Health inspection·November 20, 2025

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few stressful or terrifying event), Depression (a mood disorder which causes a persistent feeling of sadness and loss of interest), and Alzheimer's Disease (a progressive disorder which was the most common cause of dementia, characterized by memory loss, cognitive decline, and behavioral changes). Resident #2's face sheet also revealed he had been discharged to another nursing facility on 08/28/2025. Record review of Resident #2's quarterly MDS assessment, dated 08/20/2025, revealed a BIMS score of 03, which indicated severely impaired cognition. The MDS also revealed Resident #2's active diagnoses of Anxiety, Depression, PTSD, Alzheimer's and Dementia. MDS section P0100 revealed wander/elopement alarm used daily. Record review of Resident #2's care plan, dated 03/06/2025, revealed Resident #2 was an elopement risk and wanderer. Interventions included the use of a wander guard, identify patterns of wandering and intervene as appropriate, provide structured activities, as well as distract Resident #2 by offering pleasant diversions, structured activities, food, conversation, television, and/or books. Interventions revealed the facility was working on finding appropriate placement in a secured unit for Resident #2. Resident #2 had a care plan dated 08/19/2025, which revealed Resident #2 had an episode of wandering into another resident's room and allegedly hitting him on the right side of his forehead. Care Plan revealed it was suspected Resident #2 thought he was in his room since it was directly across the hall from his room. Interventions included placing a picture of Resident #2 and his motorcycle outside of his room to help him identify the room, psychiatric consult to review medication regimen, lab work ordered, to include CBC and CMP, and continue to monitor Resident #2 for increased wandering episodes. Record review of PIR revealed the incident between Resident #1 and Resident #2 occurred on 08/19/2025 at 2:00 AM but was reported to state survey agency on 08/20/2025 at 1:37 PM. The PIR also revealed Resident #2 struck Resident #1 on the right side of the head. The assessment section of the PIR revealed no physical injuries were noted. In an interview on 11/18/2025 at 2:30 PM, the Administrator stated Resident #2 entered Resident #1's room in the middle of the night around 2:00 or 3:00 AM on 08/19/2025; Resident #1 was still awake and on his computer and yelled at Resident #2 to get out of his room, which startled Resident #2. The staff responded and got Resident #2 out of Resident #1's room. The Administrator and the DON were not made aware of the incident until their morning meeting on 08/19/2025. The Administrator stated he went and spoke with Resident #1, and it was explained to Resident #1 during the night Resident #2 got confused while getting up to use the restroom, and he had entered the wrong room by accident, and Resident #1 had told him nothing physical had occurred, but the Administrator stated Resident #1 later changed his story and stated Resident #2 got startled and hit him in his head, and Resident #1 felt anxious and upset by the event after the fact. The Administrator stated Resident #1 changed his story multiple times from no physical aggression was involved to being hit in the head and feeling anxious and upset. The Administrator stated he did not initially report the incident because he was not made aware of any physical contact between the residents, and when he questioned Resident #1 about physical contact, Resident #1 initially denied any physical contact during the incident. The Administrator also stated that Resident #1 denied feeling scared or intimidated by Resident #2. The Administrator stated he reported abuse per the HHSC LTCR provider letter, which was to report any instance of abuse immediately or no later than two hours, and since he was not notified initially, and then Resident #1 denied any physical altercation, as well as denied and physical or psychosocial injuries when he was interviewed, he did not feel it was a reportable incident at that time. In an interview on 11/18/2025 at 3:05 PM, Resident #1 stated Resident #2 came into his room in the middle of the night because he was confused and trying to find the bathroom. Resident #1 stated he told him to get out of his room, but he was grumbling, cursing and arguing with him; he then stated Resident #2 hit him on the side of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455822 If continuation sheet Page 2 of 7 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 455822 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Nursing and Rehabilitation Center of Harli 820 Camelot Dr Harlingen, TX 78550 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few his head with a closed fist. Resident #1 stated Resident #2 did not hit him hard enough to have any bruising or redness from the incident. Resident #1 stated Resident #2 did not scare him or worry him, but Resident #2 made him a little nervous that he would walk into his room without him knowing it because he is on his computer frequently, and he had already seen him hold one of the nurses down on the floor and choke her, but now Resident #2 was gone to a different facility which had a place for people like him with confusion, so he was not nervous and did not need to keep his door closed all the time. In an interview on 11/18/2025 at 4:45 PM, CNA-D stated she remembered hearing Resident #1 yelling at Resident #2 to get out of his room. When CNA-D went into the room, Resident #1 stated Resident #2 had hit him once before. CNA-D did not remember seeing any redness, bruising or otherwise, but stated LVN-C did skin assessments on both residents after the incident. CNA-D stated she was supposed to notify her charge nurse when there was resident to resident physical aggression, but the charge nurse was already aware because they entered the room at the same time. She stated Resident #2 was confused and had gone into the wrong room by accident. In an interview on 11/18/2025 at 4:13 PM, LVN-C stated she was covering for the charge nurse for the 100 hall around 3:00 AM on 08/19/2025, and she was at nurses station doing reports and heard a scream yelling for help; walking down 100 hall, LVN-C saw Resident #2 in Resident #1's room standing at end of the bed, but he was heading toward the door, like he had been startled. CNA-D came in and helped escort Resident #2 back to his room and restroom. Resident #1 stated he hit him on the right side of his face. LVN-C stated skin assessments were done on both residents, and neither resident had any changes, redness, bruising, swelling, or marks otherwise. LVN-C stated Resident #2 would typically get up during the night when he needed to go to the bathroom and would sometimes get confused and walk into the wrong room. LVN-C stated she reported the incident and the fact there were no injuries to the charge nurse for the 100 hall when she came back from break, but she did not notify the Administrator or DON. She assumed the charge nurse would notify the Administrator, but she now realized she should have notified the Administrator and DON of the incident when it happened so the incident could be further investigated or reported for abuse. In an interview on 11/18/2025 at 4:57 PM, the DON stated the staff do not always contact her during the night if there was not a significant injury, so she and the Administrator were not notified of the incident until they got to the facility the morning of 08/19/2025 and went to their morning meeting. The DON stated the nurse did not call the administrator or the DON during the night (early morning hours) to report a resident had been hit in the face, but she should have. The DON stated HHSC was not notified until 08/20/2025 at 1:27 PM due to the fact Resident #1 denied any physical altercation or aggression at first. The DON stated counseling was done with LVN-C for not notifying the Administrator and DON when the incident happened as it could have been considered abuse. The DON stated the facility reported abuse per the HHSC LTCR provider letter, which was to report any instance of abuse immediately or no later than two hours, and the night nurse should have notified the Administrator and DON immediately when it was known to her Resident #2 entered Resident #1's room and hit him in the head. Record review of the facility's Employee Counseling Report, dated 08/23/2025, revealed LVN-C was counseled on level two offenses to include failure to report an incident and failing to meet job expectations. Incident description revealed on 08/19/2025, LVN-C, responded to a call for help from a resident and found Resident #2, who had dementia, had wandered into Resident #1''s room. LVN-C and another staff immediately redirected Resident #2 out of the room. Resident #1 stated he had been hit. LVN-C notified the primary nurse of the allegation when she returned from break, but she failed to notify her supervisors immediately after finding out of the allegation. Record review of the facility's Abuse Prevention Policy, implemented 08/15/2022, revealed It is the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455822 If continuation sheet Page 3 of 7 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 455822 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Nursing and Rehabilitation Center of Harli 820 Camelot Dr Harlingen, TX 78550 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, and exploitation and misappropriation of resident property. Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. Record review of the HHSC LTCR Provider Letter, issued 08/29/2025, 2.4 Reportable Incidents and Timeframes, Do Report: abuse (with or without serious bodily injury) immediately, but not later than two hours after the incident occurs or is suspected. Event ID: Facility ID: 455822 If continuation sheet Page 4 of 7 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 455822 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Nursing and Rehabilitation Center of Harli 820 Camelot Dr Harlingen, TX 78550 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm 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 13 of 13 residents reviewed for infection control practices. The facility failed to ensure all EBP residents in the facility had PPE available immediately near the residents' rooms. This failure could place residents at risk for cross contamination and infection.Findings included: Record review of the list of residents on precautions, from the ICN, dated 08/20/2025, revealed 13 residents in the facility were on EBP, and 4 residents were on contact precautions. In an observation on 11/17/2025 at 1:45 PM, it was observed multiple rooms, to include rooms on Halls 100, 300, 400, 500, 600 and 700, had EBP signage which revealed providers and staff must wear gloves and gown for the following high contact activities: dressing, bathing, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, device care, and/or wound care. The rooms that were on EBP had appropriate signage located on the doors, but there was no PPE located on the doors or next to the rooms. It was observed the rooms which had contact precaution signs on the doors had PPE located on the doors or next to the rooms. In an interview on 11/19/2025 at 3:05 PM, ADON-A stated only residents on contact precautions had PPE on their doors or next to their rooms because it had to be utilized every time someone entered that room, but PPE for residents on EBP was kept in the supply closet located on each unit, as well as on the linen carts, since it only had to be utilized for high contact activities. After reviewing all of the linen carts on each hall, ADON-A stated there was no PPE on the carts, only in the supply closets located on the 200 hall on Unit A, and the 800 hall on Unit B. ADON-A stated she knew EBP required PPE for high contact activities for residents with wounds, indwelling medical devices, or certain contagious illnesses, but was not sure about policies, guidelines, or recommendations for where it should be kept or placed for residents on EBP. In an interview on 11/19/2025 at 3:15 PM, ADON-B stated PPE was not kept next to any of the EBP rooms or on their doors; he stated PPE was only kept on the door of or next to residents' rooms on contact precautions. ADON-B stated there was a supply closet located on the 200 hall in Unit A and the 800 hall in Unit B which had PPE in it, and the staff knew to go to these closets to get PPE prior to going into the EBP rooms to provide care. ADON-B stated visitors knew which PPE to utilize in rooms on EBP because the signage on the door notified visitors to check with the nurses' desk prior to entering the room, and they were then instructed on and provided the appropriate PPE to use if they were going to provide any care. Upon looking at the signage on the door, ADON-B stated it did not reveal visitors were to come to the nurses' station prior to entering the