Health inspection·April 27, 2023

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A record review of Resident #25's MDS assessment dated [DATE] reflected no BIMS score, which indicated the resident was not assessed for cognition. A record review of Resident #25's care plan last revised on 4/27/2023 reflected he was at risk for imbalanced nutrition, unintended weight loss secondary to CVA, and received a pureed diet. Resident #25's care plan reflected he received hospice services and was at risk for decline in nutritional status. A record review of Resident #25's physician order dated 11/23/2022 reflected he required a pureed diet. Resident #25's physician order dated 1/26/2023 reflected DC all weekly and monthly weights. Activity is too taxing for resident. A record review of Resident #97's face sheet dated 4/27/2023 reflected an [AGE] year-old female admitted on [DATE] with diagnoses of urinary tract infection, hypertension (high blood pressure), atherosclerotic heart disease (narrowed arteries), and chronic obstructive pulmonary disease (lung disease). A record review of Resident #97's MDS assessment dated [DATE] did not reflect a BIMS score. A record review of Resident #97's BIMS assessment dated [DATE] reflected a score of 2, which indicated severely impaired cognition. A record review of Resident #97 care plan last revised on 4/26/2023 reflected she was at risk for imbalanced nutrition, unintended weight loss, and received a pureed diet. A record review of Resident #97's physician order dated 4/25/2023 reflected she required a pureed diet. A record review of Resident #9's face sheet dated 4/27/2023 reflected a [AGE] year-old female admitted on [DATE] with diagnoses of Alzheimer's disease (brain disorder), dysphagia (difficulty swallowing), muscle wasting and atrophy (muscle loss), obsessive-compulsive disorder (mental and behavioral disorder), gastro-esophageal reflux disorder (acid reflux), cerebral infarction (stroke), major depressive disorder (depression), hyperlipidemia (high cholesterol), deficiency of other vitamins and hypertension (high blood pressure). A record review of Resident #9's MDS assessment dated [DATE] reflected a BIMS score of 3, which indicated severely impaired cognition. A record review of Resident #9's care plan last revised on 4/27/2023 reflected she was at risk for imbalanced nutrition, unintended weight loss, and received a pureed diet. A record review of Resident #9's physician order dated 4/06/2022 reflected she required a pureed diet. Observations on 4/25/2023 at 12:48 p.m. revealed Resident #12 and Resident #25 were in the dining room being fed pureed food by caregivers. Resident #25 had finished eating most of his food. Both Resident #12 and Resident #25 were non-interviewable. During an observation and interview on 4/26/2023 at 10:57 a.m., the FSD was pureeing lunch items (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675356 If continuation sheet Page 2 of 8 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 675356 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Nursing and Rehabilitation Center of Bastr 400 Old Austin Hwy Bastrop, TX 78602 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 0803 Level of Harm - Minimal harm or potential for actual harm for residents on a pureed diet. The FSD measured 15 scoops of turkey [NAME] using the grey (4 ounce) scoop and pureed it. The FSD stated there were 11 residents on a pureed diet and that she was preparing 15 servings. The recipe for turkey [NAME] was on the kitchen counter and it reflected instructions for pureeing the turkey [NAME] in increments of 5. It reflected that for 15 servings, 15- 8 ounce servings needed to be pureed. Residents Affected - Some During an interview on 4/26/2023 at 11:25 a.m., the FSD stated she was finished with pureeing the food items for lunch. During an interview on 4/26/2023 at 11:28 a.m., when asked how she knew how much to puree for the turkey [NAME] dish, the FSD stated the recipe called for 15 grey (4 ounce) scoops and she pointed to the recipe which reflected it called for 15- 8 ounce portions to be pureed. The FSD stated the grey scoop (4 ounces) contained 8 ounces. When asked how she knew the grey scoop (4 ounces) contained 8 ounces, the FSD pointed to a chart posted on the refrigerator which reflected each scoop, its color, its size number, and the ounces it contained. The chart reflected the grey scoop held 4 ounces, not 8 ounces. When asked how many ounces a half cup (4 ounces) was, the FSD stated 8. When asked how she knew a half cup (4 ounces) was 8 ounces, the FSD consulted with the RDN, who was standing in the kitchen. An observation on 4/26/2023 at 11:30 a.m. revealed the RDN checked the diet spreadsheet, discovered the FSD had not pureed enough turkey [NAME], and instructed the FSD to puree 15 more grey (4 ounce) scoops of turkey [NAME]. The FSD then began