Health inspection·July 20, 2023

F 0602 Methylphenidate 10 mg tablets were delivered for Resident #1 and signed in by LVN B. Level of Harm - Minimal harm or potential for actual harm Record review of a Controlled Substance Record (Shift Count Documentation) for 06/27/2023, revealed MA B's signature only, whereas all other dates for June 2023 shows two different signatures. Residents Affected - Few Record review of a handwritten statement dated 06/28/23 by MA A indicated on 06/26/23, she passed medication, and it is her belief that she passed Resident #1's Methylphenidate twice that day. She made a mental note of who's medication needed to be refilled as she was working that day on refilling medications. She did not believe that medication to be out or low at that time. She did not work on 06/27/23. When she returned to work on 06/28/23, she counted with the night shift nurse and took over the cart. While passing medications, she realized that Resident #1's Methylphenidate medication was out. She asked LVN A about it and commented on how she thought it was odd. Later, she checked with medical records and found the last drug record sheet was turned in on 6/22/23. She called the pharmacy and verified that it was signed for and delivered to the facility on 6/22/23 and compared this information to their pharmacy record. She immediately notified the DON. It is her personal judgment that she administered this medication on 6/27/23 and it was here when she left work to the best of her knowledge. Record review of a handwritten statement dated 06/28/23 by LVN B indicated he counted with the shift key nurse and the counts were all accurate and no cards were missing. Once MA B arrived, him and her counted both medication carts and both were accurate. He did not see MA B at the end of her shift, nor did she ask him to count the carts with her before she left for the day. MA B did not at any time during the shift advise him that any residents were out of any medications that needed to be reordered. He was also not made aware of any medications that were not given. Record review of a provider investigation report dated 06/29/2023 indicated MA A was passing medications and discovered that a card of prescribed medication was not available. She knew that it had been prior, and an ample supply was previously available. All nursing and medication aides were asked to submit to drug screens. All except for 3 were available. We allow 3 hours from drug screen request to present for their drug screen. If they pass the 3-hour limit to present for testing, we suspend them from further work assignments. Local Police were notified, and nursing staff were in-serviced on facility pharmacy practice regarding maintaining med-cart keys, counts, and notification of any discrepancies to be reported to include med-error reports and proper notifications. During an interview on 07/19/23 at 11:10 a.m., Resident #1 said he gets his medications each day. One day one of his medications was missing and the doctor re-ordered it. He said it did not make him sick. He said he would be upset if it happened again. During an interview on 07/19/23 at 03:00 p.m., the DON said they looked everywhere for the Methylphenidate 10 mg tablets and the Shift Count Card and found neither. They checked the MAR (7AM and 12PM) on 06/27/23 and noted MA B documented she was unable to administer the medication as it was not available. The DON said that LVN A reported to her that MA B left early and failed to notify LVN A that Resident #1 was out of any medications. The DON said that LVN A also reported to her that MA B did not ask anyone to count with her and MA B left the keys in the Medication Book on top of the Cart behind the nurse's enclosed glass station. The DON said she had the Pharmacist send over the Manifest and it showed the Methylphenidate 10 mg tablets was delivered on 06/21/23. The DON said the doctor re-ordered the medication and the local Police Department was notified. The DON said they completed in-services on Key Handling and Narcotic Counts. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675139 If continuation sheet Page 2 of 5 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 675139 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Healthcare Residence 1025 W Yeagua Groesbeck, TX 76642 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 0602 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 07/19/23 at 03:30 p.m., MA C said when he arrived to work on 06/27/23, MA B had already left so he counted with LVN A. Their count was correct. At the end of his shift, he counted with the Charge Nurse on duty. The next day on 06/28/23, he was informed by the DON that medication and the medication card was missing. MA C said he was informed by the DON the medication was for Resident #1, but it was not a medication that he administers. He said their policy was when you start and end your shift, you must complete a narcotic count prior to accepting the keys. MA C stated with the resident missing an entire day of medication, it could cause him to become uneasy and have behavior issues. During an interview on 07/19/23 at 04:00 p.m., the DON stated they added an additional sign-off sheet to be kept in all medication carts with each drug listed to be checked off that the medication and card was accounted for regardless of if the drug was only administered in the morning, afternoon, or evening. During an interview on 07/19/23 at 04:15 p.m., the HRD said she reached out to MA B via phone and text. MA B never called her back, but she sent her a text message informing her she was out of town over 100 miles away and would not be able to come in to submit for a drug test. She informed MA B that their policy required her to submit to a drug test within 3 hours whenever there was a suspected drug diversion, or it would be an automatic positive. The HRD said per their policy, she knows the MAs and Nurses were supposed to count at the end of their shift and pass the keys to the oncoming shift. They did not discover the medication was missing until the next day. During an interview on 07/19/23 at 04:30 p.m., MA D said per policy, you were to inform the Charge Nurse as soon as you discover any drugs missing. MA D said you are to make sure you count prior to your shift and again at the end of your shift with another staff member. MA D said your keys should remain with you at all times and should not be handed over or accepted until a Narcotic Count has been completed. During a phone interview on 07/19/23 at 08:20 p.m., MA B (AP) said Resident #1 was out of his Methylphenidate 10 mg tablets, and she gave LVN A a note that he needed a refill. She stated Charge Nurses were the only ones that can request an order for narcotics. She entered in the MAR that Resident #1's Methylphenidate 10 mg tablets