Health inspection·March 6, 2025

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Residents Affected - Few Based on interviews, and record review the facility failed to ensure the assessment accurately reflected the resident's status for 2 (Resident #55 and Resident #212) of 11 residents for accuracy of assessments. 1.The facility failed to identify Resident #55 was receiving dialysis on his Quarterly MDS assessment dated [DATE]. 2. The facility failed to ensure Resident#212's MDS admission assessment accurately reflected the use of high-risk drug classes, use, and indication. This failure could place residents at risk for receiving inadequate care and services based on inaccurate assessments. The findings included: 1. Record review of Resident #55's admission Record dated 03/05/25 revealed Resident #55 was a [AGE] year-old male admitted to facility on 07/22/24 and had a readmission on [DATE] with diagnoses of dependence on renal dialysis, end stage renal disease (a long-term condition where the kidneys gradually lose their ability to filter waste products from the blood), and type 2 diabetes mellitus with hyperglycemia (a disease that occurs when your blood glucose, also called blood sugar, is too high). Record review of Resident #55's Quarterly MDS dated [DATE] revealed: BIMS score of 15 indicating Resident #55 was cognitively intact. Did not exhibit any behavioral symptoms. Required supervision or touching assistance for his activities of daily living. Section O0110 - Special treatments, procedures, and programs - section J1 was not checked. Record review of Resident #55's comprehensive care plan revised on 01/09/25 revealed Resident #55 needed dialysis (hemo) r/t ERSD with interventions to check and change dressing daily at access site. Document, monitor vital signs, notify MD of significant abnormalities, and monitor/document/report PRN any s/sx of infection to access site: redness, swelling, warmth, or drainage. Page 1 of 11 675415 675415 03/06/2025 Windsor Las Palmas Nursing and Rehabilitation Cent 1301 E Quebec Ave McAllen, TX 78503

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few In an interview on 03/05/26 at 4:17 PM, MDS/RN said Resident #55 had multiple visits to the hospital due to wounds to the foot. Resident #55 had infections to the left foot, so every time Resident #55 was sent to the hospital there was a discharge and entry MDS. If there was a significant change from the hospital, the MDS staff would address the MDS assessment by reviewing the documents form the hospital. MDS/RN said Resident #55 had always been on dialysis. MDS/RN said it was an item coding error. The MDS said the care plan still showed that Resident #55 received dialysis. There was no negative outcome because Resident #55 still received dialysis and received his medications. In an interview on 03/05/25 at 5:15 PM, the DON said they have meetings every morning and they review residents that would be admitted or readmitted from the hospital. The nursing staff reviewed the incoming resident's diagnosis and care they would require. The DON said the MDS nurses reviewed the resident's documents in the clinical system. The clinical system allowed the facility MDS to review the new or readmitting resident's medical records. The DON said the error was a coding issue for reimbursement. The DON said the error did not affect the care of Resident #55 because he received the dialysis, and it was on the care plan. The DON said they started their clinical pathways to catch all the resident's triggers. 2.Record review of Resident #212's face sheet dated 03/06/2025 reflected a [AGE] year-old female with an admission date of 02/07/2025. Pertinent diagnoses included type 1 diabetes mellitus, unspecified psychosis (lose contact with reality), mood disorder, depression, chronic kidney disease, and colostomy status (an opening for the large intestine through the belly). Record review of Resident #212's comprehensive care plan dated 2/18/2025 revealed: Resident #212 uses antipsychotic medications r/t psychosis and depression. Interventions administer medications, discuss side effects of medication with resident/RP, monitor behaviors .Resident #212 has altered endocrine status, hyperglycemia (high blood sugar), r/t Diabetes Mellitus. Interventions Monitor/document/report as needed for signs and symptoms of hyperglycemia (high blood sugar), Monitor/document/report as needed for signs and symptoms of hypoglycemia (low blood sugar). Record review of Resident #212 's admission MDS dated [DATE] revealed: Section N 0415 - High Risk Drug Classes: Use and Indication 1. Is taking Check if the resident is taking any medications by pharmacological classification, not how it is used, during the last 7 days or since admission/entry or reentry if less than 7 days. 2. Indication noted If column 1 is checked, check if there is an indication noted for all medications in the drug class. The facility did not check offA. Antipsychotic J. Hypoglycemic (including insulin) 675415 Page 2 of 11 675415 03/06/2025 Windsor Las Palmas Nursing and Rehabilitation Cent 1301 E Quebec Ave McAllen, TX 78503