pureeing additional servings of turkey [NAME]. An observation on 4/26/2023 at 11:56 a.m. revealed the [NAME] was serving lunch in the kitchen. As the [NAME] served pureed turkey [NAME] using a 4 ounce scoop, the FSD instructed the [NAME] by stating, remember it's two scoops of the 8 ounce. This indicated the FSD did not know how many ounces the scoop contained. Observations of the kitchen on 4/26/2023 at 12:04 p.m. revealed a portion control chart was posted on the refrigerator. This chart reflected different scoops, their color, size, and capacity. Menu extensions were available in a binder, however, they were not posted or dated. During an interview on 4/26/2023 at 12:06 p.m., the FSD stated she had completed in-services with staff on portion control and preparing puree food items. The FSD stated she received video trainings on those topics from the dietitians, including the RDN. During an observation and interview on 4/26/2023 at 1:45 p.m., the FSD stated the scoops had the number of ounces they contained written on the inside of the scoop. Observed the interior of the grey scoop (scoop #8/4 ounces) and it contained a #8 engraved on the inside of the scoop. FSD stated this was how many ounce it contained. An observation of the kitchen on 4/27/2023 at 11:33 a.m. revealed the service line was set up in preparation for lunch and scoops were in their respective steam pans. There were two steam pans of mashed potatoes-one larger one with a grey (4 ounce) scoop and one smaller one with a blue (2 ounce) scoop. The FSD stated both were mashed potatoes, both were the same, and that she had placed the smaller pan next to the pureed items for convenience of serving. During an interview on 4/27/2023 at 11:41 a.m., when asked why a blue (2 ounce) scoop was used to serve mashed potatoes to residents on a pureed diet whereas residents on a regular diet were to be (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675356 If continuation sheet Page 3 of 8 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 675356 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Nursing and Rehabilitation Center of Bastr 400 Old Austin Hwy Bastrop, TX 78602 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some served using a grey (4 ounce) scoop, the FSD stated they got a smaller scoop because that was what was on the diet spreadsheet. When asked why those residents received a smaller portion than other residents, the FSD stated she did not know but she would find out by asking the FSD, who was standing in the kitchen. An observation on 4/27/2023 at 11:42 a.m. revealed the [NAME] began serving lunch. The [NAME] did not check the diet spreadsheet prior to serving. The FSD was present in the kitchen and had not verified that scoop sizes were correct prior to the start of service. The [NAME] used a blue (2 ounce) scoop to serve mashed potatoes to a resident on a pureed diet. Observed the RDN check the diet spreadsheet and communicate to the FSD that the wrong scoop size had been used. The FSD then instructed the [NAME] to replace the blue (2 ounce) scoop with the grey (4 ounce) scoop. During an interview on 4/27/2023 at 12:17 p.m. the RDN stated he was covering at that facility because they had recently switched dietitians. The RDN stated his first time in the facility was the day prior (on 4/26/2023). When asked how the facility ensured residents on a pureed diet received enough to eat, the RDN stated they're supposed to follow the standardized recipes and when they use the recipes, they're supposed to refer to the dietary spreadsheet for the meal that day. When asked how the facility ensured kitchen staff used the correct scoop sizes, the RDN stated typically the cook will go through it and the FSD will go through the serving line and check. The RDN stated the [NAME] had been getting nervous all day with so many people in the kitchen and that caused her to get confused with the scoops at lunch that day so that was why she used the blue scoop for the mashed potatoes. When asked how staff had been trained on which scoop sizes to use, the RDN stated we do a roll out of in-services with dietary managers and stated the dietitians would review the new menus and diet spreadsheets with dietary managers. The RDN stated the FSD then shared this information with kitchen staff. The RDN stated the dietitians could provide further education if needed. When asked how kitchen staff had been trained on knowing the scoop numbers, colors, and how much each held, the RDN stated the cooks reviewed the menu extensions with the portions and stated they had a cheat sheet on the refrigerator so they knew which color matched the scoop # and how many ounces it held. When asked if kitchen staff had been trained on reading the diet spreadsheet, the RDN stated, I can't verify the names but stated the FSD had a sign in sheet for an in-service she completed