room. ADON-B stated he was not sure what the recommendations were for the facility infection control policy or enhanced barrier policy in regard to placing or storing PPE for EBP rooms, as well as he was not sure what the CDC guidelines or recommendations for placing or storing PPE for EBP rooms were other than it should be made available and utilized with high contact activities for residents with draining wounds, certain infections, and/or indwelling medical devices. In an interview on 11/19/2025 at 4:05 PM, LVN-E stated EBP precautions were used for high contact on residents with draining wounds, certain infections, and indwelling medical devices, and the PPE involved was typically gown, gloves, and sometimes face shields. LVN-E stated the PPE for residents on EBP was located in the supply closet on the 300 hall, and it was tedious to go back and forth to the area to grab supplies for the EBP rooms. She stated she believed the PPE was supposed to be kept right outside of the residents' rooms which were on EBP just like residents on contact precautions, but she was not sure. In an interview on 11/19/2025 at 4:13 PM, CNA-F stated EBP precautions were Residents Affected - Some (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455822 If continuation sheet Page 5 of 7 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 455822 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Nursing and Rehabilitation Center of Harli 820 Camelot Dr Harlingen, TX 78550 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some used for residents with wounds or things such as foley catheters or g-tubes to keep from spreading infection to these residents. She stated she had to go to the supply room on the 300 hall to get PPE supplies each time she went in to care for a resident on EBP. She stated it was difficult to go back and forth so much to get new PPE supplies every time she had to provide care. She was not sure where they were supposed to be kept, but the supply room on the 300 hall was where they were kept on her side of the facility. CNA-F stated the residents who were on contact precautions had the PPE located on the door of their room, and it was much easier to grab it at the door to put on prior to entering their room for anything. In an interview on 11/19/2025 at 4:44 PM, the DON stated residents who were on EBP did not have PPE kept at or close to their room since it was only required for staff rendering high contact activities. The DON stated staff knew they had to go to the supply room to grab PPE prior to going into a resident's room which was on EBP. The DON also stated families of these residents were in-serviced over EBP as to what PPE was required for which activities. She stated there were 2 supply rooms, so one on each unit, and they were kept locked, but the staff knew the codes to be able to go in and get PPE. If family, friends, or caregivers needed PPE, the staff obtained it for them. The DON stated if she were a CNA, she would grab enough PPE to keep it handy on the linen carts so as to not have to go back and forth between all the residents' rooms on EBP and the supply closets. The DON stated the facility was not required to have the PPE for residents on EBP in any specific location as long as it was available in the facility. The DON defined the word immediately as meaning fast or readily available, but felt like the definition of the word immediately was meant differently for the EBP PPE protocol than for contact precautions PPE protocol. She stated for contact precautions immediately means you had to have it ready right then and there, but for EBP immediately means you just needed to have PPE readily available in the facility, and she stated down a separate hall to the supply closet could have constituted as immediately near or outside an EBP room. In an interview on 11/19/2025 at 5:11 PM, the ICN stated she was the person responsible for placing precautions signs and PPE, and PPE was only kept next to the residents' rooms which were on contact isolation, but the CNAs knew to go to the supply rooms on each unit and grab PPE prior to going into a resident's room on EBP. She stated as long as PPE was made available in the facility residents on EBP, it did not matter where it was located. The ICN stated the CDC guidelines and the facility's infection control policy just stated to make PPE available but did not state where it had to be located. After reading the infection control policy, and enhanced barrier policy, the ICN stated PPE needed to be located immediately near or outside the residents' rooms. The ICN stated immediately means right away. The ICN stated the supply room down the hall did constitute immediately since the staff were able to get to the supplies and get what's needed. Immediately availability for PPE for EBP and Contact precautions, even if worded the same in the policy and CDC regulations, was not the same, even if stated make PPE available immediately. The ICN continued to state immediately did not mean the same for residents on EBP as immediately did for residents on contact precautions. The ICN also stated the facility used CMS guidelines, as well as HHSC's infection prevention and control guidelines for residents on precautions. Record review of the facility's Infection Prevention and Control policy, dated 05/13/2023, revealed This facility has established and maintains 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 as per accepted national standards and guidelines. 13. A. Resident, family members, and visitors are provided information relative to the rationale for the isolation, behaviors required of them in observing these precautions, and the conditions for which to notify the nursing staff. Record review of the facility's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455822 If continuation sheet Page 6 of 7 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 455822 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Nursing and Rehabilitation Center of Harli 820 Camelot Dr Harlingen, TX 78550 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 0880 Level of Harm - Minimal harm or potential for actual harm Enhanced Barrier policy, dated 04/05/2024, revealed 3. Implementation of Enhanced Barrier Precautions: a. Make gowns and gloves available immediately near or outside the resident's room. Note: face protection may also be needed if performing activity with risk of splash or spray. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455822 If continuation sheet Page 7 of 7