F 0641 Level of Harm - Minimal harm or potential for actual harm Record review of Resident 212's physician order summary dated range 2/1/2025-2/28/2025 revealed, Quetiapine Fumarate Oral (antipsychotic) Tablet 50 MG by mouth at bedtime for agitation, Lantus Subcutaneous Solution 100 UNIT/ML (Insulin Glargine) Inject 18 unit subcutaneously at bedtime for diabetes, and Humalog Solution 100 UNIT/ML (Insulin Lispro Human) Inject 3 units subcutaneously before meals for diabetes. Residents Affected - Few During an interview on 03/06/2025 at 11:34 a.m. with MDS RN, she stated that she signed off Resident #212's MDS admission assessments and the error was an overcite. She stated that there was another MDS staff who was also responsible for completing the facility's MDS. They work as a team. They get the MDS assessment information from what the nurses give them. Resident #212's MDS assessment did not reflect the high-risk medications she was taking. She stated that she can modify it and enter that information. She stated the MDS was important for reimbursement purposes. The MDS RN stated that the negative outcome of not accurately completing the MDS assessment was that the facility would not get paid. During an interview on 03/06/2025 at 11:55 a.m. with the DON, that she did not oversee MDS assessments. She stated the facility has two MDS staff who were responsible for the MDS assessments. The DON stated that they meet in the mornings, Monday through Friday, for their IDT meeting. During this meeting they review the resident's diagnosis, diet, code status, and medications. She stated it was important for MDS assessments to be accurate for paper trail purposes. The DON stated the negative outcome was none on the resident. She stated that it paints a clear picture of the type of treatment that she was receiving. Record review of CMS's RAI version 1.19.1 dated October 2024 revealed section: O0110: Special Treatments, Procedures, and Programs a. On admission b. while a resident c. at discharge J1: Dialysis Code peritoneal or renal dialysis which occurs at the nursing home or at another facility, record treatments or hemofiltration, Slow Continuous Ultrafiltration (SCUF), Continuous Arteriovenous Hemofiltration (CAVH), and Continuous Ambulatory Peritoneal Dialysis (CAPD) in this item. Record review of the CMS's RAI Version 3.0 Manual dated October 2024, revealed section:

N0415: High Risk Drug Classes: Use and Indication 1. Is taking Check if the resident is taking any medications by pharmacological classification, not how it is used, during the last 7 days or since admission/entry or reentry if less than 7 days. 2. Indication noted If column 1 is checked, check if there is an indication noted for all medications in the drug class. 675415 Page 3 of 11 675415 03/06/2025 Windsor Las Palmas Nursing and Rehabilitation Cent 1301 E Quebec Ave McAllen, TX 78503

F 0641 A. Antipsychotic Level of Harm - Minimal harm or potential for actual harm J. Hypoglycemic (including insulin) Item Rationale: Health related Quality of Life. Residents Affected - Few Medications are an integral part of the care provided to residents of nursing homes. They are administered to try to achieve various outcomes, such as curing an illness, diagnosing a disease or condition, arresting, or slowing a disease progress, reducing or eliminating symptoms, or preventing a disease or symptom. Residents taking medications in these medication categories and pharmacologic classes are at risk of side effects that can adversely affect health, safety, and quality of life. 675415 Page 4 of 11 675415 03/06/2025 Windsor Las Palmas Nursing and Rehabilitation Cent 1301 E Quebec Ave McAllen, TX 78503

