication. During an interview on 4/5/2023 at 1:55 pm with RN A regarding resident transfers. RN A said she would usually call the receiving facility's nurse and give the resident's current diagnoses, relevant data including medicines and wounds if present. RN A stated the transferring facility would also send a paper discharge packet along with the resident. RN A said If receiving facility requested copies via fax or email, then discharging facility would forward the needed copies as well. During an interview on 4/5/23 at 2:03 p.m., LVN C said she sent all paperwork with Resident #1's current condition with the resident when he left for the ALF in another state. She said she did not call the facility to give a report on Resident #1. She said the SW had been in charge of the discharge process for Resident #1. She said she usually called report when a resident was discharged . During an interview on 4/13/2023 3:33 p.m., the SW said he did not know there had been a changed in Resident #1's wound status. He said the nurses should have informed him and he would have communicated the information to the ALF to see if the ALF was still able to meet the needs of Resident #1. He said the discharge planning for Resident #1 had started a long while prior to his discharge and he, the SW, was in charge of discharge planning. He said while he accompanied the Resident to the new facility, Resident #1 had a bandage and a cushioned boot on his right foot. During an interview on 4/20/2023 at 11:04 a.m., the assisted living ED said around 12/9/2022 or 12/10/2022, he spoke with a facility nurse or SW regarding the pending transfer of Resident #1 to ALF. ED said he was not able to recall the name of the staff. ED said the communication between the nursing facility staff indicated Resident #1 did not have any skin issues or breakdown at that time. ED said Resident #1 arrived at their facility on 12/12/2022 and said looked ashy grey and lethargic. ED added Resident #1's buttocks was raw but not open. He said Resident #1's right heel had signs of infection and necrotic tissue in the center. ED said he took a picture of Resident #1's right heel and showed it to their facility physician. ED said their physician ordered Resident #1 to be transferred out to the hospital for wound management. ED stated their facility would not have admitted Resident #1 if information regarding his right heel had been relayed to them prior to his arrival on 12/12/2022. ED added their facility was not capable of providing care to stage 2 and above pressure wounds. He said if the nursing facility had called the morning of the discharge and said the resident had the wound on his foot, they would not have accepted him as a resident in the ALF. During an interview on 4/26/2023 at 4:00 p.m., the DON said the current and active clinical information of residents being transferred to another facility should be communicated to the receiving facility upon their discharge both verbally and written. She said the failure to do so could leave residents at risk of not getting the necessary care and services in the receiving facility. 675415 Page 8 of 13 675415 05/17/2023 Windsor Las Palmas Nursing and Rehabilitation Cent 1301 E Quebec Ave McAllen, TX 78503

F 0661 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents had a discharge summary that included a recapitulation of the resident's stay that included, but was not limited to diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results for 1 (Resident #1) of 3 residents reviewed for discharge summaries. The Discharge Summary for Resident # 1 did not include a complete recapitulation of the resident's stay for a resident discharged to another facility. The Facility failed to include details of Resident # 1's change in wound status for his right heel wound prior to discharge. This failure could place residents discharged from the facility at risk for incorrect, incomplete, or misleading information recorded regarding discharged residents, and failure in the continuity of care for residents. The Findings included: Record review of Resident #1's electronic face sheet dated 12/12/2022 indicated an [AGE] year-old male admitted on [DATE] with the following diagnoses: unspecified paraplegia (paralysis of legs and lower body), disorder of peripheral nervous system (Weakness, numbness, and pain from nerve damage, usually in the hands and feet), other specified depressive episodes, pressure ulcer of right buttock, and hypertensive heart disease without heart failure (high blood pressure). Record review of Resident #1's nursing progress note dated 7/29/2022, completed by LVN A indicated resident arrived via ambulance, alert, and oriented x 4, discolorations to bilateral upper extremities due to intravenous lines and blood draws at hospital. Resident with stage II (the loss of soft tissue involving the full thickness layers of the skin up to the subcutaneous layer) wound to sacrum and right heel pressure ulcer (no stage given). Record review of Resident #1's health assessment dated [DATE] completed by NP A indicated no pressure sores. Record review of Resident #1's nursing progress notes dated 12/6/2022, completed by RN A indicated a dark purple discoloration to Resident #1's right heel with open area, light serous drainage. Some edema noted to right foot. No odor. Notified wound care physician of change. Further review of resident #1's progress notes and electronic clinical records indicated no evidence of active skin breakdown or wound to his right heel 1 week prior to 12/6/2022. Record review of Resident #1's signed Physicians discharge summary with a received date of 12/22/2022, indicated a discharge date of 12/12/2022. Further review of this document indicated a list of final diagnoses that did not include Resident #1's right heel pressure wound. Further review of this document indicated the receiving facility was an assisted living facility (ALF) in another state. Record review of Resident #1's Skin Assessment record from the assisted living facility dated 12/12/2022, completed by the ED, indicated Resident (#1) arrived at [Facility Name] in the afternoon. Resident presented with an unstageable ulcer (a full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough or eschar in the wound bed) on his right heel. Resident also 675415 Page 9 of 13 675415 05/17/2023 Windsor Las Palmas Nursing and Rehabilitation Cent 1301 E Quebec Ave McAllen, TX 78503

F 0661 presented with raw but unopened buttock. Resident was sent to Hospital for treatment of wounds. Level of Harm - Minimal harm or potential for actual harm During an interview on 4/5/2023 at 12:27 pm with DON regarding resident transfers and discharge to another facility. DON said resident's clinical records, including an accurate discharge summary, were supposed to be forwarded or faxed to the receiving facility in addition to verbal communication. Residents Affected - Few During an interview on 4/20/2023 at 11:04 am with the assisted living ED, he stated around 12/9/2022 or 12/10/2022, he spoked with a facility nurse or SW regarding the pending transfer of Resident #1 to ALF. ED said he was not able to recall the name of the staff. ED said the communication between the nursing facility staff indicated Resident #1 did not have any skin issue or breakdown at that time. ED stated Resident #1 arrived at their facility on 12/12/2022 and said he looked ashy grey and lethargic. ED added Resident #1's buttocks was raw but not open. His right heel wound was covering the entire heel with signs of infection and had necrotic tissue on the center. ED said he took a picture of Resident #1's right heel and showed it to their facility physician. ED said their physician ordered Resident #1 to be transferred out to the hospital for further management. ED stated their facility would not have been able to admit Resident #1 if information regarding his right heel had been relayed to them prior to his arrival on 12/12/2022. ED added their facility was not capable of providing care to stage 2 and above pressure wounds. During an interview on 4/26/2023 at 4:00 pm with DON, she said the discharge summary should include the current and active clinical information of residents being transferred to another facility and should be communicated to the receiving facility upon their discharge. She said the failure to do so could leave residents at risk of not getting the necessary care and services in the receiving facility. Record review of facility's policy on Discharge summary and plan of care policy dated 10/24/2022 indicated #3 .The discharge summary should include a. An overview of the resident's stay that includes but not limited to diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results, and instructions or precautions for ongoing care. 675415 Page 10 of 13 675415 05/17/2023 Windsor Las Palmas Nursing and Rehabilitation Cent 1301 E Quebec Ave McAllen, TX 78503

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. 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 with pressure ulcers receive treatment and care in accordance with the comprehensive assessment, professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for two residents of four residents reviewed for wound assessments. (Resident #1 and Resident #3). Residents Affected - Few Resident #1 and Resident #3 had pressure wounds on their heels but were being claimed as arterial wounds by the facility. This failure could place residents at risk for inconsistent assessment resulting in the deterioration of existing wounds, a decline in health, pain, and hospitalization. Findings included: 1. Record review of Resident #1's electronic face sheet dated 12/12/2022 indicated an [AGE] year-old male admitted on [DATE] with the following diagnoses: unspecified paraplegia (paralysis of legs and lower body), disorder of peripheral nervous system (Weakness, numbness, and pain from nerve damage, usually in the hands and feet), other specified depressive episodes, pressure ulcer of right buttock, and hypertensive heart disease without heart failure (high blood pressure). Record review of an MDS dated [DATE] indicated Resident #1 was cognitively intact, was understood by others and was able to understand others. Resident #1 was at risk for pressure sores. He had no current pressure sores. The MDS indicated the resident had 1 venous/arterial ulcer present with an open lesion on his foot. Record review of a facility skin assessment dated [DATE], completed by RN A, indicated Resident #1 had a suspected deep tissue pressure injury (DTI) (A DTI is a type of pressure ulcer occurs most commonly at the heels sacrum and buttocks) on his right heel measuring 5.5cm x 5.0 cm x 0.1 cm. Record review of physician's wound note for Resident #1 dated 7/25/22, completed by MD A, indicated Wound #3 (rt heel DTI) presents improving regressively . will benefit from debridement (the removal of damaged tissue). Debridement was performed today to Wound #3 (RT heel DTI) down to health, viable subcutaneous tissue (recorded 7/21/22). Post debridement measurement of the right heel were 3.7cm x 2.6cm x 0.2cm. One of the diagnoses attached to the encounter was Deep tissue pressure injury of right heel. Record review of a physician's wound note dated 8/5/22, completed by MD A, indicated an arterial duplex bilateral lower extremities ultrasound was completed on Resident #1. The findings suggested mild bilateral ischemia (an inadequate blood supply to a part of the body). MD A reclassified the pressure wound on the right heel to a right heel arterial ulcer. Record review of a facility skin assessment dated [DATE], completed by RN A, indicated Resident #1 right heel was previously staged as DTI, the Resident was reevaluated by the physician and restaged the wound as an arterial ulcer. 2. Record review of a face sheet dated 4/5/2023 indicated Resident #3 was admitted [DATE], was an [AGE] year-old male and had diagnoses including osteomyelitis (infection of the bone), peripheral 675415 Page 11 of 13 675415 05/17/2023 Windsor Las Palmas Nursing and Rehabilitation Cent 1301 E Quebec Ave McAllen, TX 78503

