Health inspection·September 6, 2025

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, interviews and record reviews, 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 of 3 (Resident #1) residents reviewed for EBP. The facility failed to post EBP signage for Resident #1 when she had a permcath (a flexible tube used for dialysis treatment) to right chest. This failure could place residents at risk of MDRO contamination. The findings included: Record review of Resident#1's admission sheet, dated 09/05/25, revealed the resident was a [AGE] year-old female with an admit date of 09/02/25 and an original admission date of 08/20/25. Her relevant diagnoses included: dependence on renal dialysis (a process of removing excess water, solutes, and toxins from the blood), diabetes mellitus (a disease that result in too much sugar in blood), acute kidney failure (a condition in which the kidneys suddenly can't filter waste from the blood), and hypertensive heart disease (a long-term condition that develops from chronic high blood pressure, or hypertension). Record review of Resident #1's electronic medical record revealed Resident #1 had not been at the facility long enough for an admission MDS assessment. Record review of Resident 1's comprehensive care plan initiated on 08/20/25 reflected a Focus of the resident needs hemodialysis (a machine that filters waste, salts, and fluid from the blood) r/t acute kidney failure. Interventions in part included monitor/document/report PRN any s/sx of infection to access site: redness, swelling, warmth or drainage. Record review of Resident #1's active orders as of 09/06/25, reflected dialysis: permcath right chest restrictions: no heavy lifting effective 09/02/25, dialysis: check shunt for s/s of infection or bleeding effective 09/02/25. EBP: use gown and gloved for high contact resident care activities for those known to be colonized or infected with a CDC targeted MDRO as well as those with increased risk of MDRO (residents with wounds or indwelling medical devices) effective 09/06/25 at 6:00 a.m. In an observation and interview on 09/06/25 at 9:45 a.m., Resident #1 said in late August 2025, she had a permcath inserted to her right chest due to her diagnosis of kidney failure and required dialysis. Resident #1 was observed with a white gauze on her right chest. Resident #1 said that was where she had her permcath for dialysis. No EBP signage was seen on her door. An observation and interview on 09/06/25 at 10:02 am, LVN A said Resident #1 was under EBP because she had a permcath to her right side (for dialysis). She said she remembered seeing an active order for EBP effective 09/06/25. LVN A said a resident was required to be under EBP whenever they had a foley, permcaths, midlines, IV's, or open wounds. She said having an EBP sign on their door would advise staff if they were going to touch the resident, they needed to wear ppe. LVN A was observed in front of Resident #1's door and said, there's no EBP sign. She said the order for EBP was effective 09/06/25 but it should have been effective from her re-admission date (09/02/25). LVN A said a negative outcome for Resident #1 not having an EBP sign could be that staff would not know to take proper precautions when touching Resident #1 and the risk of infection for Residents Affected - Few (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 2 Event ID: 675415 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 675415 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Las Palmas Nursing and Rehabilitation Cent 1301 E Quebec Ave McAllen, TX 78503 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)