Windsor Quail Valley Post-Acute Healthcare

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to coordinate assessments with the pre-admission screening and resident review program (PASARR) to the maximum extent practicable to avoid duplicative testing and effort for 1 of 1 (Resident #2) reviewed for PASARR. The facility failed to ensure Resident #2 who had a diagnosis of mental illness, received a positive PASARR Level I and PASARR Level II screening. This failure could place residents at risk of not receiving needed care and services, causing a possible decline in mental health. Findings include: Record review of Resident #2's face sheet reflected the resident was a [AGE] year-old male who admitted to the facility on [DATE] and readmitted on [DATE]. The resident's diagnosis included depression (serious mood disorder that causes persistent sadness, and loss of interest in activities), mood disorder due to known physiological condition with mixed features (symptoms of depression and mania or hypomania), memory deficit following…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 3 residents (Residents #21) and 1 of 3 (CMA Q) staff observed during medication administration. The facility failed to ensure staff clarified the order for Resident #21's Miralax prior to administering the medication on 05/13/2026. The failure could place residents at risk of not receiving the intended therapeutic benefit. Findings included: Record review of Resident #21's undated admission record revealed a [AGE] year-old female with an admission date of 05/31/2024. Resident #21 diagnoses included dysphagia (trouble swallowing), gastro-esophageal reflux disease (a chronic digestive condition where stomach acid or bile repeatedly flows back into the food pipe, irritating its lining), muscle wasting, and cerebral infarction (blockage in…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews and record reviews the facility failed to 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 1 (WCN) staff observed for infection control practices. The facility failed to ensure WCN followed proper infection control procedures after she completed a wound care procedure on 05/14/2026. The failure could place residents and staff at risk of infections. Findings included:During an observation on 05/14/2026 at 9:12 a.m., the WCN completed wound care, and while she still had her yellow gown on, and held a trash bag that contained the soiled supplies and dressings. The WCN left the room and went to the treatment cart, she logged in to her computer that was on top of the cart, opened the treatment cart using the cart key, and grabbed a red trash bag (used to dispose trash from isolation rooms) out of the treatment cart and disposed the regular trash bag inside the red trash bag and placed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide pharmaceutical services including procedures to accurately administer medications to meet the needs of each resident 1 (Resident #1) of 6 reviewed for pharmacy services. -RN A instructed CNA B to administer Resident #1's medication Eliquis. This failure placed residents at risk for medication errors. Findings: Record review of Resident #1's face sheet dated 12/02/25 revealed a [AGE] year-old male admitted to the facility on [DATE] and readmitted again on 09/08/25. Resident #1's diagnoses included the following: chronic kidney failure, colostomy (surgical procedure that creates a new way for waste to exit the body into a bag), sepsis (infection), type 2 diabetes mellitus (when the body does not utilize sugar efficiently in the body for energy), abnormalities of gait and mobility, and rhabdomyolysis (condition where damaged muscle tissue breaks down, releasing harmful proteins and electrolytes {tiny particles in the body that carry…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to provide the necessary services to maintain personal care for one of seven residents (Resident #19) reviewed for ADL care in that: -Resident #19 waited over an hour to receive incontinent care. -The call light activator switch was placed out of reach. -During that hour, three staff entered and exited the room without assisting the resident with incontinent care. -One staff turned off the call light and left the room. The deficient practice could cause residents at risk of not receiving the care as needed and place them at higher risk for skin breakdown. Findings included: Record review of the admission Record for Resident #19 revealed he was [AGE] years old and was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, quadriplegia (loss of use of all four extremities), anxiety disorder, and muscle wasting and atrophy. Record review of the MDS assessment dated [DATE] revealed Resident #19 scored 10/15 on the BIMS,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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 resident (Resident #19) of 7 residents reviewed for infeciton control. -Staff provided incontinent care for the resident and did not practice hand hygiene prior to repositioning the resident and arranging the linens. The deficient practice placed the residents at risk for infection. Findings included: Record review of the admission Record for Resident #19 revealed he was [AGE] years old and was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, quadriplegia (loss of use of all four extremities), anxiety disorder, and muscle wasting and atrophy. Record review of the MDS assessment dated [DATE] revealed Resident #19 scored 10/15 on the BIMS, indicative of moderately impaired…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and records reviewed, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promoteds maintenance or enhancement of his or her quality of life, for 1 (Resident #1) of 6 residents reviewed for resident rights. -The facility failed to allow Resident #1 to exercise his right to choose that CNA B not provide him care. This failure could place residents at risk for decreased feelings of self-worth and dignity. The findings included: Record review of Resident #1's admission Record, dated 07/31/2024, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. The resident's diagnoses included bipolar disorder (a mental health condition that causes extreme mood swings between emotional highs and lows), intervertebral disc disorders with myelopathy (injury to the spinal cord caused by severe compression), spinal stenosis (condition in which the spaces in the spine narrow, compressing the spinal cord), muscle…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide the necessary services to maintain grooming and personal care for 1 of 5 residents (Resident #1) reviewed for ADL care. 1. The facility failed to ensure Resident #1 received proper grooming, including hair washing, three times a week (Monday, Wednesday and Friday) as per her bed bath and shower schedule. 2. The facility failed to address Resident#1's refusal to have her hair washed with FM on 3/6/2024. These failures could place Residents at risk for skin breakdown, infection, and loss of self-esteem. Findings Included: Record review of the undated Face Sheet for Resident#1 revealed, a [AGE] year-old female who was admitted to the facility on [DATE] and re-admitted to the facility on [DATE] with diagnoses of apraxia (a motor speech disorder that makes it hard to speak), hemiplegia (paralysis on one side of the body), Cerebrovascular Disease (a group of conditions that affect the blood vessels of the brain, usually caused by having…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Tag:842 S/S= D Surveyor Name(s): [NAME] Immediate Supervisor: [NAME] Based on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 1 of 5 Residents (CR#1) reviewed for clinical records accuracy, there was only one progress note Record Review of the Progress Notes for CR#1: There was only one progress note entered since 1/3/2024; then, on 2/21/2024 at 16:17 (4:17pm), there was a note which was titled Admin Note and stated the Administrator notified FM of the HHSC investigation on 2/21/2024 with allegations of abuse. The facility failed to maintain an accurate record by indicating CR #1's unexplained or unknown eye injury, what medical staff did after observing the injury, who they called and the type of assessment completed. This deficient practice could affect residents whose records are maintained by the facility and could place resident(s) at risk for errors in care and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review the facility did not provide, in writing, a bed-hold notice upon transfer at the time of transfer of a resident to a hospital or for therapeutic leave, for 1 of 3 residents (CR#1) reviewed for transfers and discharge. -The facility failed to provide bed-hold notifications to CR#1 when she was transferred to the hospital. This failure could place residents at risk for not receiving notice of the facility's bed hold policy before being transferred. Findings included: Record review of CR#1's Face Sheet (undated) revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included: spinal stenosis (a narrowing of the spinal canal), pneumonia (infection that inflames air sacs in one or both lungs, which may fill with fluid) and hypokalemia (a blood level that is below normal in potassium). CR#1 was transferred to an acute care hospital on [DATE]. Record review of CR#1's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 15 out of 15…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.