Health inspection·June 9, 2023

F 0656 A record review of Resident #44's Physician orders dated [DATE] documented CPR. Level of Harm - Minimal harm or potential for actual harm A record review of Resident #44's Out of Hospital DNR dated [DATE] documented an Out of Hospital DNR, signed by Resident #44. Residents Affected - Few A record review of Resident #44's Physician orders dated [DATE] documented DNR. A record review of Resident #54's face sheet dated [DATE] documented an [AGE] year-old female with diagnoses that included COPD, Alzheimer's, Chronic kidney disease, Diabetes, high blood pressure, depression, glaucoma, and malnutrition. Resident #54's code status was DNR. A record review of Resident #54's MDS assessment dated [DATE] documented a BIMS score of 10, which indicated moderate cognitive impairment. A record review of Resident #54's care plan dated [DATE] revealed a Problem that documented, I, Resident #54, choose to have CPR; date initiated: [DATE], revision date: [DATE]; next revision date: [DATE]. The Goal documented, Resident #54, will have all wishes and advanced directives honored until requested otherwise, or until the next review period; Date Initiated: [DATE] Revision on [DATE] Target Date: [DATE]. The Interventions documented, Please provide CPR. Date Initiated: [DATE]. The same care plan also revealed a Problem that documented, Resident #54 is a full code; Date initiated: [DATE] and revised on [DATE]. The Goal documented Facility will comply with resident #54, and/or family wishes and chosen advanced directive initiated on [DATE] and revised on [DATE], and a target date of [DATE]. The Intervention documented If the resident has a cardiac arrest, initiate CPR and call 911. Notify MD/RP and follow MD orders after notification date initiated [DATE]. Keep crash cart well supplied and ready for use at all times date initiated [DATE], and Mark chart and all pertinent documents with FULL CODE date initiated [DATE]. A record review of Resident #54's Physician orders dated [DATE] documented DNR (Do Not Resuscitate) Observation of the Code Status binder on the crash cart revealed Resident #54's face sheet had FULL CODE written across it. An interview with RN-B on [DATE] at 01:06 PM revealed she knew the resident's code status by what was in the binder on the crash cart. RN-B stated the SW (part-time) updated the binder. RN-B stated she was not sure what the days were-she saw the SW on the weekends sometimes. RN-B stated a resident's code status would come up on their electronic charting system in the misc. tab. RN-B stated Resident #54 was DNR because it said in the electronic charting system, in Misc. When asked what she would go by if there were an emergency, RN-B stated, The code status binder. She was asked to look at Resident #54's code status in the code status binder on the crash cart. RN-B stated, Oh my goodness! when she saw the code status binder with Full code written on Resident #54's face sheet. RN-B stated, when the SW was not here, the nurses were responsible for updating the code status book. She stated the SW put the full code status in the book 6 months ago. Interview with Charge Nurse, LVN-A on [DATE] at 03:17 PM stated he would look at the resident's profile in the computer to know the code status. LVN-A stated if he could not find the code status on the profile, then he would look at the miscellaneous tab to check the most updated code status. LVN-A stated he did not know where to look for the most updated code status. LVN-A stated the SW would know the code status, but she was not working here anymore. LVN-A stated he would look at the admission date on the profile, but that did not tell him when the order was written. LVN-A was prompted by (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455662 If continuation sheet Page 2 of 6 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 455662 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Nursing and Rehabilitation Center of McAll 900 S 12th St McAllen, TX 78501 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few LVN-B, to look in the orders for the CPR and DNR orders. Both LVN-A and LVN-B stated they did not have a code status binder on the crash cart. LVN-A stated the families would know the code status. After a very long pause, both LVN-A and LVN-B stated the nurses were responsible for knowing the resident's code status. LVN-A stated he only knew a resident's code status by looking it up-he did not make it a practice as a charge nurse, to know the code status of the residents he oversaw. LVN-A stated, If there were an emergency with a power outage and no generator, he would call IT for the code status. When asked how much time it would take for IT to tell him the code status of a resident, LVN-A stated, They would start CPR, and had nothing to say when asked what if the resident was DNR. LVN-A stated that ADON was responsible for updating the profiles of the residents with the correct code status. Interview on [DATE] at 02:00 PM with the MDS Coordinator/Care Management Specialist. MDS Coordinator stated, The reason Resident #44's care plan was not updated was that she did not get a chance to update Resident #44's care plan. MDS Coordinator stated, It was important to update care plans so the residents have appropriate individualized care, and if care plans were not updated, care for the residents may not be provided appropriately