Windsor Quail Valley Post-Acute Healthcare

In the surveyor’s words

From the most serious findings on record at Windsor Quail Valley Post-Acute Healthcare, in the surveyor’s own words.

• Immediate jeopardy, isolatedF686Jul 19, 2024

  Based on observations, interviews, and record review the facility failed to ensure residents received care, consistent with professional standards of practice to identify, prevent pressure ulcers from developing and promote healing for 1 (Resident CR# 1) of 9 residents reviewed for pressure ulcers. The facility failed to prevent, identify, and treat pressure sores on Resident CR#1's right buttock and right hip. CR #1 was sent to the hospital after family intervention, and there it was determined she had an unstageable wound to her buttocks and a stage 3 wound to her hip. The noncompliance was identified as Past Non-Compliant. The IJ began on 07/13/2024 and ended on 07/16/2024. […]

• Immediate jeopardy, isolatedF600Feb 29, 2024

  Abbreviations: ADMIN - Administrator ADON-Assistant Director of Nursing AS-Agency Staff BIMS-Brief Interview for Mental Status MA- Medical Aides CNA-Certified Nursing Assistant CR-Closed Record CW-Confidential Witness DON - Director of Nursing DORC - Director of Resident Care ED - Executive Director ERN - emergency room Nurse EMS-Emergency Medical Services EMT-Emergency Medical Technician FM-Family Member HHSC-Health and Human Services Commission IJ-Immediate Jeopardy IT-Immediate Threat LE-Law Enforcement LVN-Licensed Vocational Nurse PD- Police Dept MD-Medical Doctor MT - Resident Med Tech NP- Nurse Practitioner R-Resident RA-Resident Assistant RN-Registered Nurse RP-Responsible Party Based on observations, interviews, and record review, the facility failed to ensure residents were… […]

• Immediate jeopardy, isolatedF607Feb 29, 2024

  Based on Interview, and record review, the facility failed to implement abuse and neglect policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents for 1 (CR#1) of 5 residents reviewed for abuse by not implementing their abuse policy to prohibit and prevent abuse by conducting an investigation immediately; thus, failing to protect resident when there is a warranted suspicion of abuse and identifying staff responsible for the investigation. The facility failed to ensure each resident was free from abuse when CR#1 was physically abused by CNA C on 2/20/2024 around 6:30am, which was the time CNA A started her morning shift and observed the bruising to CR#1's face. […]

• Immediate jeopardy, isolatedF610Feb 29, 2024

  Based on observation, interview, and record review, the facility failed to have evidence that all alleged violations of abuse were thoroughly investigated, to prevent further potential abuse or mistreatment while the investigation was in progress, and report the result of all investigations to other officials in accordance with State law, including to the State Survey Agency within 5 working days of the incident for 1 of 5 residents (CR #1) reviewed for abuse. The facility failed to complete the investigation of the allegation of abuse, report the results of the investigation to HHSC within 5 days, and prevent further potential abuse while the investigation was in progress when CR #1 was found with suspicious injuries of unknown origin. […]

• No harm, potential for more than minimal, widespreadF563Feb 24, 2022

  Based on interview and record review the facility failed to ensure residents had the right to receive visitors of his or her choosing, subject to the resident's right to deny visitation when applicable, and in a manner that did not impose on the rights of another resident for 96 of 96 residents reviewed for resident rights. The facility failed to ensure all residents had the right to unrestricted visitation hours inside the facility. This failure could place residents at risk for isolation, decreased emotional well-being and a diminished quality of life. Findings include: Resident #1 Record review Resident #1, undated, face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . […]