Health inspection·December 7, 2023

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few accuracy along with an RN and ADON. The MDS Coordinator/Care Management Specialist stated Resident #31 and Resident #209's code status was not in the care plan and was not updated and stated it was missed and an error. The MDS Coordinator/Care Management Specialist stated baseline care plans are done on admission and that is when the code status would have been entered by the nurse who did the admission. The MDS Coordinator/Care Management Specialist stated she was unsure which nurse entered the baseline care plan and which RN oversaw the care plan for accuracy and closed out the care plan without ensuring code status was updated. The MDS Coordinator/Care Management Specialist stated that Resident #31 and Resident #209's code status does show on Resident #31 and Resident #209's orders and on main chart so staff are aware of Resident #31 and Resident #209's code status. Interview on [DATE] at 03:09 PM the DON stated the ADON and herself oversaw closed out baseline care plans for all residents. The DON stated the ADON brings up a checklist on the computer system and after the nurse completed the resident admission , the ADON checks the computerized care plan and fills in any boxes that might have been missed. The DON stated the main profile chart and orders for Resident #31 and Resident #209 does reflect a full code status. The DON stated by not having the code status updated in Resident #31 and Resident #209's care plan could delay immediate care and an admission and in-service on care planning would be conducted immediately. Interview on [DATE] at 3:15 PM thePM the ADON stated that she does ensure care plans are completed after resident admission and could not answer why Resident #31 and Resident #209's code status on the care plan was missed. The ADON stated Resident #31 and Resident #209's code status does reflect on the main chart and orders, so staff are aware of current code status. The ADON stated by not having the code status updated in Resident # 31 and Resident #209's care plan could delay immediate care. Record review of Comprehensive Care Plans Policy dated [DATE] stated; It is the policy of this facility to develop and implement A comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and time frames to meet a residence medical, nursing, and mental and psychosocial needs that are identified of the resident's comprehensive assessment. 2. The comprehensive care plan will be developed within 7 days after the completion of the comprehensive MDS assessment. 3. The comprehensive care plan will describe, at minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practical, physical, mental, and psychosocial well-being. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675309 If continuation sheet Page 2 of 9 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 675309 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Nursing and Rehabilitation Center of Alice 606 Coyote Tr Alice, TX 78332 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for sanitation in that: 1. The facility failed to ensure the juice dispenser guns were sanitary 2. The facility failed to ensure the dishes were clean and sanitized 3. The facility failed to ensure equipment was clean and sanitized 4. The facility failed to remove a dented can from service 5. The facility failed to discard and replace unsanitary cooking utensils 6. The facility failed to refrain from having personal items in the prep areas 7. The facility failed to maintain cleanliness of the floor in the nutrition room 8. The facility failed to label and date items in the nutrition room refrigerator 9. The facility failed to report unsafe temperatures in the nutrition room refrigerator 10. The facility failed to follow hand hygiene guidelines These failures could place residents at risk of foodborne illnesses. Findings include: Observation and initial tour of the kitchen on 12/04/23 at 1:50 p.m. revealed 2 of 2 juice guns hanging from the juice machine. The nozzles of both appliances were touching boxes below the machine. The boxes had colorful blotches, in varying states of dryness, of what appeared to be the same liquid dripping from one of the juice gun nozzles. There was a slimy looking substance in the holster for the juice guns. There were sixty-six of sixty-nine plastic coffee cups on the dry/clean racks with a white substance coating the insides of the cups; 44 of them were on carts that were being used for residents' snacks and beverages. There were five of five small plastic dessert cups with scratches in the bottoms. The inside of the steam table wells were crusted with a whitish yellow substance that was flaking from the sides and bottoms, with floating debris in the water. There was a dented 6 pound can of pineapple on the prep table. The puree machine had a pink substance inside the plastic part that kept the lid on. There were 3 metal spatulas with melted and deformed handles and 2 rubber spatulas-one with chipped edges, the other had a brown substance on it and had a hair stuck to it. Personal items were found on the shelf of the steam table; one pair of sunglasses and 1 pair of purple