Health inspection·March 1, 2024

F 0690 indwelling urinary catheter. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #1's progress note dated 12/29/24 and written by LVN E which stated Resident #1 arrived from the hospital to facility on 12/29/24 at 8:15pm with a 16 French foley catheter for urine retention. Residents Affected - Few Record review of Resident #1's progress note dated 01/04/24 written by LVN A stated Resident #1 was having bloody urine in foley and was attempting to pull out foley. Nurse practitioner gave order to discontinue the foley and get a urine analysis. Record review of Resident #1's physician orders dated 03/01/24 revealed no orders for indwelling catheter and no order with specifications of sizing of tubing needed for catheter. Record review of Resident #1's note dated 01/06/24 completed by LVN B stated he inserted a 14 French indwelling catheter that showed positive urine flow dark amber in color with signs of pain. During an interview with LVN A on 03/01/24 at 1:35pm she stated Resident #1 had an indwelling catheter in place when he was readmitted from the hospital a little before January 2024 LVN A stated catheter care was being provided to Resident #1, she stated the aides were able to empty the canister where the urine was and would let them [the nurses] know how much urine output there was. LVN A stated the nurses would check for any sediments or signs/symptoms of a urinary tract infection (infection in urinary system that can involve your urethra, bladder kidneys or urine) and for any signs of crusty on the penis. LVN A stated catheter care was provided once per shift or as needed, LVN A stated she knew the frequency of catheter care because of past experiences and asking other nurses or the ADON questions such as where to put documentation of how much Resident #1 voided and sated she would write it in the progress notes. LVN A stated she provided Resident #1 with regular irrigation flushes once per shift to his catheter. LVN A stated she knew the frequency on flushes because it would show on their documentation and would show foley care each shift and irrigation each shift and stated she would click yes or no and document on daily tasks. LVN A she did not insert a catheter to Resident #1 but did remove it one time to attempt bladder training and to see if he was urinating regularly, LVN A stated she documented every shift when checking for urination. LVN A stated a night shift nurse did an in and out catheter and Resident #1 had 50 milliliters output. LVN A showed Surveyor F a text between her and Resident #1's attending physician from 01/06/24 which stated Resident #1 had not been urinating at night and had 50milliliters of [urine] output with an in and out catheter. Resident #1's attending physician responded, insert foley please. LVN A stated she gave report to on coming nurse about inserting a foley but did not input order because they provide 24-hour care and stated the oncoming nurse could have put in the order if they were already there. LVN A stated she did not know why there weren't any catheter orders aside from catheter care in place, she stated she thought they were in place and stated who ever admitted the resident or ADON/DON were responsible for inputting those orders. LVN A stated orders had to be in place before providing residents with services and care such as inserting, flushing and using an indwelling catheter. LVN A stated she has been told by the ADON and DON when she gets a new order but has not had an Inservice over following physician orders and stated she had not had any training over catheters at the facility. LVN A stated the ADON and DON ensured the appropriate orders were put in whenever they give report in reports in the morning and stated ADON/DON will ask if orders had been put in for certain things. LVN A stated in this case no one asked her about the foley. LVN A stated if the oncoming nurse she gave report to forgot to put foley and she did not document the resident may not get a foley and would not receive the proper care. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455662 If continuation sheet Page 2 of 12 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 03/01/2024 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview with LVN B on 03/01/24 at 6:09pm he stated he had been trained over following physician orders during his orientation in December 2023. LVN B stated he had not received training over catheters. LVN B stated Resident #1 had an indwelling catheter in place that he returned with from hospital. LVN B stated it was around January when Resident #1 returned with catheter in place. LVN B stated catheter care was completed every shift and he knew the frequency because it was on the skilled MAR. LVN B stated he provided irrigation flushes for Resident #1's catheter but did not recall how often. LVN B stated he had to insert the catheter to Resident #1. LVN B stated he inserted catheter because he had either got report from previous nurse about Resident #1's attending physician ordering it to be placed or from the attending physician himself but could not recall which. LVN B stated he knew the size of tubing and balloon needed because the orders stated it, LVN B then said no one told him what size of tubing was needed and stated he retrieved and used the catheter tubing that was in the storage. LVN B could not recall the previous tubing that was being used or the tubing he used. LVN B stated orders had to be in place before providing residents with services and care such as inserting, flushing and using an indwelling catheter. When asked why there were not any catheter orders other than catheter care in place he stated he did previously did not know that orders had to be in place to insert a catheter. LVN B stated he was responsible for inputting orders related to Resident #1's catheter. LVN B stated the DON completes monitoring to ensure the appropriate orders were put in. LVN B stated not having the appropriate orders and instructions in place could affect the resident because the resident could have a decline in health. During an interview 03/01/24 at 6:26pm with LVN E she stated Resident #1 returned from the hospital around 12/29/23 and had an indwelling catheter in place. LVN E stated orders were on the resident transfer forms, LVN E stated she input the order for catheter care every shift but not for irrigation. LVN E stated she knew the tubing and balloon size of the catheter because she got report over the phone from the hospital and from the transfer form orders. LVN E stated she had not inserted the catheter to Resident #1 and stated orders had to be in place before providing residents with services and care such as inserting, flushing and using an indwelling catheter. When asked why there were not any catheter orders other than catheter care in place she stated she had thought she put them in. LVN E stated, the nurse was responsible for inputting the orders. LVN E stated she was trained by the ADON around December 2023 over catheters at the facility but had not received any training at the facility regarding inputting or following physician orders. LVN E stated the ADON and DON completed monitoring to ensure the appropriate order have been input. LVN E stated not having the appropriate orders and instructions in place could affect the resident by not getting the proper care. During an interview on 03/01/24 at 7:43pm with the DON she stated, her and the facility staff had been trained over following physician orders and inputting new orders with the last training completed in February 2024. The DON stated facility staff had been trained over catheters with the last training completed in January 2024. The DON stated her and the ADON had provided these trainings. The DON stated Resident #1 had a indwelling catheter in place and stated he had returned with it in place when he readmitted from the hospital on [DATE]. The DON stated catheter care was provided each shift and stated they had orders in place for catheter care. The DON stated although there was no documentation, the staff was completing irrigation flushes and monitoring urine output [for Resident #1] and stated she knew this because she would ask about these areas on their 24 hour repot. The DON stated staff was aware to complete catheter every shift, to monitor urine output, empty drainage bag, use a privacy bag, keep the drainage bag off the floor because they had mentioned it during their in-services. The DON stated in order to know what size tubing and balloon to use for a catheter you would need a doctor to tell you what to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455662 If continuation sheet Page 3 of 12 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 03/01/2024 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few put and what size. The DON stated she was aware that LVN A had removed the foley to start bladder training. The DON stated she could not answer for LVN B but restated an order would be needed to know what to input. The DON stated orders had to be in place before providing residents with services and care such as inserting, flushing and using an indwelling catheter. When asked why there were not any catheter orders other than catheter care in place the DON stated she did not know and could not answer. The DON stated the admitting nurse was responsible for inputting the orders. The DON stated the ADON and herself discuss orders and the 24 hour reports during their morning meetings to ensure the appropriate orders have been input. The DON stated not having the appropriate orders and instructions in place could affect the resident's care. The DON stated they did not have a specific policy for physician orders. The Administrator stated on 03/01/24 at 8:02pm that they did not have a specific policy for physician orders. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455662 If continuation sheet Page 4 of 12 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 03/01/2024 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to providecare included but was not limited to assessing, evaluating, planning and implementing resident care plans and responding to resident's needs for 1 of 7 residents (Resident #1) reviewed for incontinent care and catheter care, in that: The facility LVN A failed to document orders for the removal (01/04/24) and insertion (01/06/24) of R#1's indwelling urinary catheter. LVN B did not obtain catheter size before inserting R#1's indwelling urinary catheter. This deficient practice could place residents at-risk for infection due to improper care practices, injury, leakage and decreased quality of life. The findings included: Record review of Resident #1's face sheet, dated 03/01/24, revealed the resident was a [AGE] year-old male who was admitted to the facility on [DATE] and discharged on 01/28/24 with diagnoses that included: sepsis, unspecified organism (potentially life threatening condition that arises when the body's response to infection causes injury to its own tissues and organs) pneumonia, unspecified organism (an infection of the air sacs in one or both lungs), age-related physical debility (a condition of decreased physiological reserves due to aging), unspecified dementia (decline in a cognition abilities that impacts a person's ability to perform every day activities, can involve memory, thinking, behavior), unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Record review of Resident #1's Medicare 5-day minimum data sheet assessment, dated 01/25/24, revealed Resident #1 did not have a BIMS completed due to the resident rarely/ never understood. Record review of patient transfer form dated 12/29/23 from the hospital stated Resident #1 had a 16 [French] foley placed: 12/29/23 [related to] retention. Record review of Resident #1's orders, reviewed on 03/01/24, revealed an order for foley catheter care every shift for urine retention with a start date of 12/29/24 and an end date of 01/31/24. Record review of Resident #1's care plan, reviewed on 03/01/24, revealed no care plan regarding an indwelling urinary catheter. Record review of Resident #1's progress note dated 12/29/24 and written by LVN E which stated Resident #1 arrived from the hospital to facility on 12/29/24 at 8:15pm with a 16 French foley catheter for urine retention. Record review of Resident #1's progress note dated 01/04/24 written by LVN A stated Resident #1 was having bloody urine in foley and was attempting to pull out foley. Nurse practitioner gave order to discontinue the foley and get a urine analysis. Record review of Resident #1's physician orders dated 03/01/24 revealed no orders for indwelling catheter and no order with specifications of sizing of tubing needed for catheter. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455662 If continuation sheet Page 5 of 12 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 03/01/2024 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of Resident #1's note dated 01/06/24 completed by LVN B stated he inserted a 14 French indwelling catheter that showed positive urine flow dark amber in color with signs of pain. During an interview with LVN A on 03/01/24 at 1:35pm she stated Resident #1 had an indwelling catheter in place when he was readmitted from the hospital a little before January 2024 LVN A stated catheter care was being provided to Resident #1, she stated the aides were able to empty the canister where the urine was and would let them [the nurses] know how much urine output there was. LVN A stated the nurses would check for any sediments or signs/symptoms of a urinary tract infection (infection in urinary system that can involve your urethra, bladder kidneys or urine) and for any signs of crusty on the penis. LVN A stated catheter care was provided once per shift or as needed, LVN A stated she knew the frequency of catheter care because of past experiences and asking other nurses or the ADON questions such as where to put documentation of how much Resident #1 voided and sated she would write it in the progress notes. LVN A stated she provided Resident #1 with regular irrigation flushes once per shift to his catheter. LVN A stated she knew the frequency on flushes because it would show on their documentation and would show foley care each shift and irrigation each shift and stated she would click yes or no and document on daily tasks. LVN A she did not insert a catheter to Resident #1 but did remove it one time to attempt bladder training and to see if he was urinating regularly, LVN A stated she documented every shift when checking for urination. LVN A stated a night shift nurse did an in and out catheter and Resident #1 had 50 milliliters output. LVN A showed Surveyor F a text between her and Resident #1's attending physician from 01/06/24 which stated Resident #1 had not been urinating at night and had 50milliliters of [urine] output with an in and out catheter. Resident #1's attending physician responded, insert foley please. LVN A stated she gave report to on coming nurse about inserting a foley but did not input order because they provide 24-hour care and stated the oncoming nurse could have put in the order if they were already there. LVN A stated she did not know why there weren't any catheter orders aside from catheter care in place, she stated she thought they were in place and stated who ever admitted the resident or ADON/DON were responsible for inputting those orders. LVN A stated orders had to be in place before providing residents with services and care such as inserting, flushing and using an indwelling catheter. LVN A stated she has been told by the ADON and DON when she gets a new order but has not had an Inservice over following physician orders and stated