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few vascular disease (a narrowing of blood vessels reducing the blood flow to the limbs), and diabetes (a group of diseases that result in too much sugar in the blood) Record review of an MDS, dated [DATE], indicated Resident #3 was cognitively intact. He understood others and was understood. Resident #1 required extensive assistance of 2 persons for bed mobility and transfers. Resident #3 was at risk for pressure ulcers. He had one unstageable pressure ulcer that was present on admission. Record review of a nursing weekly pressure ulcer evaluation dated 3/9/23, completed by RN B, indicated Resident #3 had an unstageable pressure ulcer on his left heel. Record review of a nursing non-weekly pressure ulcer evaluation dated 3/13/23 indicated admitted with unstageable pressure ulcer. New diagnosis given by MD to non-pressure arterial ulcer. During an interview on 4/4/23 at 3:15 p.m., the DON said a wound on the heel would be caused from pressure and should not be called an arterial wound. During an observation and interview on 4/5/23 at 9:06 a.m., RN D completed wound care on Resident #3's left heel. The wound on the left heel was approximately 1.9cm x 1.5cm x 0.3cm. RN B said the wound was an arterial wound per a doppler test. During an interview on 4/5/23 at 11:21 a.m., RN D said Resident #3's heel wound was an unstageable pressure wound and was changed to an arterial wound after the doppler study ordered by the physician. During an interview on 4/5/23 at 11:44 a.m., MD A said Resident #1's wound was caused from pressure. He said when wounds would not heal in an appropriate amount of time, he wanted to find the underlying cause. He said he ordered arterial dopplers for diagnostic reasons. He agreed the heel was a bony prominence and pressure caused the wound and the decreased arterial flow made it difficult to heal the wound. Record review of the facility's Pressure Injury Prevention and Management policy dated 8/15/22 indicated Pressure Ulcer/Injury refers to localized damage to the skin and/or underlying soft tissue over a bony prominence or related to a medical or other device. 675415 Page 12 of 13 675415 05/17/2023 Windsor Las Palmas Nursing and Rehabilitation Cent 1301 E Quebec Ave McAllen, TX 78503

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to, in accordance with accepted professional standards and practices, maintain medical records on each resident that were complete and accurately documented for 1 (Resident #1) of 5 residents reviewed for medical records. Resident #1's medical record indicated a diagnosis of anemia related to antineoplastic chemotherapy with no evidence Resident #1 had chemotherapy. This failure could place, all the residents who resided in the facility, at risk of incomplete and inaccurately documented medical records. Findings included: Record review of an admission Record, Resident Information sheet dated 4/5/23 indicated Resident #1 was admitted [DATE], was an [AGE] year-old male and had a diagnosis of anemia (blood does not have enough health red blood cells) due to antineoplastic chemotherapy (medications used to treat cancer). Record review of a hospital history and physical dated 7/24/22 indicated Resident #1 had a diagnosis of anemia. The Resident denied a history of chemotherapy or radiation for his history of colon cancer. During an interview on 3/28/2023 at 2:15 p.m., a family member said Resident #1 had never had any chemotherapy for his colon cancer. She said the physician told them the chemotherapy would kill him before the cancer. During an interview on 4/25/23 at 3:17 p.m., the ADM said the MDS coordinator was responsible for the input of diagnosis in the computer. She said the MDS person who was working during the time Resident #1 was in the facility was no longer an employee. ADM said resident #1 was not provided chemotherapy while he was in the facility. She said the previous DON would have ultimately responsible for the accuracy of the diagnoses. During an interview on 4/25/23 at 4:42 p.m., the DON said the interdisciplinary team composed of the dietician, therapy department, DON and MDS nurse were responsible for the accuracy of clinical data in the electronic medical record. During an interview via email on 5/5/23 at 10:51 a.m., the ADM indicated she would try to get the policy used at the time Resident #1 was in the facility from the previous owners. A policy was not provided prior to exit. 675415 Page 13 of 13