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed develop and implement a comprehensive person-centered care plan for each resident, consistent with resident the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial need that were identified in the comprehensive assessment for 1 of 5 residents (Resident #79) reviewed for comprehensive person-centered care plans. The facility failed to develop a comprehensive person-centered care plan for Resident #79 to address pain management. This deficient practice could place residents at risk of not being provided with the necessary care or services and not having personalized plans developed to address their specific needs. Findings included: 1. Record review of Resident #79's face sheet, dated 3/6/2025, reflected an [AGE] year-old female who was originally admitted to the facility on [DATE]. Resident #3 had a diagnosis which included: Poly osteoarthritis (a condition in which multiple joints experience the symptoms of osteoarthritis, a chronic joint disease that causes pain, stiffness, and loss of function). Record review of Resident #79's Care Plan, dated 12/19/24, reflected Pain medication, Tramadol-Acetaminophen was not cared planned. Record review of Resident #79's quarterly MDS assessment, dated 12/26/24, reflected a BIMS score of 6, which indicated Resident #79's cognition was moderate to severely impaired. Pain management was marked on MDS. Record review of Resident #79's Doctor's Order Summary, dated 3/6/2025, reflected Resident #79 was prescribed Tramadol-Acetaminophen Oral Tablet 37.5-325 milligrams, Give 1 tablet by mouth one time a day for pain. Record review of Resident #79's Medication Administration Record, dated 3/6/2025, reflected an order for Resident #79 to receive Tramadol-acetaminophen 37.5-325 milligrams 1 tablet by mouth one time a day. Interview on 3/6/25 at 10:00 AM with LVN D, MDS nurse, stated that the negative effect for not having the pain care planned was that the residents could develop adverse reactions to medication if pain was not managed. LVN D, MDS nurse, stated that it was overlooked, and missed it. LVN D, MDS nurse said that she was responsible for the care plan, and it was based on the MDS assessment. Interview on 3/6/25 at 3:40 PM, the DON said Resident #79 did not have pain management care planned. She stated the MDS nurses were responsible for updating the care plans. The DON said that the resident was getting her medication whether was care planned it or not. The DON said that the resident was not getting hurt without that care planned. Record review of the Comprehensive Person-Centered Policy, date implemented 10/24/2022, read in 675415 Page 5 of 11 675415 03/06/2025 Windsor Las Palmas Nursing and Rehabilitation Cent 1301 E Quebec Ave McAllen, TX 78503

F 0656 Level of Harm - Minimal harm or potential for actual harm part It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. The resident comprehensive care plan is developed within seven days of the completion of the resident's comprehensive assessment MDS. Residents Affected - Few 675415 Page 6 of 11 675415 03/06/2025 Windsor Las Palmas Nursing and Rehabilitation Cent 1301 E Quebec Ave McAllen, TX 78503

F 0760 Ensure that residents are free from significant medication errors. 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 residents were free of significant medication errors for one (Resident #7) of five residents reviewed for medications errors in that: Residents Affected - Few The facility administered a medication for high blood pressure to Resident #7 outside the blood pressure parameter as ordered by the physician. This deficient practice could place residents who receive blood pressure medications at an increased risk for complications such as decreased blood pressure, decrease pulse, an exacerbation of symptoms and disease process, and potential hospitalization. Findings include: Record review of Resident #7's face sheet dated 3/06/2025 reflected an [AGE] year-old female with an admission date of 01/06/2023. Pertinent diagnoses included Essential Primary Hypertension (high blood pressure), Type 2 Diabetes Mellitus, Muscle wasting and Atrophy (the shrinking or wasting away of muscle). Record review of Resident #7's MDS comprehensive assessment dated [DATE], reflected a BIMS score of 07, which indicated her cognition was severely impaired. Review of Care Plan dated 02/16/24 reflected Resident #7 had hypertension. Interventions revealed to give antihypertensive medications as ordered. Review of physician order dated 02/05/2025 reflected Resident #7 was ordered to receive Losartan 25 milligrams give one tablet by mouth three times a day, hold if systolic blood pressure less than 110, diastolic blood pressure less than 70. This order was open-ended and had indefinite for stop date. Observation: Medication Administration for Resident #7 on 03/05/25 at 07:50 a.m. MA D, checked blood pressure using an electronic cuff on Resident #7. Blood pressure reading was 142/64 and pulse 60. She read eMAR and pulled out medications from drawer individually one at a time. Two medications were blood pressure medications but with different parameters (Metoprolol -Hold if SBP less than 110 and/or DBP less than 60 and Losartan -Hold if SBP less than 110 and/or DBP less than 70). MA D handed both blood pressure medications to Resident #7. During an interview on 03/05/25 at 08:00 a.m. with MA D stated she did not know what she had done wrong during the administration of medications with Resident #7. She then stated she did not check the parameters on the blood pressure medications today because she got nervous. She stated that she normally checks the parameters before administering blood pressure medications. MA D stated when administering medications, she is to check that it's the correct patient, the correct dosage, the correct route, and any parameters. She stated that it was important to check the parameters because if administered out of parameter, it would cause the blood pressure to go down and it can be critical for the residents. MA D stated the negative outcome if Resident #7 would have swallowed the pill, would be that her blood pressure would go down and she can code. During an interview on 03/5/25 at 03:21 p.m. with the ADON stated she trains the medication aides 675415 Page 7 of 11 675415 03/06/2025 Windsor Las Palmas Nursing and Rehabilitation Cent 1301 E Quebec Ave McAllen, TX 78503