as prescribed. MDS Coordinator stated, DON only helps update acute care plans for residents and she is the primary individual that had the responsibility to update resident care plans on a regular basis. MDS Coordinator stated she had been working for the facility since November of 2022 and had prior MDS Coordinator experience and understood the importance of making sure resident care plans were updated promptly and as needed. MDS Coordinator stated she did her own audit on care plans but had only done one self-audit while being employed with this facility. An interview with the DON on [DATE] at 01:10 PM verified the code status page was printed on [DATE]. The DON stated the SW was responsible for updating the binder and at the time, the SW was full-time but left, and now the facility had a part-time SW that came in after 5 pm most days, Monday -Friday unless she had personal issues, and she was there for 2-3 hours at a time, and occasionally Saturdays or Sundays. The DON stated, I guess the charge nurses were responsible for updating the binder when the SW was not there and for new admissions. The DON verified Resident #54's code status was initiated on [DATE] on the computer. The DON stated, It was about 7 weeks ago-the nurses always check the computer-it was always correct because it was a doctor's order. The DON stated, The binder was not updated, and the care plan was not updated, and the binder was there in the event power went out, it was good to have a backup. The DON stated, The danger in having inaccurate code status in the book was that someone could potentially initiate CPR when the resident was DNR. The SW was unavailable for an interview or phone interview throughout the duration of the survey. Review of Care Plan Revision Upon Status Change Policy dated [DATE] documents, The purpose of this procedure is to provide a consistent process for reviewing and revising the care plan for those residents experiencing a status change. Policy Explanation and Compliance Guidelines: 1. Comprehensive care plan will be reviewed and revised as necessary when a resident experiences a status change. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455662 If continuation sheet Page 3 of 6 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 455662 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Nursing and Rehabilitation Center of McAll 900 S 12th St McAllen, TX 78501 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 0656 2. Procedure for reviewing and revising the care plan when a resident experiences a status change: Level of Harm - Minimal harm or potential for actual harm a. Upon identification of a change in status, the nurse will notify the MDS Coordinator, the physician, and the resident representative, if applicable. Residents Affected - Few b. The MDS Coordinator and the Interdisciplinary Team will discuss the resident condition and collaborate on intervention options. c. The team meeting discussion will be documented in the nursing progress notes. d. The care plan will be updated with the new or modified interventions. e Staff involved in the care of the resident will report the resident's response to new or modified interventions. f. Care plans will be modified as needed by the MDS Coordinator or other designated staff member. g. The unit manager or other designated staff member will communicate care plan interventions to all staff involved in the resident's care. h. The unit manager or other designated staff member will conduct an audit on all residents experiencing a change in status, at the time the change in status is identified, to ensure care plans have been updated to reflect current resident needs. 3. The MDS Coordinator will determine whether a Significant Change in Status Assessment is warranted. If so, the assessment will be completed according to established procedures. Record review of the admission record dated [DATE] for Resident #39 revealed Resident #39 was admitted to the facility on [DATE] and was a [AGE] year-old female. Resident #39's diagnosis included Congestive Heart Failure (when the heart muscles doesn't pump blood as well as it should), Atrial Fibrillation (abnormal heart rhythm, rapid and irregular beating of the atrial chambers), Heart failure (a disease that affects pumping action of the heart muscles), Nonrheumatic Mitral (VALVE) Insufficiency (type of heart valve disease ), anxiety disorder, Hypothyroidism (when the thyroid gland does not make enough thyroid hormones to me the body's needs?. Record review of Resident # 39's physician orders dated [DATE] indicated an order for Eliquis Oral Tablet (anticoagulant medication) give 5mg by mouth two times a day for AFIB (atrial fibrillation, abnormal heart rhythm, rapid and irregular beating of the atrial chambers). Record review of Resident # 39's quarterly MDS assessment dated [DATE] indicated Resident #39 was cognitively impaired, required limited assistance with dressing, and extensive assistance with personal hygiene and indicated the use of Anticoagulants. Record review of Resident #39's care plans dated [DATE], indicated no care plan for the anticoagulant medication, Eliquis. Interview on [DATE] 11:23 AM with Resident #39 stated, she was content with the care she was receiving, the staff are pleasant and attentive. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455662 If continuation sheet Page 4 of 6 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 455662 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Nursing and Rehabilitation Center of McAll 900 S 12th St McAllen, TX 78501 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 0656 Level of Harm - Minimal harm or potential for actual harm Interview on [DATE] at 11:21 AM with RN A stated, Resident #39 had orders for Eliquis used for AFIB. Resident #39 started the medication on [DATE]. The Eliquis should be care planned by MDS Coordinator or DON because there is a possibility of throwing out blood clots (gel-like collections of blood that forms in veins or artieries when blood changes from liquid to partially solid). Resident #39 could have a stroke if she is not taking the Eliquis. AFIB is when the heart kind of quivers. Residents Affected - Few Interview on [DATE] at 11:30 AM with Resident #39 stated, she takes the medication (Eliquis), and was a small pill the nurse gives to her. Interview with DON on [DATE] 11:36 AM. DON stated, anticoagulants were supposed to be care planned for all residents receiving anticoagulant medications. Anticoagulants are care planned for the risk of side effects so adverse reactions can be monitored by care staff. DON stated, the facility must follow the plan of care to give adequate care for each resident. DON stated, on the MARs (Medication Administration Record) the electronic system nurses use, has a monitoring alert for anticoagulant side effects in the orders and prompts the nurses to look for side effects such as bleeding and bruising. DON stated the IDT (Inter Disciplinary Team) that consists of, Social Services, Activities Director, Dietary, MDS Coordinator, and DON, are responsible for reporting resident changes that could warrant the care plan needing to be updated. DON stated, MDS Coordinator and herself (DON) oversees resident care plans and makes sure they are up to date with the current information for each resident. Interview on [DATE] 02:00 PM with MDS Coordinator/Care Management Specialist. MDS Coordinator stated, the reason Resident # 39's scare plan was not updated was because she did not get a chance to update Resident # 39's care plan. MDS Coordinator stated, it is important to update care plans so the residents have appropriate individualized care, and if care plans are not updated, care for the resident may not be provided appropriately as prescribed. MDS Coordinator stated, DON only helps update acute care plans for residents and she is the primary individual that has the responsibility to update resident care plans on a regular basis. MDS Coordinator stated, she has been working for the facility since November of 2022 and has prior MDS Coordinator experience and understands the importance of making sure resident care plans are updated promptly and as needed. MDS Coordinator stated, Resident # 39 's care plan has been updated as of now. MDS coordinator stated, she does her own audit on care plans but, has only done oneself audit while being employed with this facility. According to [NAME] (lww.com), Eliquis side effects could be, bruising, hemorrhaging, anemia (low blood cell count), low blood pressure, thrombocytopenia (low platelet count). Review of Care Plan Revision Upon Status Change Policy dated [DATE] states, The purpose of this procedure is to provide a consistent process for reviewing and revising the care plan for those residents experiencing a status change. Policy Explanation and Compliance Guidelines: 1. Comprehensive care plan will be reviewed, and revised as necessary, when a resident experiences a status change. 2. Procedure for reviewing and revising the care plan when a resident experiences a status change: a. Upon identification of change in status, the nurse will notify the MDS Coordinator, the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455662 If continuation sheet Page 5 of 6 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 455662 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Nursing and Rehabilitation Center of McAll 900 S 12th St McAllen, TX 78501 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 0656 physician, and the resident representative, if applicable. Level of Harm - Minimal harm or potential for actual harm b. The MDS Coordinator and the Interdisciplinary Team will discuss the resident condition and collaborate on intervention options. Residents Affected - Few c. The team meeting discussion will be documented in the nursing progress notes. d. The care plan will be updated with the new or modified interventions. e Staff involved in the care of the resident will report resident response to new or modified interventions. f. Care plans will be modified as needed by the MDS Coordinator or other designated staff member. g. The unit manager or other designated staff member will communicate care plan interventions to all staff involved in the resident's care. h. The unit manager or other designated staff member will conduct an audit on all residents experiencing a change in status, at the time the change in status is identified, to ensure care plans have been updated to reflect current resident needs. 3. The MDS Coordinator will determine whether a Significant Change in Status Assessment is warranted. If so, the assessment will be completed according to established procedures. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455662 If continuation sheet Page 6 of 6