Health inspection·October 18, 2022

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Resident #23's MAR revealed the medication was administered on the following date and time with the following BP: 10/02/22 at 8:00 PM BP was 106/77 by MA A. Record review of Resident #23's Medication Administration Record (MAR) dated 10/01/22 - 10/31/22, revealed hydralazine HCL 50 Mg two times a day for hypertension. Hold for SBP <110, HR <60. Resident #23's MAR revealed the medication was administered on the following date and time with the following BP: 10/09/22 at 5:00 PM BP was 100/67 by MA A. In an observation on 10/17/22 at 10:44 AM Resident #23 was in the hall self-propelling in his wheelchair. Attempted to interview but resident refused to be interviewed . In an interview on 10/17/22 at 12:00 PM, MA A stated the initials on Resident #23's MAR were her initials, and the check marks indicated the two medications were given. The MA stated before she gave BP medications, she checked the resident's blood pressure to make sure it was within the parameters and if it was not, she would not give the medication she marked it as held and notified the nurse. The risk to the resident was the blood pressure could drop too much if the medication is given outside the ordered parameters. The MA refused to state why the medications were given on 10/02 and 10/09 and how to prevent it from occurring again . In an interview on 10/17/22 at 12:15 PM, the DON stated her expectations were the ordered parameters for blood pressure medications were followed. These medications were given outside the ordered parameters and should not have been given. The risk to the resident was the resident's blood pressure could drop too low. To prevent this from occurring again the staff would be in-serviced. In an interview on 10/18/22 at 10:01 AM, the Administrator stated he was not clinical, but his expectations were that medications were administered according to the nursing policies and to follow physician's orders. He stated the risk to the resident best to his knowledge was the blood pressure could go low. To prevent it from occurring again he would reeducate, In-service and monitor the staff. 2. Record review of Resident #91's face sheet, dated 10/16/22, revealed a [AGE] year-old female initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included: Pneumonia, iron deficiency anemia, age-related physical debility, muscle wasting and hypotension. Record review of Resident #91's Annual MDS, dated [DATE], revealed the resident had severely impaired vision, moderately impaired cognition as indicated by a BIMS score of 12 out of 15, required extensive assistance to total dependence on most ADLs, wheelchair use, was always incontinent of both bladder and bowel and an active diagnosis of orthostatic hypotension . Record review of Resident #91's Care Plan revealed: Problem- Resident #91 has a diagnosis of hypotension; Goal- The resident will remain free of complications related to hypertension through the review date; Intervention- Give anti-hypertensive medications as ordered. Monitor for side effects such as orthostatic hypotension and increased heart rate and effectiveness. Resident #91 was not care planned for hypotension. Record review of Resident #91's Physician Orders, dated 09/29/22, revealed, Midodrine 5 mg- Give 1 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676371 If continuation sheet Page 2 of 10 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 676371 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Quail Valley Post-Acute Healthcare 3640 Hampton Dr Missouri City, TX 77459 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)

F 0658 tablet by mouth two times a day for hypotension. Give for SBP <110 . Level of Harm - Minimal harm or potential for actual harm Record review of Resident #91's October MAR revealed, multiple facility nursing staff administered Resident #23 Midodrine 5 mg outside of physician set parameter of SBP <100 on: Residents Affected - Some 10/1/22 at 5:00 PM with BP 100/69 by DON 10/3/22 at 5:00 PM with BP 143/71 by MA E 10/4/22 at 9:00 AM with BP 100/68 by MA C 10/5/22 at 5:00 PM with BP 144/71 by MA E 10/7/22 at 9:00 AM with BP 101/63 by LVN A and 5:00 PM with BP 125/60 by MA A 10/8/22 at 9:00 AM with BP 112/66 by ADON 10/10/22 at 5:00 PM with BP 143/70 by MA E 10/11/22 at 9:00 AM with BP 100/65 by MA C and 5:00 PM with BP 141/70 by MA E 10/12/22 at 5:00 PM with BP 143/71 by MA E 10/13/22 at 9:00 AM with BP 124/70 by MA B and 5:00 PM with BP 143/70 by MA E 10/14/22 at 5:00 PM with BP 143/70 by MA E 10/15/22 at 9:00 AM with BP 100/69 by MA C and 5:00 PM with BP 127/59 by MA D In an interview on 10/17/22 at 12:31 PM, the DON said prior to medication administration nursing staff must verify the 10 rights first, ensuring administration involved the right person and right drug. Once verified nursing staff must introduce themselves to the patient and check for ordered parameters such as BP and if the patient was within parameters the medication was to be administered. She