scissors. There were 2 personal cups on a cart with clean ceramic plates in the kitchen. The vent hood filters had a grey fuzzy substance on them. Observation of the Nutrition Room on 12/06/23 at 10:41 a.m. revealed 1 unlabeled and undated 16.9 oz. bottle of water, 1 unlabeled and undated open, partially empty 20 oz. bottle of soda in the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675309 If continuation sheet Page 3 of 9 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 675309 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Nursing and Rehabilitation Center of Alice 606 Coyote Tr Alice, TX 78332 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many refrigerator. The refrigerator log reflected temperatures over 40F twice daily from 12/01/23 to 12/05/23. The floor in front of the refrigerator had a large area of a very sticky reddish substance on it. Observation of COOK C on 12/06/23 at 4:40 p.m. revealed he picked up an extinguished cigarette butt off the kitchen floor with his bare hand and threw it in the trash. Without washing his hands, COOK C proceeded to push a beverage cart out of the kitchen. Observation of COOK B on 12/06/23 at 4:40 p.m. revealed while calibrating thermometers to temp the dinner service foods, had 3 thermometers in a glass of cubed ice that had no water in it. COOK B told the CFM the thermometers were not getting cold. COOK B showed the surveyor each thermometer- One read 0 degrees F, and the other two read 20 degrees F. COOK B told the CFM about the temperatures on the thermometers. The CFM showed COOK B how to adjust the calibration on the thermometers. COOK B proceeded to temp the foods, calibrating the thermometer between each food item. An interview with the CFM on 12/04/23 at 1:55 p.m. she had been having problems with the dishwasher for 2 months. The CFM stated the company had been in to adjust the dishwasher 3 times last month, but she was still having the problem of residue in the plastic cups and was not sure what it was. The CFM stated she had not mentioned the continued problem with the dishwasher to anyone. The CFM stated the can of pineapple was going to be used for service. An interview with the DW on 12/04/23 at 2:00 p.m. revealed he was responsible for checking the dishes when they came out of the washer. The DW stated if the dishes were still dirty or had residue in them, he would run them through the washer a second time. The DW stated the cups on the carts were being used for residents' snacks and beverages. The DW stated sometimes he got in a hurry and could have missed some of the dirty ones (dishes). The DW stated he would not like to drink from the clean cups that were on the carts because they were dirty. The DW stated the residents could get sick with some kind of bacteria or get a GI infection. The DW stated the scratches on the bottoms of the dessert cups were not supposed to be there-that germs could get in them and after food was put in them, the germs could get into the food and make the residents sick. The DW did not speak, but only stared at the surveyor when asked why it was ok for the residents to drink or eat from the dirty dishes. An interview with COOK A on 12/04/23 at 2:07 p.m. revealed she had put lemon juice in the steam table wells to clean them. COOK A could not say why the insides of the wells were crusted and flaking if they were clean. COOK A could not say how long it took for the lemon juice to clean the steam wells. COOK A did not know if lemon juice was an approved cleaner. An interview with COOK B on 12/04/23 at 2:12 p.m. revealed the pink substance inside the plastic part that kept the lid on the puree machine was food that had not been cleaned out. COOK B was not sure how long it had been there. COOK B stated when kitchen staff pureed food, sometimes it overflowed. COOK B stated the cooks were responsible for cleaning the puree machine. COOK B stated the melted and deformed handles of the metal spatulas could have germs in the crevices, and when kitchen staff touched them, cross contamination could occur and make someone (resident's) sick. COOK B stated the chipped rubber spatula could break off in the food and if a resident ate it, it could hurt their mouth or make them sick. COOK B stated the hair on the other rubber spatula was just gross and both the metal and the rubber spatulas should have been thrown out. COOK B did not throw them out, nor could say why they were not thrown out. COOK B stated the personal items should not be in the kitchen at all and did not know who they belonged to. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675309 If continuation sheet Page 4 of 9 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 675309 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Nursing and Rehabilitation Center of Alice 606 Coyote Tr Alice, TX 78332 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many An interview with COOK C on 12/04/23 at 2:19 p.m. revealed the juice guns had always been that way (hanging from the machine) because they did not have a holster. COOK C stated he had worked at the facility for seven years. COOK C saw a holster for the juice guns on the counter where the juice machine was, under the machine. COOK C stated the holster was dirty and needed to be cleaned. COOK C stated the juice guns should not be hanging as they were because they could get clogged and there could be slime in the hoses of the juice guns. COOK C stated the entire kitchen staff was trained by the CFM. COOK C stated he was trained to keep the juice guns in their holsters. An interview with CNA A on 12/06/23 at 10:48 a.m. revealed the nurses took the temperatures in the nutrition room refrigerators and wrote them on the refrigerator log. CNA A stated there should not be bottles of water or soda in the refrigerator and everything in the refrigerator should be labeled with a name and a date of when it was put in there. CNA A did not know who was responsible for monitoring the contents of the refrigerator, and assumed it was the nurses because they took the temperatures. CNA A stated no personal items were allowed in the refrigerator. An interview with the ADON, on 12/06/23 at 1:24 p.m. revealed the nurses were responsible for everything in the nutrition room, including the floors. The ADON stated the facility used a spigot-type of container for water and an ice chest for ice for the residents. The ADON stated there should not be any drinks in the refrigerator without a name and date on it, especially any opened ones. The ADON stated the temperatures below the required temperature logged for the nutrition room refrigerator should have been reported to maintenance. An interview with LVN A on 12/06/23 at 2:12 p.m. revealed there should not be any drinks in the refrigerator without a name and date on it, especially any opened ones, and never any staff items. LVN A stated the temperatures below the required temperature logged for the nutrition room refrigerator should have been reported to maintenance. An interview with the CFM on 12/06/23 at 02:19 p.m. revealed the kitchen staff were using the purple scissors they borrowed from a nurse to cut preference cards. The CFM stated there were other scissors the kitchen staff should have been using. The CFM stated there could be different kinds of stuff on the purple scissors, like germs that could spread because the preference cards went on the trays. The CFM stated the personal cups on the cart were there because kitchen staff did not know who they belonged to, so they kept them in case someone asked for them, such as visitors. The CFM stated it probably was not sanitary at the time to store unknown cups with clean dishes the resident's used. The CFM stated the washer was fixed today (12/06/23) and she had an invoice for it. The CFM stated she only called the washer maintenance company only once (in November 2023) and they did regular maintenance once a month. The CFM stated the washer started acting up again a few days after October 2023 maintenance was done between the first of the month or the middle of the month, but she did not call the washer maintenance company, nor notify the ADM. The CFM stated she called the washer maintenance company in November 2023 a couple of weeks into November. The washer maintenance company came near the beginning of November 2023 and again in mid-November 2023. The machine started acting up again about a week after that. She did not call them again because it just got away from her. The CFM stated the DW had not told her about the washer. The CFM stated the washer maintenance company came back yesterday (12/05/23) and told her there was a draining sensor that was out and the machine was supposed to drain the water but it was only draining half of it and mixing (food particles) with the clean/rinse water and getting back on the dishes. The CFM stated she thought the residue seen on 12/04/23 was food. The CFM stated the process was to re-wash, wash by hand, or soak dirty dishes before putting them out for service. The CFM stated she was not monitoring the dishes, even though she knew about the problem. The CFM stated she was not monitoring the DW because she would get busy. The CFM (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675309 If continuation sheet Page 5 of 9 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 675309 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Nursing and Rehabilitation Center of Alice 606 Coyote Tr Alice, TX 78332 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many stated the dish washer was supposed to be cleaned daily, but now was not sure if it was getting done. The CFM stated the steam table wells were supposed to be cleaned after every meal. The CFM stated she would expect to see clean water and no debris or grease in the steam table wells, and they should be shiny on the bottoms and sides. The CFM stated soap and water were supposed to be used to clean the steam table wells then air dried. The CFM stated she should be monitoring for that but she has not because it just got away from her. The CFM stated the debris in the puree machine was food and she did not know how it could have gotten in there. The CFM stated the cooks were responsible for cleaning the puree machine. The CFM stated she usually told the cooks to soak the puree machine to clean it. The CFM stated she was responsible for making sure the cooks were cleaning the equipment. The CFM stated the metal