Windsor las Palmas Nursing and Rehabilitation Cent

In the surveyor’s words

From the most serious findings on record at Windsor las Palmas Nursing and Rehabilitation Cent, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF609May 17, 2023

  41770 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. […]

• No harm, potential for more than minimal, patternF761Jul 2, 2021

  Based on observation, interview, and record review, the facility failed to ensure all controlled drugs and biologicals were stored in separately locked, permanently affixed compartments, for one medication room (back medication room) of two medication rooms inspected. The facility failed to ensure stored controlled medications and biologicals were separately locked and in a permanently affixed compartment kept in the Back Medication Room. This failure could place residents and staff at risk for drug diversion or unintended ingestion of controlled medication that could cause significant adverse effects. […]

• No harm, potential for more than minimal, patternF880Jul 2, 2021

  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 two (R #288 and R #291) of three Residents observed for transmission based precautions, in that: 1. Certified Nurse Aide (CNA) A entered Resident #288's room, who was identified as being on droplet transmission based precautions, without wearing the required eye protection/face shield. 2. […]

• No harm, potential for more than minimal, isolatedF644May 7, 2026

  Based on interview and record review, the facility failed to coordinate assessments with the Pre-admission Screening and Resident Review (PASRR) program to the maximum extent practicable to avoid duplicative testing and effort for 1 (Resident #6) of 2 residents reviewed for PASRR. The facility failed to refer Resident #6 for PASRR Level II assessment when the resident was newly diagnosed with a mental illness. This failure could place residents at risk of not having their special needs assessed and met by the facility. Findings include: Record review of Resident #6's face sheet dated 5/07/2026 with an admission date of 2/27/2025, indicated a [AGE] year-old female. […]

• No harm, potential for more than minimal, isolatedF657May 7, 2026

  Based on observation, interview and record review, the facility failed to ensure the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment including both the comprehensive and quarterly review assessments to reflect the current condition for 1 (Resident #32) of 5 residents whose care plans were reviewed for timing and revision.The facility failed to ensure Resident #32's care plan was revised to accurately reflect current precaution status.This deficient practice could place residents at risk of receiving inadequate, individualized care and services. The findings included:During an observation on 05/05/2026 at 10:52 AM, Resident #32's room had a sign for EBP posted on the door. […]