said if the patient was outside of parameters such as a SBP of 100 and above for Resident #91 the medication was not to be administered and documentation should be completed in the facility EMR. The DON said Midodrine should not be administered outside of parameters because administration could cause the resident's BP to sky rocket placing them at risk for side effects . In an observation and interview on 10/18/22 at 11:50 AM, Resident #91 in bed and receiving oxygen via nasal canula, she appeared well fed, well-groomed in no immediate distress. Resident #91 said she had problems with her BP sometimes and it had gone as high as 190 at which point she experienced headache, chest pain/SOB . She said her blood pressure normally went high prior to hospitalization, which she had a few, from worsening of her CHF (a weakened heart condition that causes fluid buildup in the feet, arms, lungs and other organs) but she felt better ever since she was placed on a renal diet (diet low in sodium, phosphorous and protein) and fluid restriction. Record review of MA C's Medication Administration Observation Report, dated 01/21/22, revealed, 5- For meds with parameters, vital signs are taken prior to administration. Competency met. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676371 If continuation sheet Page 3 of 10 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 676371 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Quail Valley Post-Acute Healthcare 3640 Hampton Dr Missouri City, TX 77459 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)

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of LVN A Medication Pass Worksheet, dated 04/20/22, revealed LVN A passed her medication administration assessment, and medications were administered in accordance with the patient's physician's orders. Record review of MA A's Medication Pass Audit, dated 04/22/22, revealed, 8- Medications are administered in accordance with current physician's orders?- competency met-yes. Record review of MA E's Medication Pass Audit, dated 05/13/22, revealed, 8- Medications are administered in accordance with current physician's orders?- competency met-yes. Record review of MA C's Medication Administration Observation Report, dated 10/15/22, revealed, 5- For meds with parameters, vital signs are taken prior to administration. Competency met. Record review of the facility policy titled Medication Administration revised, 10/01/19, revealed, 2Administration . B- Medications are administered in accordance with written orders of the prescriber . Right Assessment/Response- Medications like blood pressure medications always warrant a quick blood pressure check before giving a blood pressure medication. Nurses must be aware of parameters for administration specific to a medication. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676371 If continuation sheet Page 4 of 10 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 676371 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Quail Valley Post-Acute Healthcare 3640 Hampton Dr Missouri City, TX 77459 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)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interview, and record review, the facility failed to provide pharmaceutical services, which included procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident for 1 of 6 residents (Resident #86) and 2 of 3 medication carts (100-300 Hall Medication Aide Cart and 200-400 Hall Nursing Cart) reviewed for pharmacy services. - The facility failed to discard an expired bottle of Pro-Stat, a protein supplement, located in the 100-300 Hall Medication Aide Cart. - The facility failed to discard an expired bottle of Pro-Stat located in the 100-300 Hall Medication Aide Cart. - The facility failed to discard expired Insulin prescribed for Resident #86 that was located in the 200-400 Hall Nursing Cart. These failures could place residents at risk of not receiving the therapeutic benefit of medications and/or adverse reactions to medications. Findings include: 100-300 Medication Aide Cart In an observation and interview on 10/17/22 at 11:00 AM, inventory of the Medication Aide Cart with MA C revealed: - 10 full and 3 partial loose pills - An open and in use bottle of Pro-Stat, with an open date of 03/2022 with manufacturer's instructions to discard 3 months after opening. MA C said nursing staff were expected to check their carts weekly and while in use for loose pills and expired medications. She said once found loose pills should be discarded and she was not aware the Pro-Stat had a 3 month shelf life. MA C said she always used the expiration date under the bottle. She said once medication expired it could become less effective and if the Pro-Stat was administered to the resident it could cause GI upset. 200-400 Hall Nursing Cart In an observation and interview on 09/12/22 at 09:12 AM, inventory of the 100 Hall Nursing Cart with LVN A revealed: - An open and in use vial of Insulin Aspart for Resident #86 with an open date of 09/07/22 with manufacturer's instructions to discard 28 days (10/5/22) after opening. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676371 If continuation sheet Page 5 of 10 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 676371 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Quail Valley Post-Acute Healthcare 3640 Hampton Dr Missouri City, TX 77459 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)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some - an open and in use bottle of Pro-Stat, with an open date of 03/29/2022 with manufacturer's instructions to discard 3 months after opening. LVN A said nursing staff were expected to check their carts while in use and daily for expired medications and supplements. She said Insulin Aspart expired 28 days after it was opened and the insulin vial for Resident #86 was expired and should had been discarded previously. LVN A said after insulin expired it became less effective and if used it could place residents at risk of uncontrolled blood sugars. LVN A said she did not know Pro-Stat had a shelf life of 3 months and since it was expired it could not be used because it might be less effective and could cause GI upset. She said since both the Insulin and Pro-Stat were expired they could not be used and must be discarded in the drug disposal bin located in the medication storage room. In an interview on 10/17/22 at 11:38, the DON said nursing staff were to check their carts daily for loose pills and expired medications. She said the pharmacist consultant also did monthly cart audits while the chart nurses inspected the carts weekly. The DON said all loose pills should be tossed in the trash with the expectation that all trash cans were covered and inaccessible to residents. The DON said she did not know Pro-Stat expired 3 months after dating and all insulin should be used before their beyond use date because after that date there was a decreased efficacy and if used the insulin could fail to properly regulate a patient's blood sugar. She said expired medications should be discarded in the drug disposal bin located in the medication storage room. The DON said the facility did not have a policy that addressed medication storage. Record review of the manufacturer's Insulin Aspart Injection Highlights of Prescribing Information revised 10/2019, revealed, After vials have been opened: throw away all Insulin Aspart vials after 28 days, even if they still have insulin left in them . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676371 If continuation sheet Page 6 of 10 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 676371 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Quail Valley Post-Acute Healthcare 3640 Hampton Dr Missouri City, TX 77459 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)

F 0759 Ensure medication error rates are not 5 percent or greater. 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 the medication error rate was not five percent (%) or greater. The facility had a medication error rate of 6 percent based on 2 errors out of 33 opportunities, which involved 2 of 7 residents (Resident #33 and Resident #77); and 2 of 4 staff (MA A and MA C) reviewed for medication errors. Residents Affected - Some 1. MA C failed to administer Resident #33's Nasal Spray as ordered by administering 2 sprays in each nostril instead of 1. 2. MA A failed to administer Resident #77 Nifedipine ER (extended release), a medication that should not be crushed, by crushing the medication. These failures could place residents at risk of inadequate therapeutic outcomes, increased negative side effects, and a decline in health. Findings Include: 1. Record review of Resident #33's face sheet, dated 10/17/22, revealed an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included: hypertension, age-related cataract, heart failure and constipation. Record review of Resident #33's Quarterly MDS, dated [DATE], revealed moderately impaired vision with use of corrective lenses, moderately impaired cognition as indicated by a BIMS score of 13 out of 15, extensive assistance with most ADLs and always incontinent of both bladder and bowel. Record review of Resident #33's care plan, revised 09/07/22, revealed no related focus areas, goals or interventions. Record review of Resident #33's Physician's Orders, dated 07/01/21, revealed Systane Eyedrops- 1 drop in both eyes two times a day for dry eyes. Record review of Resident #33's Physician's Orders, dated 07/02/22, revealed Fluticasone 50 mcg/act- 1 spray in both nostrils one time a day for allergies. An observation on 10/17/22 at 07:58 AM revealed, MA C prepared medication for administration for Resident #33. She retrieved the bottle of Systane eye drops and Fluticasone nasal spray put on gloves, entered the resident's room and informed the resident she would be administering her eye drops. After administering 1 drop of Systane in each of Resident #33's eyes she told the resident she would need help to reposition the resident prior to administering the other medications. MA C exited the resident's room and returned with a CNA who helped move the resident up on the bed in order to elevate her head at a 45 angle. After removing her gloves and performing hand hygiene, MA C returned to the resident room while holding the nasal spray bottle with her bare hands, primed the nasal spray by squirting one spray into the air and then inserted the nasal spray into Resident #33's right nostril and administered 2 sprays followed by 2 sprays to the left nostril. MA C exited the resident room, placed the nasal spray back into the box, into her medication cart and then prepared oral medication for administration to Resident #33. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676371 If continuation sheet Page 7 of 10 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 676371 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Quail Valley Post-Acute Healthcare 3640 Hampton Dr Missouri City, TX 77459 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)

F 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 2. Record review of Resident #77's face sheet, dated 10/17/22, revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included: dementia without behavioral disturbance, hemiplegia and hemiparesis (one-sided paralysis), difficulty swallowing and hypertension . Record review of Resident #77's Quarterly MDS, dated [DATE], revealed moderately impaired vision with the use of corrective lenses, moderately impaired cognition as indicated by a BIMS score of 10 out of 15, extensive assistance to total dependence with ADLs, frequently incontinent of bladder and always incontinent of bowel. Record review of Resident #77's Care Plan, dated 08/30/22, revealed Focus- diagnoses of hypertension, is on medication; Goal- free of complications related to hypertension, free from s/sx of hypertension .Interventions- give anti-hypertensive medications as ordered. Record review of Resident #77's Physician's Orders, dated 01/26/22, revealed, may crush medications and/or open capsules PRN as per pharmacy guidelines. Record review of Resident #77's Physician's Orders, dated 02/15/22, revealed Nifedipine ER Extended Release 24 hour 90 mg- give 1 tablet by mouth one time a day for hypertension hold if SBP less than 110, DBP less than 60, HR less than 60. An observation and interview on 10/17/22 at 09:00 AM revealed, MA A prepared oral medication for administration to Resident #77. She retrieved a blister pack of Nifedipine ER 90 mg as well as other oral medications for the resident, the blister back of Nifedipine ER did not have an assessor label (sticker) that stated Do not Crush. MA A crushed Nifedipine ER 90 mg along with other oral formulations, mixed them with pudding and administered the crushed medications to Resident #77 at 09:07 AM. MA said the only medications that should not be crushed were enteric coated medications because crushing them would change their taste. She said extended release formulations could be crushed and administered at the resident's request. In an interview on 10/17/22 at 11:38 AM , the DON said medication should be administered as ordered and MA C said she administered 2 sprays instead of 1 spray into the nostril of Resident #33. She said EC and ER medications should not be crushed because it interrupted their delivery method and administering do not crush medications could result in resident's not receiving the right dose of the medication. Record review of MA A's Medication Pass Audit, dated 04/22/22, revealed, 8- Medications are administered in accordance with current physician's orders?- competency met-yes. 10- Medications are crushed appropriately per pharmacy recommendations or physician orders, competency met-no. Record review of MA C's Medication Administration Observation Report, dated 01/21/22, revealed 6Correct medication verified by visual check of med, label & MAR Record review of the facility policy titled Medication Administration revised 10/01/19 revealed, (1) Preparation .G- Tablet Crushing/Capsule Crushing .a- Long-acting or enteric coated dosage forms should not be crushed; an alternative should be sought .e- For residents able to swallow or having difficulty swallowing, tablets which can be appropriately crushed may be ground coarsely and mixed with the appropriate vehicle such as applesauce so that the resident receives the entire dose ordered. Please consult with product literature or 'Do Not Crush' list which the facility may have or with the pharmacist if there is a question about medications to be crushed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676371 If continuation sheet Page 8 of 10 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 676371 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Quail Valley Post-Acute Healthcare 3640 Hampton Dr Missouri City, TX 77459 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)