she had not had any training over catheters at the facility. LVN A stated the ADON and DON ensured the appropriate orders were put in whenever they give report in reports in the morning and stated ADON/DON will ask if orders had been put in for certain things. LVN A stated in this case no one asked her about the foley. LVN A stated if the oncoming nurse she gave report to forgot to put foley and she did not document the resident may not get a foley and would not receive the proper care. During an interview with LVN B on 03/01/24 at 6:09pm he stated he had been trained over following physician orders during his orientation in December 2023. LVN B stated he had not received training over catheters. LVN B stated Resident #1 had an indwelling catheter in place that he returned with from hospital. LVN B stated it was around January when Resident #1 returned with catheter in place. LVN B stated catheter care was completed every shift and he knew the frequency because it was on the skilled MAR. LVN B stated he provided irrigation flushes for Resident #1's catheter but did not recall how often. LVN B stated he had to insert the catheter to Resident #1. LVN B stated he inserted catheter because he had either got report from previous nurse about Resident #1's attending physician ordering it to be placed or from the attending physician himself but could not recall which. LVN B stated he knew the size of tubing and balloon needed because the orders stated it, LVN B then said no one told him what size of tubing was needed and stated he retrieved and used the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455662 If continuation sheet Page 6 of 12 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 03/01/2024 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few catheter tubing that was in the storage. LVN B could not recall the previous tubing that was being used or the tubing he used. LVN B stated orders had to be in place before providing residents with services and care such as inserting, flushing and using an indwelling catheter. When asked why there were not any catheter orders other than catheter care in place he stated he did previously did not know that orders had to be in place to insert a catheter. LVN B stated he was responsible for inputting orders related to Resident #1's catheter. LVN B stated the DON completes monitoring to ensure the appropriate orders were put in. LVN B stated not having the appropriate orders and instructions in place could affect the resident because the resident could have a decline in health. During an interview 03/01/24 at 6:26pm with LVN E she stated Resident #1 returned from the hospital around 12/29/23 and had an indwelling catheter in place. LVN E stated orders were on the resident transfer forms, LVN E stated she input the order for catheter care every shift but not for irrigation. LVN E stated she knew the tubing and balloon size of the catheter because she got report over the phone from the hospital and from the transfer form orders. LVN E stated she had not inserted the catheter to Resident #1 and stated orders had to be in place before providing residents with services and care such as inserting, flushing and using an indwelling catheter. When asked why there were not any catheter orders other than catheter care in place she stated she had thought she put them in. LVN E stated, the nurse was responsible for inputting the orders. LVN E stated she was trained by the ADON around December 2023 over catheters at the facility but had not received any training at the facility regarding inputting or following physician orders. LVN E stated the ADON and DON completed monitoring to ensure the appropriate order have been input. LVN E stated not having the appropriate orders and instructions in place could affect the resident by not getting the proper care. During an interview on 03/01/24 at 7:43pm with the DON she stated, her and the facility staff had been trained over following physician orders and inputting new orders with the last training completed in February 2024. The DON stated facility staff had been trained over catheters with the last training completed in January 2024. The DON stated her and the ADON had provided these trainings. The DON stated Resident #1 had a indwelling catheter in place and stated he had returned with it in place when he readmitted from the hospital on [DATE]. The DON stated catheter care was provided each shift and stated they had orders in place for catheter care. The DON stated although there was no documentation, the staff was completing irrigation flushes and monitoring urine output [for Resident #1] and stated she knew this because she would ask about these areas on their 24 hour repot. The DON stated staff was aware to complete catheter every shift, to monitor urine output, empty drainage bag, use a privacy bag, keep the drainage bag off the floor because they had mentioned it during their in-services. The DON stated in order to know what size tubing and balloon to use for a catheter you would need a doctor to tell you what to put and what size. The DON stated she was aware that LVN A had removed the foley to start bladder training. The DON stated she could not answer for LVN B but restated an order would