were not available for his morning and afternoon dose. She said at the end of her shift she completed a Count with LVN A and gave LVN A the keys. During an interview on 07/20/23 at 10:30 a.m., LVN A said towards the end of their shift, she did not realize MA B was leaving early. LVN A said she was on the phone, looking up something on the computer and in her peripheral vision she saw MA B and heard MA B say, You better come and visit me in Midland, and she said I sure will. LVN A said she continued to work on the computer and did not realize MA B was leaving at that particular time because her attention was not on MA B. LVN A said MA B never mentioned to her about completing a count or specifically that she was leaving for the day. LVN A said MA B did not verbally, nor give her a note informing her that Resident #1 needed a new order for Methylphenidate. LVN A said MAs know when a resident gets down to a 5-to-7-day supply, you must notify the Charge Nurse. LVN A said unfortunately, they were unable to know how many pills Resident #1 had left due to the Card and the Medication being missing. LVN A said the next morning on 06/28/23, MA A noticed Resident #1 was out of his Methylphenidate medication and that was when she notified the MD that he needed a refill. During an interview on 07/20/23 at 11:00 a.m., the ADM said they reported the concerns to the local Police Department and to the State. The ADM said the alleged perpetrator, MA B did not have any (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675139 If continuation sheet Page 3 of 5 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 675139 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Healthcare Residence 1025 W Yeagua Groesbeck, TX 76642 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 0602 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few write-ups in her file. MA B only worked one day during the month of June and there were no additional risks to other residents, nor staff. The ADM said due to MA B not returning to the facility to submit to a drug test, MA B was terminated and was no longer allowed to work at the facility. The ADM said the staff were in-serviced on Keeping Keys on Person throughout Shift and Making Sure a Count is completed at the end of each shift. The ADM stated the simple fact that it happened, everyone should know their role in this and if they know something, they should speak up. During an interview on 07/20/23 at 11:30 a.m., the ADON said MA B was all over the place on Tuesday (06/27/2023) and left work a little early. The ADON said she did not witness MA B counting with anyone. The ADON said she knew MA A worked the day prior and needed 06/27/2023 off. The ADON said when MA A returned to work the following morning, MA A remembered Resident #1 still had a lot of Methylphenidate 10 mg tablets two days prior. The ADON said they looked in the cart and all over and could not find the card or the narcotic slip. The ADON said the medication was there on Monday (06/26/2023) and gone on Wednesday (06/28/2023). The ADON said she reported it to the DON. The ADON said she found it strange that MA B would put Unavailable opposed to reporting it to the nurse. The ADON said if a resident with Attention Deficit Disorder misses two doses of their Methylphenidate medication, it messes up their cycle as far as keeping them calm and causes them to have behaviors and act out. During an interview on 07/24/23 at 10:58 a.m., the PC said she was made aware by the ADM that Resident #1's Methylphenidate medication was missing. The PC said that the ADM informed her of her suspicions as far as an entire blister pack being taken and there was no concrete evidence as to who actually took it. The PC said if an entire blister packet along with the card was missing, she was not sure how they would catch that error. The PC said when a Controlled Substance goes missing it was on the facility's end and she has nothing to do with that other than being informed. During an interview on 07/24/23 at 01:50 p.m., the MD said he was informed by the DON that the facility realized Resident #1 had not received his Methylphenidate 10 mg tablets for the day. They noticed his medication was missing and had already reported it to the State and the Police. The MD said the DON informed him that they thought they may know who did it but was not certain. The MD said the DON called him to request a new Order. The MD stated with Resident #1 missing two doses of the medication could cause him to become more tired and not be able to concentrate as normal. During an interview on 07/24/23 at 02:34 p.m., the NP said she and the MD was made aware of the drug diversion by the DON. The DON informed them Resident 1's Card of Methylphenidate was missing along with the Sheet. She informed me this was not a drug that she ordered, so it would have to be ordered by the MD. The NP said she has only been assigned to Resident #1 for 3 weeks. The NP said the medication was short-acting and from missing 2 doses, Resident #1 could suffer from anxiety and agitation. During an interview and record review on 07/24/23 at 11:28 a.m., PO B said the report dated 06/29/2023 was not finalized yet and has not been sent up for approval. PO B emailed surveyor an initial copy of the report listing the Offender as: Relationship Unknown and the Property as: Medication Card w/51 Methylphenidate. An undated Abuse Prevention policy defined misappropriation of resident property as the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent. An undated Controlled Drugs Audit and Accountability policy states, The Change of shift audit (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675139 If continuation sheet Page 4 of 5 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 675139 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Healthcare Residence 1025 W Yeagua Groesbeck, TX 76642 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 0602 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete sheets is where nursing staff will sign to indicate that the controlled drugs were audited and that the responsibility of accountability of the controlled drugs is being changed to a different nursing staff. This form has columns to indicate the total number of controlled drug audit sheets present at each shift change audits. An undated Storage and Documentation of Schedule II Controlled Medications policy states, All Schedule II controlled medications will be stored under double lock and checked for accountability at each change of shift by the nurse going off duty and the nurse coming on duty. Documentation of the audit will be completed on the appropriate form. Evidence of the shift change audit must be maintained by the facility for three years. Event ID: Facility ID: 675139 If continuation sheet Page 5 of 5