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few and does skill checks offs as often as she needs to. She stated she completed a skill check on MA D last month. The ADON stated when administering medications, medication aides are supposed to be check vitals if required and parameters. She stated that following the parameters was important because it can cause an adverse effect on the resident and to prevent tragedy, for safety. If they do not administer medication due to being out of parameters, then they are to notify the nurse, document that it was not administer and the reason. She does medication administration audits as well and reports them at least every week. The ADON stated Resident #7 blood pressure medication parameters were recently changed. She stated the negative outcome of administering blood pressure medication out of parameters would cause Resident#7 to feel dizzy, a decrease in her blood pressure, and different other side effects. During an interview on 03/05/25 at 03:32 p.m. with the DON, she stated that the ADON's train the medication aides and the pharmacist also do check offs with them. She stated they have annual skill checks offs. The DON stated before administering the Losartan blood pressure medication MA D should be checking the blood pressure to make the reading was within to administer. If outside the parameters, then she would notify nurse and dispose of medication not given. She stated it was important to follow parameters to keep residents stabilized. The DON stated the negative outcome of administering blood pressure medication outside the parameters would be stressing the resident. She stated that keeping the resident safe was priority. Record review of facility provided policy titled, Medication Administration dated 10/24/2022, reflected: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice in a manner to prevent contamination or infection. Policy Explanation and Compliance Guidelines: 8. Obtain and record vital signs, when applicable or per physician orders. When applicable, hold medication for those vital signs outside the physician's prescribed parameters. 675415 Page 8 of 11 675415 03/06/2025 Windsor Las Palmas Nursing and Rehabilitation Cent 1301 E Quebec Ave McAllen, TX 78503

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, interviews, 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 reviewed for sanitationt: The facility failed to ensure dry foods were properly stored. This failure could place residents at risk of foodborne illnesses. Findings included: During an observation and initial tour of the kitchen on 03/04/25 at 9.00 a.m. the dry food storage revealed one plastic storage container with an open bag of pasta that did not have a lid. During an interview on 03/04/25 at 9:05 a.m., Dietary Manager first said the lid was being washed. He later said while the lid was being washed on 03/04/25 the lid had broken and been thrown away. The Dietary Manager was not able to identify the staff member that had washed the lid. The Dietary Manager was not able to say if there were any negative outcome for the plastic storage container not having a lid. During an interview on 03/05/25 at 4:00 p.m., the Dietician said all food storage containers should be tightly sealed with lids. The dietician was not able to say if there were any negative outcome to the residents if the plastic storage in covered containers. An interview on 03/05/25 at 5:30 p.m., the Administrator said the Dietary Manager was responsible to ensure food wfas safely stored. The Administrator provided Policy on Food Storage that was provided by the Dietician. He said the facility did not have a policy of food storage. The Adminstrator was not able to say if there were any negative outcome for the plastic storage container not having a lid. Record review of the Food Storage policy from the Nutrition & Foodservice Policies & Procedures Manual dated 10/01/18 and revised 06/01/19 reflected Policy: To ensure that all food served by the facility is of good quality and safe for consumption, all food will be stored according to the state, federal and US Food Codes and Hazard Analysis and Critical Control Point guidelines. Procedure: 1. Dry storage rooms d. to ensure freshness, store opened and bulk items in tightly covered containers. 675415 Page 9 of 11 675415 03/06/2025 Windsor Las Palmas Nursing and Rehabilitation Cent 1301 E Quebec Ave McAllen, TX 78503