be needed to know what to input. The DON stated orders had to be in place before providing residents with services and care such as inserting, flushing and using an indwelling catheter. When asked why there were not any catheter orders other than catheter care in place the DON stated she did not know and could not answer. The DON stated the admitting nurse was responsible for inputting the orders. The DON stated the ADON and herself discuss orders and the 24 hour reports during their morning meetings to ensure the appropriate orders have been input. The DON stated not having the appropriate orders and instructions in place could affect the resident's care. The DON stated they did not have a specific policy for physician orders. The Administrator stated on 03/01/24 at 8:02pm that they did not have a specific policy for physician orders. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455662 If continuation sheet Page 7 of 12 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 03/01/2024 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 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 3 of 7 Residents (Resident #3, Resident #4 and Resident #6) reviewed for medical records accuracy, in that: 1.Resident #3's October 2023 Medication Administration Record documentation record was incomplete as it did not include dates for physician ordered Haloperidol (medication for mental/mood disorders) was given. 2.Resident #4's February 2024 Medication Administration documentation was incomplete for physician orders related to his indwelling (left within a bodily organ) suprapubic (area above pubic bone) catheter (a tube inserted into bladder to drain urine). Staff did not document catheter care, irrigation, and urine output on each shift 5 times in February 2024 3. Resident #6's February 2024 Medication Administration Record documentation was incomplete for physician orders related to enteral feedings (peg tube feedings). This deficient practice could affect residents whose records are maintained by the facility and could place them at risk for errors in care, and treatment. The findings included: 1.Record review of Resident #3's face sheet, dated 03/01/24, revealed the resident was a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses that included: Alzheimer's disease (brain disorder that causes problems with memory, language, problem solving, behavior and thinking) with late onset (develops after age [AGE]), hypertension ( Blood pressure that is higher than normal), unspecified dementia (decline in cognitive abilities that impacts a person's ability to perform everyday tasks), unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, mixed hyperlipidemia ( Too many fats such as cholesterol and triglycerides in blood), and other amnesia (memory loss caused by brain damage or brain diseases, may be temporary due to various drugs). Record review of Resident #3's admission Minimum Data Set assessment, dated 09/15/23, revealed Resident #3 had a BIMS score of 3, indicating she had severe cognitive impairment. Record review of Resident #3's care plan, retrieved on 03/01/24, revealed Resident #3 had a problem of, Resident #3 is physically aggressive at times due to dementia with behaviors, delusion with an initiation date of 09/29/23 and an intervention of administer medications as ordered with an initiation date of 10/15/23. Record review of Resident #3's physician's orders, retrieved on 03/01/24, revealed an order for Haloperidol Lactate (medication used to treat certain mental/mood disorders) Injection Solution with direction to inject 5mg intramuscularly (to inject substance into a muscle) every 12 hours as needed for agitation until 10/11/2023 23:59 (11:59pm) with a start date 10/07/23 and an end date of 10/11/23. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455662 If continuation sheet Page 8 of 12 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 03/01/2024 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of Resident #3's progress note dated 10/07/23 at 1:12pm, revealed LVN A had Administered Haldol (Haloperidol) 5mg IM (intramuscularly) injection at this time. Record review of Resident #3's Medication Administration Record for October 2023 revealed no signature for administration of physician order for Haloperidol Lactate (medication used to treat certain mental/mood disorders) Injection Solution with direction to inject 5mg intramuscularly (to inject substance into a muscle) every 12 hours as needed for agitation until 10/11/2023 23:59 (11:59pm) with a start date 10/07/23. 