spatulas were not ok to use because the handles were burned out. The CFM stated the rubber spatulas were not ok to use. The CFM stated loose particles could come off of the rubber spatulas and bacteria could get stuck in there causing cross contamination when the cooks handled them, then touched something else and the residents could get sick. The CFM stated the cooks should have tossed them out and let her know so she could replace them. The CFM stated she did not know why the spatulas were not thrown out. The CFM stated she needed to have an in-service with the kitchen staff. The CFM stated the juice guns should be stored in their holsters because it could mess up the machine, and germs could get in them with people rubbing up against it, or the nozzles touching the dirty boxes. The CFM stated she trained the staff. There was a cleaning log with all days initialed. The CFM stated she felt kitchen staff were just signing off without doing the job-they do things in a hurry to get out of here, to be honest with you. An interview with the MS on 12/06/23 at 4:55 p.m. revealed the filters on the vent hood were supposed to be getting cleaned every so often. The MS stated he had work orders of when the filters had been cleaned. The MS stated the filters did not look clean. The MS stated, That greasy dust could fall in the food. An interview with COOK B on 12/06/23 at 4:45 p.m. revealed she had a lot of experience taking temperatures and calibrating thermometers on food before service. COOK B stated usually when she took temperatures, she would just stick it (the thermometer) in the food. COOK B stated that was not ok because the food could be too hot or too cold. COOK B stated food or beverages that were too hot could burn the residents and warm food that was too cold could make residents sick because bacteria could grow. Record review of the facility's life safety inspection manual table of contents listed on #7. Range Hood Cleaning Reports-semi annual. The invoices in tab #7 for the kitchen vent hood cleaning were dated 01/04/22, 01/18/23, and 07/25/23. Record review of In-services: Undated Temperature Logging, 03/07/23 Follow Tray Tickets and Food Preferences of Residents, 03/21/23 Mock Survey-Survey Readiness, 05/18/23 Food handling on tray Line/Label and Dating/Calibrating Thermometers/How to Communicate, 06/02/2023 Choking Hazards, 08/26/23 Phones/Employee Rule, 09/08/23 Snacks/Levels of Thickened Fluids, 12/07/23 Sanitation and Disinfection with a 12-page hand-out and a 5-question Dish Room Quiz. From the hand-out, under Cleaning Checklist, it documented tray line clean, sanitized, and free of debris .cleaning schedules are followed and signed-off. Under Major Survey Focus, it documented a clean and sanitized kitchen is key to success, Under Dish Machine, Regular maintenance inspections should be scheduled, ensure the following are completed: The automatic detergent dispenser and/or liquid sanitizer injector is working properly. The dish machine is cleaned at least once a day.11/09/23 Handwashing, Uniforms, 11/21/23 Calibration and Food Hold Temperatures, 11/28/23 Call-in and No call/ No show, 12/01/23 Personal Phone calls/use of phone, 12/05/23 Cleanliness, Temperatures, Infection Control (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675309 If continuation sheet Page 6 of 9 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 675309 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Nursing and Rehabilitation Center of Alice 606 Coyote Tr Alice, TX 78332 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Record review of the facility policy titled Employee Sanitation dated 10/01/18 under 3.e. Employee Cleanliness Requirements Employees will not eat or drink in food storage and preparation areas, or in areas containing exposed food or unwrapped utensils, or where utensils are cleaned or stored. Record Review of the facility policy titled Sanitizing and Calibrating Thermometers dated 10/01/18 revealed The facility realizes the critical nature of serving foods at the correct temperatures to ensure the health of its residents. The facility will use a properly calibrated and sanitized thermometer to check the temperature of potentially hazardous foods. Under Procedure: 1. e. When monitoring cooked foods being held at 140 degrees F, it is acceptable to wipe the stem of the thermometer with an alcohol swab between measurements. 2.a. Ice Water i. Fill a large glass with finely crushed ice. ii. Add clean tap water to the top of the ice and stir well. Immerse the food thermometer stem a minimum of two inches into the mixture, touching neither the sides nor the bottom of the glass. iii. Make sure that the sensor part of the stem is in contact with the ice. iv. Wait a minimum of 30 seconds before adjusting. v. Without removing the stem from the ice, hold the adjusting nut under the head of the thermometer with a suitable tool and turn the head so the pointer reads 32 degrees F. vi. If ice cubes are used, add clean tap water to about halfway up the ice. Make sure the sensor part of the probe is in contact with the ice water mixture, to ensure a freezing point environment (32F). A freezing point environment is achieved when more ice is added to the mixture and it does not melt. Record Review of the facility policy titled Food Storage revised 06/01/19 revealed under 2. Refrigerators h.check the temperature of all refrigerators using the internal thermometer to make sure the temperature stays at 41F or below .i. When temperatures are outside of the designated range, notify Maintenance immediately. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675309 If continuation sheet Page 7 of 9 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 675309 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Nursing and Rehabilitation Center of Alice 606 Coyote Tr Alice, TX 78332 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 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observation, record reviews, and interviews, the facility failed to maintain essential equipment in safe operating condition for 1 of 1 kitchen reviewed for safe operating equipment: Residents Affected - Many 1. The dish washer machine was not operating correctly. 2. The vent hood filters were not being cleaned. These failures could place residents and staff at risk of foodborne illnesses and injury. Findings included: Observation and initial tour of the kitchen on 12/04/23 at 1:50 p.m. revealed there were sixty-six of sixty-nine plastic coffee cups on the dry/clean racks with a white substance coating the insides of the cups; 44 of them were on carts that were being used for residents' snacks and beverages. The vent hood filters had a grey fuzzy substance on them. An interview with the CFM on 12/04/23 at 1:55 p.m. during the initial tour stated she had been having problems with the dishwasher for 2 months. The CFM stated the company had been in to adjust the dishwasher 3 times last month, but she was still having the problem of residue in the plastic cups and was not sure what it was. The CFM stated she had not mentioned the continued problem with the dishwasher to anyone. An interview with the DW on 12/04/23 at 2:00 p.m. revealed he was responsible for checking the dishes when they came out of the washer. The DW stated if the dishes were still dirty or had residue in them, he would run them through the washer a second time. The DW stated the cups on the carts were being used for residents' snacks and beverages. The DW stated sometimes he got in a hurry and could have missed some of the dirty ones (dishes). The DW stated he would not like to drink from the clean cups that were on the carts because they were dirty. The DW stated the residents could get sick with some kind of bacteria or get a GI (gastrointestinal) infection. The DW stated the scratches on the bottoms of the dessert cups were not supposed to be there-that germs could get in them and after food was put in them, the germs could get into the food and make the residents sick. The DW did not speak, but only stared at this surveyor when asked why it was ok for the residents to drink or eat from the dirty dishes. An interview with the CFM on 12/06/23 at 02:19 p.m. revealed the CFM stated the washer was fixed today (12/06/23) and she had an invoice for it. The CFM stated she only called the washer maintenance company only once (in November 2023) and they did regular maintenance once a month. The CFM stated the dish washer started acting up again a few days after October 2023 maintenance was done between the first of the month or the middle of the month, but she did not call the washer maintenance company, nor notify the ADM. The CFM stated she called the washer maintenance company in November 2023 a couple of weeks into November. The washer maintenance company came near the beginning of November 2023 and again in mid-November 2023. The machine started acting up again about a week after that. She did not call them again because it just got away from her. The CFM stated the DW had not told her about the washer. The CFM stated the washer maintenance company came back yesterday (12/05/23) and told her there was a draining sensor that was out and the machine was supposed to drain the water but it was only draining half of it and mixing (food particles) with the clean/rinse water and getting back on the dishes. The CFM stated she thought the residue seen on 12/04/23 was food. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675309 If continuation sheet Page 8 of 9 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 675309 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Nursing and Rehabilitation Center of Alice 606 Coyote Tr Alice, TX 78332 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 0908 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete An interview with the MS on 12/06/23 at 4:55 p.m. revealed the filters on the vent hood were supposed to be getting cleaned every so often. The MS stated he had work orders of when the filters had been cleaned. The MS stated the filters did not look clean. The MS stated, That greasy dust could fall in the food. Record review of the facility's life safety inspection manual table of contents listed on #7. Range Hood Cleaning Reports-semiannual. The invoices in tab #7 for the kitchen vent hood cleaning were dated 01/04/22, 01/18/23, and 07/25/23. Event ID: Facility ID: 675309 If continuation sheet Page 9 of 9