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews, 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 2 (Resident #212 and Resident # 52)out of 4. Residents Affected - Few 1. LVN A did not perform hand hygiene for 20 seconds or longer after wound care of Resident # 212. 2. CNA B failed to provide Resident #52 with appropriate foley catheter care. These failures could place residents at risk for infection through cross contamination of pathogens. The findings included: 1. Record review of Resident # 212's face sheet dated 3/5/2025 reflected a [AGE] year-old female with an admission date of 2/7/2025. Diagnoses included pressure ulcer of sacral region stage 4, type two diabetes (insufficient production of insulin in the body), and acute osteomyelitis (a serious infection of the bone that develops rapidly). Record review of Resident #212's MDS dated [DATE] reflected a BIMS score of 3 (severe cognitive impairment) and was always incontinent and stage 4 full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often included undermining and tunneling. Record review of Resident #212's care plan dated 2/8/2025 reflected Resident #212 had a stage IV pressure to sacrum. During an observation of wound care for Resident #212 on 03/5/2025 at 10:30 AM, LVN A performed hand hygiene for approximately 15 seconds after LVN A performed wound care. In an interview on 3/5/2025 at 11:00 AM, LVN A stated hand washing should be at least 20 seconds to prevent the spread of germs to residents and others. 2. Record review of Resident #52's face sheet dated 3/5/2025 reflected a [AGE] year-old-male with an original admission date of 2/3/2025. Diagnoses included retention of urine, and obstructive and reflux uropathy (a medical condition where the flow of urine is blocked within the urinary tract, causing urine to back up and potentially damage one or both kidneys). Record review of Resident #52's quarterly MDS resident assessment, dated 2/7/2025 reflected a BIMS score of 10 (moderate cognitive impairment) and had an indwelling catheter. Record review of Resident #52's care plan dated 2/4/2025 reflected the resident had an indwelling foley catheter 18 French with 5 milliliter bulb related to neurogenic bladder. The resident had a urinary tract infection. During an observation of perineal care for Resident #52 on 03/5/25 at 11:20 AM, CNA B and CNA C 675415 Page 10 of 11 675415 03/06/2025 Windsor Las Palmas Nursing and Rehabilitation Cent 1301 E Quebec Ave McAllen, TX 78503

F 0880 Level of Harm - Minimal harm or potential for actual harm began to perform perineal care. After peri care was performed and a clean brief was donned, CNA B did not clean the foley catheter tubing. In an Interview on 03/5/25 at 11:45 AM, CNA B stated that was important to clean the foley tubing because the resident could get an infection. CNA B stated she forgot to clean it because she was nervous. Residents Affected - Few In an interview on 03/5/25 at 05:20 PM, the ADON stated effective hand washing of at least 20 seconds or greater was important to prevent the spread of infection to residents, staff, and visitors. The ADON stated hands should be washed prior to performing care and gloves should be changed after performing peri care to reduce the risk of cross contamination from a clean to dirty surface. The ADON stated with residents that have a foley catheter, the tubing needed to be cleaned to reduce the risk of urinary tract infections. In an interview on 03/5/25 at 05:35 PM, the DON stated hand washing should be 20 seconds or greater to prevent the spread of bacteria to residents and other surfaces. The DON stated all gloves should be changed between brief changes from a dirty to clean procedure to ensure effective infection control practices and stop the spread of germs to staff, residents, and other surfaces. The DON stated the last hand hygiene/ infection control in-service was done within the last month and was also conducted on an as needed basis. Record review of Hand Hygiene policy dated 10/24/2022 stated: Policy Statement All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. 5. Hand hygiene technique when using soap and water: a. wet hands with water. Avoid using hot water to prevent drying of skin. b. apply to hands the amount of soap recommended by the manufacturer. c. rib hands together vigorously for at least 20 seconds, covering all surfaces of the hands and fingers. d. rinse hands with water. e. dry thoroughly with a single-use towel. f. use clean towel to run off the faucet. Record review of Infection Prevention and Control Program implemented on 5/13/2023 stated: This facility has established and maintains 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 infections as per accepted national standards and guidelines. 675415 Page 11 of 11