2. Record review of Resident #4's face sheet, dated 03/01/24, revealed the resident was a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses that included: obstructive and reflux uropathy (blockage or backward flow of urine), acute kidney failure (a sudden decrease in kidney function), hypertension ( Blood pressure that is higher than normal), schizophrenia (a mental disorder characterized by delusions, hallucinations, disorganized thoughts, speech an behavior) and benign prostatic hyperplasia (enlarged prostate) without lower urinary tract symptoms. Record review of Resident #4's state optional Minimum Data Set assessment, dated 12/01/23, revealed Resident #4 had a BIMS score of 14, indicating he was cognitively intact. Record review of Resident #4's care plan, retrieved on 03/01/24, revealed Resident #4 had a problem of, Resident #4 has (indwelling suprapubic catheter: BPH (benign prostatic hyperplasia), uropathy, [history of] urine retention with an initiation date of 10/17/23 and interventions of change catheter (16 French) position catheter bag and tubing below the level of the bladder, check tubing for kinks each shift, monitor and document intake and output as per facility policy, monitor for signs and symptoms of discomfort on urination and frequency, monitor/document for pain/discomfort due t catheter. Monitor/record/report to medical doctor for signs/symptoms of a UTI (urinary tract infection) all with an initiation date of 10/17/23 Record review of Resident #4's physician's orders, retrieved on 03/01/24, revealed an active physician orders for the following, foley catheter care q shift (every shift) and PRN (as needed) every shift with start date of 10/20/23, irrigate suprapubic catheter with 60ML (milliliters) normal saline Q shift (every shift), to prevent clogs every shift for prevent clots with a start date of 08/02/23 and urine output every shift for suprapubic catheter with a start date of 12/28/22. Record review of Resident #4's Medication Administration Record for February 2024 revealed blanks on the evening shift of 02/02/24, day and night shift of 02/07/24 and 02/22/24 for the following physician orders, foley catheter care q shift (every shift) and PRN (as needed) every shift with start date of 10/20/23, irrigate suprapubic catheter with 60ML (milliliters) normal saline Q shift (every shift), to prevent clogs every shift for prevent clots with a start date of 08/02/23, and urine output every shift for suprapubic catheter with a start date of 12/28/22. 3. Record review of Resident #6's face sheet, dated 03/01/24, revealed the resident was a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses that included: Parkinson's disease (chronic degenerative disorder of the central nervous system that affects both the motor and non-motor systems) without dyskinesia (involuntary movement), without mention of fluctuations, dysphagia, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455662 If continuation sheet Page 9 of 12 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 03/01/2024 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 0842 Level of Harm - Minimal harm or potential for actual harm oral phase (difficulty swallowing), unspecified protein-calorie malnutrition (imbalance of essential nutrients in diet), gastrostomy status (tube inserted through abdomen and into stomach for nutritional support or gastric decompression ), unspecified dementia (decline in cognitive abilities that impacts a person's ability to perform everyday tasks), unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Residents Affected - Some Record review of Resident #6's state optional Minimum Data Set assessment, dated 11/28/23, revealed Resident #6 did not have a BIMS completed due to resident being rarely/never understood and reflected Resident #6 had a feeding tube in place. Record review of Resident #6's care plan, dated 03/01/24, revealed Resident #6 had a problem of, Resident #6 requires peg tube feeding dur to dysphagia with an initiation date of 10/25/22 with interventions including, The resident needs (total assistance) with tube feeding and water flushes. See medical doctor orders for current feeding order. Provide local care to G-Tube site as ordered and monitor for signs/symptoms of infection, check for tube placement and gastric contents/residual volume per facility protocol and record. Hold feed if greater than (100) cc (cubic centimeter) aspirate. Glucerna 1.2 70ml/h (milliliters per hour) x20h (for 20 hours) to provide 1680kcal, (calories) 84g pro, (grams of protein) 1142ml (milliliter) water. The resident needs the HOB elevated 45 degrees during and thirty minutes after tube feed. Record review of Resident #6's physician's orders, dated 03/01/24, revealed active physician orders for the following, AUSCULTATE FOR GTUBE PLACEMENT BEFORE MEDICATION/FEEDING ADMINISTRATION every shift with a start date of 10/26/22, Enteral Feed Order every shift Check for residual. If residual is greater than 100cc - hold feeding for one hour and recheck. if residual continues to be greater than 100cc call medical doctor with a start date of 04/24/23, Enteral Feed Order every shift Cleanse g tube site with normal saline, pat dry and cover with split gauze a secure with tape. Monitor for signs/symptoms of infection with a start date of 01/25/24, Enteral Feed Order every shift Elevate HOB (head of bed) 30 to 45 degrees at all times during feeding and for at least 30 to 40 minutes after the feeding is stopped with a start date of 01/25/24, Enteral Feed Order every shift Flush with 30 - 60 mls (milliliters) H2O (water) before/after meds, before initiating feeding or when there is an interruption of feeding to maintain Tube Patency with a start date of 01/25/24, Enteral Feed Order every shift Flush with 5 -10 mls (milliliters) H2O (water) between each medication. With a start date of 01/25/24 and Enteral Feed Order every shift Glucerna 1.2 65 milliliters per hour x20 [for 