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 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 of 5 residents (Resident #33) reviewed for infection control. Residents Affected - Few MA C failed to wear gloves when administering a nasal spray and failed to perform hand washing/sanitization after administering a nasal spray to Resident #33. This failure could place residents at risk for infections. Findings include: Record review of Resident #33's face sheet, dated 10/17/22, revealed an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included: hypertension, age-related cataract, heart failure and constipation . Record review of Resident #33's Quarterly MDS, dated [DATE], revealed moderately impaired vision with use of corrective lenses, moderately impaired cognition as indicated by a BIMS score of 13 out of 15, extensive assistance with most ADLs and always incontinent of both bladder and bowel. Record review of Resident #33's care plan, revised 09/07/22, revealed no related focus areas, goals or interventions. Record review of Resident #33's Physician's Orders, dated 07/01/21, revealed Systane Eyedrops- 1 drop in both eyes two times a day for dry eyes. Record review of Resident #33's Physician's Orders, dated 07/02/22, revealed Fluticasone 50 mcg/act- 1 spray in both nostrils one time a day for allergies. An observation on 10/17/22 at 07:58 AM revealed, MA C prepared medication for administration for Resident #33. She retrieved the bottle of Systane eye drops and Fluticasone nasal spray put on gloves, entered the resident's room and informed the resident she would be administering her eye drops. After administering 1 drop of Systane in each of Resident #33's eyes she told the resident she would need help to reposition the resident prior to administering the other medications. MA C exited the resident's room and returned with a CNA who helped move the resident up on the bed in order to elevate her head at a 45 angle. After removing her gloves and performing hand hygiene, MA C returned to the resident room while holding the nasal spray bottle with her bare hands, primed the nasal spray by squirting one spray into the air and then inserted the nasal spray into Resident #33's right nostril and administered 2 sprays followed by 2 sprays to the left nostril. MA C exited the resident room, placed the nasal spray back into the box, into her medication cart and then prepared oral medication for administration to Resident #33. She did not perform hand hygiene after coming into direct contact with Resident #33 and touching the nasal spray that was inserted into the resident's nostril with her bare hands. In an interview on 10/17/22 at 11:38 AM, the DON said nursing staff were not expected to wear gloves when administering nasal sprays. She said MA C was not required to wash her hands after (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676371 If continuation sheet Page 9 of 10 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 676371 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Quail Valley Post-Acute Healthcare 3640 Hampton Dr Missouri City, TX 77459 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)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few administering the nasal spray to Resident #33 since her hands were not visibly soiled but she was required to at least sanitize her hands using a hand sanitizer following administration of the nasal spray. She said hand hygiene (washing or sanitizing) was required after direct contact with residents and failure to sanitize/wash hands could lead to the potential to spread disease . Record review of MA C's Medication Administration Observation Report, dated 01/21/22, revealed 5- For meds with parameters, vital signs are taken prior to administration. Competency met. 17- Proper hand washing technique at appropriate times, competency met-yes. Record review of the facility policy titled Medication Administration, revised 10/01/19, revealed 1-Preparation .B- Handwashing and Sanitizing- The person administering medications adheres to good hand hygiene, which includes washing hands thoroughly before beginning medication pass, prior to handling any medication, after coming into direct contact with a resident, and before and after administration of ophthalmic, topical, vaginal, rectal and parental preparations and medication given via enteral tubes. Examination gloves are worn when necessary. Hand sanitizing is done with an approved sanitizer between hand washings, when returning to the medication cart or preparation (assuming hands have not touched a resident or potentially contaminated surface) .Medication Administration Guidelines gWash your hands with soap and water or sanitize your hands before giving someone medicine. Record review of the facility policy titled Handwashing- Hand Hygiene, revised January 2018, revealed, Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: . b- Before and after direct contact with residents . I- after contact with a resident's intact skin. Single use disposable gloves should be used: . when anticipating contact with blood and bodily fluids. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676371 If continuation sheet Page 10 of 10