20 hours] to provide 1560kcal, (calories) 78g pro, (protein) 1047ml water. Flush water 150ml (milliliters) q4h (every 4 hours) and 30ml (milliliters) before and after meds. Total estimated fluid 2187ml (milliliters). With a starts date of 01/15/24. Record review of Resident #6's Medication Administration Record dated February 2024 revealed blanks on the evening shift of 02/02/24 and the day shift of 02/07/24 and 02/22/24 for the following physician orders, AUSCULTATE FOR GTUBE PLACEMENT BEFORE MEDICATION/FEEDING ADMINISTRATION every shift with a start date of 10/26/22, Enteral Feed Order every shift Check for residual. If residual is greater than 100cc - hold feeding for one hour and recheck. if residual continues to be greater than 100cc - call medical doctor with a start date of 04/24/23, Enteral Feed Order every shift Cleanse g tube site with normal saline, pat dry and cover with split gauze a secure with tape. Monitor for signs/symptoms of infection with a start date of 01/25/24, Enteral Feed Order every shift Elevate HOB (head of bed) 30 to 45 degrees at all times during feeding and for at least 30 to 40 minutes after the feeding is stopped with a start date of 01/25/24, Enteral Feed Order every shift Flush with 30 - 60 mls (milliliters) H2O (water) before/after meds, before initiating feeding or when there is an interruption of feeding to maintain Tube Patency with a start date of 01/25/24, Enteral Feed Order every (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455662 If continuation sheet Page 10 of 12 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 03/01/2024 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 0842 Level of Harm - Minimal harm or potential for actual harm shift Flush with 5 -10 mls (milliliters) H2O (water) between each medication. With a start date of 01/25/24 and Enteral Feed Order every shift Glucerna 1.2 65 milliliters per hour x20 [for 20 hours] to provide 1560kcal, (calories) 78g pro, (protein) 1047ml water. Flush water 150ml (milliliters) q4h (every 4 hours) and 30ml (milliliters) before and after meds. Total estimated fluid 2187ml (milliliters). With a starts date of 01/15/24. Residents Affected - Some During an interview and record review with LVN A on 03/01/24 at 1:18pm she stated she worked on 10/07/23 with Resident #3. LVN A stated she was responsible for signing off on Resident #3's medication administration record. LVN A reviewed Resident #3's MAR for October 2023 and stated it [Haloperidol order] was blank on 10/07/23. LVN A stated a blank on the MAR meant that it was not signed. LVN A reviewed her progress note from 10/07/23 for Resident #3 and stated the note she wrote was correct and she did administer Haldol (Haloperidol) to Resident #3 on 10/07/23. LVN A stated she should have signed of on the MAR but did not remember why it was not done. LVN A stated she had been trained over documentation of medication provided within the last 3 to 4 months and stated the training was provided by the ADON or DON. LVN A stated the facility policy on documentation of medication administered was they had to document whenever they gave a medication, LVN A stated she assumed she did not follow the facility policy regarding signing the MAR. LVN A stated the ADON monitored the records to ensure accurate documents by alerting staff if they had signed off on all things. LVN A stated the ADON had told them to sign when giving medication. LVN A stated incorrect documentation could cause a resident to get a double dose and could lead the resident to become overly sedated. During an interview and record review with LVN C on 03/01/24 at 2:23pm she stated she worked on 02/22/24 with Resident #4 and #6. LVN C stated she was responsible for signing off on Resident #4 and #6's medication administration record. LVN C reviewed Resident #4's and #6's MAR for February 2024 and stated catheter orders for Resident #4 and enteral feeding orders for Resident #6 were left unsigned. LVN C stated a blank on the MAR meant that maybe she did not sign. LVN C stated she provided both Resident #4 and Resident #6 with all their care and stated she should have signed off on the MAR and did not know why it was not signed. LVN C stated she had been trained upon hire and 01/22/24 and stated she recently had a 1 to 1 training that she was supposed to sign off once services were provided, LVN C stated ADON provided her with these trainings. LVN C stated the facility policy was to provide the service and then sign off and to make a notation on progress notes and notify the doctor if a resident refused. When asked if the facility policy was followed LVN C stated she failed to document her work. LVN C stated she was not sure when the ADON or DON ran audits to monitor records for accurate documentation but stated the ADON/DON would get in contact with her if they had any questions on any forms or if she was missing anything. LVN C stated incorrect documentation such as this could negatively impact a resident because if its not signed you couldn't prove that you provided the care and if it was not provided then residents health would be put in jeopardy. During an interview and record review with LVN B on 03/01/24 at 6:03pm stated he worked on 02/02/24 with Resident #4 and #6. LVN B stated he was responsible for signing off on Resident #4 and #6's medication administration record. LVN B reviewed Resident #4's and #6's MAR for February 2024 and stated catheter orders for Resident #4 and enteral feeding orders for Resident #6 were left unsigned. LVN B stated a blank on the MAR meant it was not done or you forgot to sign. LVN B stated provided both Resident #4 and Resident #6 with all their care and stated he should have signed off on the MAR and did not know why it was not signed. LVN B stated he had been trained over documentation of services/treatment provided within the last 2 weeks and stated the training was provided by the ADON or DON. LVN B stated the facility policy on documentation was to document when you do treatment or afterwards. LVN B stated he did not follow the facility policy in this situation. LVN B (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455662 If continuation sheet Page 11 of 12 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 03/01/2024 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some stated the ADON and DON would review staff's documentation. LVN B stated incorrect documentation such as this could negatively impact a resident because the care could have not been provided. During a telephone interview with LVN D on 03/01/24 at 6:43pm she stated she worked on 02/07/24 with Resident #4 and #6. LVN D stated she was responsible for signing off on Resident #4 and #6's medication administration record. LVN D was interviewed over the telephone and was unable to review Resident #4's and #6's MAR for February 2024. LVN D stated she did not recall leaving catheter orders for Resident #4 and enteral feeding orders for Resident #6 unsigned. LVN D stated a blank on the MAR meant it was not done or it was it was forgot to be check off or missed for some reason. LVN D stated she provided both Resident #4 and Resident #6 with all their care and stated she should have signed off on the MAR and could not recall why it was not signed. LVN D stated she had been trained over documentation of services/treatment provided recently however was unable to provide a more specific time, LVN D stated the training was provided by the ADON. LVN D stated the facility policy on documentation was to make sure everything was sign, when asked if she followed the facility policy she stated, I don't know why I didn't sign it. LVN D stated the ADON and DON would review records to make sure everything was signed. LVN D stated if [documentation] was not signed or was not done it meant residents may not get the care they are supposed to get. During an interview and record review with the DON on 03/01/24 at 7:29pm and stated the nurses working one evening shift of 02/02/24, day shift of 02/07/24, 02/22/24 and 10/07/23 with Residents #3, #4 and #6 were responsible for signing off on Resident #3's #4's and #6's medication administration record. The DON stated a blank on the MAR could be a med error, or something very bad, and stated signing the MAR after you give a medication was something that had to be done. The DON reviewed Resident #3's October 2023 MAR and confirmed blanks for Haloperidol on 10/07/23. The DON reviewed Resident #4's February 2024 MAR and confirmed blanks related Resident #4's catheter orders on 02/02/24, 02/07/24 and 02/22/24. The DON reviewed Resident #6's February 2024 MAR and confirmed blanks related Resident #6's enteral feed orders on 02/02/24, 02/07/24 and 02/22/24. The DON reviewed Resident #3's progress note dated 10/07/23 written by LVN A and confirmed Haloperidol was administered to Resident #3. The DON stated staff told her they had provided Residents #3, #4 and #6 with all the care but had forgot to document. The DON stated the MAR should have been signed. The DON stated she and her ADON had provided staff with training over documentation of services, treatment and medication provided in the month of February. The DON stated it was facility policy to document anything that was done otherwise it did not happen. The DON stated in this situation her staff did not follow the facilities policy. The DON stated to monitor the records to ensure accurate documentation she would review orders every morning and make sure the orders that are input are being followed. The DON stated when she identified any that were not complete she or her ADON would notify the staff. The DON stated they would now be checking before staff finish their shift to make sure there was nothing pending. The DON stated incorrect documentation such as this could cause miscommunication between nursing and stated if something like foley care was not documented it could affect the care of the foley, urine output or cause infection. Record review of facility policy titled, Documentation on Medical Record with an implementation date of 10/24/22 included verbiage stating, 1. Licensed staff and interdisciplinary team members shall document all assessments, observations, and services provided in the resident's medical record in accordance with state law and facility policy. Section 3 sub section f stated, Sign each entry with name and credentials of the person making the entry. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455662 If continuation sheet Page 12 of 12