with staff on portion sizes. The RDN stated the FSD as well as himself were responsible for training staff. The RDN stated he trained the FSD and the FSD trained kitchen staff. The RDN stated that since the FSD was in the facility every day, she was responsible for monitoring the kitchen to ensure staff used the correct scoops. When asked how staff were monitored to ensure compliance of the menu, the RDN stated the FSD reviewed the menu with cooks before they cooked the meal. The RDN stated when the cooks set up their service line, the FSD checked the service line. The FSD stated that day (4/27/2023), the FSD had a deadline to submit her food order so she went into the kitchen late. The FSD stated that without intervention, he was not sure whether the FSD would have caught that the [NAME] used the wrong scoop to serve mashed potatoes. When asked if he had observed the FSD checking the service line before meal service that day (4/27/2023), the RDN stated, no. The FSD stated he did not observe the FSD checking the service line prior to service the day before (4/26/2023) either but he stated he thought that she did. The RDN stated that after lunch on 4/26/2023, he reviewed the recipes with the FSD to see where the miscommunication was because there was a casserole (turkey [NAME]) that needed to be 8 ounces. The RDN stated it seemed as if the FSD did not see the number 2 in front of the scoop number listed as the portion size on the recipe for pureed turkey [NAME]. The RDN stated the FSD monitored portion sizes every month by completing a tray line check. When asked what a potential negative resident outcome could be if residents on a pureed diet received less food than they were supposed to, the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675356 If continuation sheet Page 4 of 8 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 675356 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Nursing and Rehabilitation Center of Bastr 400 Old Austin Hwy Bastrop, TX 78602 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 0803 Level of Harm - Minimal harm or potential for actual harm RDN stated, they could slowly lose weight depending on the resident and depending on which serving it was and how many calories the resident needed, there could be a slow weight loss. An observation on 4/27/2023 at 12:10 p.m. revealed Resident #97 was eating a plate of pureed food in the dining room. Resident #97 was talking with family and unavailable for an interview. Residents Affected - Some An observation on 4/27/2023 at 12:11 p.m. reveal Resident #9 was eating pureed food in the dining room. Resident #9 said the food was good. During an interview on 4/27/2023 at 2:27 p.m., when asked how the facility ensured residents got enough to eat, the ADM stated, we have the diets that we follow and the RDN checks off. The ADM stated she went into the kitchen to do random rounds. The ADM stated the majority of residents had gained weight since they had been in the facility and if residents had lost weight, they had medical issues. When asked what the facility's policy was on following menus, the ADM stated, they follow the recipes because it says on there what they're supposed to utilize. The ADM stated the FSD and the RDN were responsible for ensuring compliance of that policy. When asked how the RSD and RDN monitored, the ADM stated, I know they're in there watching and looking at recipes. When asked how staff were trained on using the correct scoop sizes, the ADM stated she believed there was visual training with the scoop chart posted on the refrigerator as a visual cue. The ADM stated the recipes reflected which scoops to use. The ADM stated kitchen staff had been trained on scoops sizes by the FSD and the RDN. When asked if the FSD was checking the service line before each meal, the ADM stated, she should be checking it. When asked what a potential negative resident impact could include if residents did not receive adequate portions, the ADM stated, I feel comfortable with the weight system and I think this was an isolated thing and she was nervous. The ADM stated she would make sure there was additional education and monitoring. A record review of the facility's Monthly Weight Report dated 4/25/2023 reflected the following: Resident #25 lost 7.8% of his body weight from October 2022 - January 2023, which is considered severe weight loss. Resident #25 had no recorded weights for February, March, or April of 2023. Resident #9 and Resident #12 had gained weight from January 2023 - April 2023. Resident #97 had no recorded weights. A record review of the facility's recipe for pureed turkey [NAME] reflected Portion Size: 2 #8 SCOOPS. A record review of the facility's recipe for pureed mashed potatoes reflected Portion Size: #8 SCOOP. A record review of the facility's Diet Spreadsheet reflected residents on a pureed diet were to receive 2 #8 scoops of turkey [NAME] for lunch on 4/26/2023. A record review of the facility's Diet Spreadsheet reflected residents on a pureed diet were to receive a #8 scoop of mashed potatoes for lunch on 4/27/2023. A record review of the facility's in-service dated 1/09/2023 reflected the FSD trained dietary staff on portion size breakdown and the recipes book. The [NAME] was listed on the sign in sheet. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675356 If continuation sheet Page 5 of 8 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 675356 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Nursing and Rehabilitation Center of Bastr 400 Old Austin Hwy Bastrop, TX 78602 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A record review of the facility's in-service dated 1/24/2023 reflected the FSD trained dietary cooks on following portion sizes. The [NAME] was listed on the sign in sheet. A record review of the facility's in-service dated 3/09/2023, 3/17/2023, 3/23/2023, 3/30/23 reflected the FSD was trained by the RDN on the Spring-Summer 2023 menu, menu extensions, texture instructions on recipes, menu guide textures and menu guide. A record review of the facility's in-service dated 3/17/2023 reflected dietary staff were trained on pureed diets. The [NAME] was listed on the sign in sheet. A record review of the facility's in-service dated 4/14/2023 reflected the FSD trained dietary staff on scoop sizes and chart reading breakdown to use the right size. A record review of the facility's policy titled Menu planning dated 6/01/2019 reflected the following: Policy: The facility believes that nutrition is an important part of maintaining the well-being and health of its residents and is committed to providing a menu that is well-balanced, nutritious and meets the preferences of the resident population. A standardized menu which meets the nutritional recommendations of the residents in accordance with the recommended dietary allowances of the Food and Nutrition Board of the National Research Council, Nationals Academy of Sciences will be used. Modification for resident population and preferences may be made as appropriate. Procedure: 1. Menus will be prepared for each facility by their food vendor. Menus are updated twice each year with Spring-Summer and Fall-Winter cycles and are updated intermittently based on resident preferences. The menus will be for a five-week cycle and will include a week-at-a-glance menu, alternates, diet extensions for all diets offered for each day, nutritional analysis, standardized recipes, a production guide and an order guide. Menus are available in paper form and web-based. A record review of the facility's policy titled Portion Control dated 10/01/2018 reflected the following: Policy: The facility will use standard portion control procedures and utensils to ensure that adequate portions are served to residents. Procedure: 1. Standardized recipes should be used to prevent over-production. Recipes should be adjusted as needed to provide the amount of servings required. Amounts may vary when various serving methods and menus are utilized. 2. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675356 If continuation sheet Page 6 of 8 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 675356 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Nursing and Rehabilitation Center of Bastr 400 Old Austin Hwy Bastrop, TX 78602 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 0803 A dated copy of the daily menu extensions with portion sizes should be posted in the kitchen near the preparation and serving areas. Level of Harm - Minimal harm or potential for actual harm 3. Residents Affected - Some Portions for each food item should follow the specific portion sizes listed on the menus. 4. Food items should be served using standard size ladles, scoops, spoodles and spoons. Standard scoop and ladle sizes are listed in the following tables: A record review of the facility's policy titled Portion Control dated 10/01/2018 reflected a table for scoop sizes. The following was reflected: A #8 scoop was ½ cup and 4 oz. A #10 scoop was 3/8 cup and 3-3 ½ oz. A #12 scoop was 1/3 cup and 2 ½ - 3 oz. A #16 scoop was ¼ cup and 2-2 ½ oz. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675356 If continuation sheet Page 7 of 8 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 675356 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Nursing and Rehabilitation Center of Bastr 400 Old Austin Hwy Bastrop, TX 78602 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 0912 Level of Harm - Potential for minimal harm Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. Based on observation, interview, and record review the facility failed to ensure the required 80 square feet per resident for 48 of 48 rooms licensed for double occupancy. Residents Affected - Many The facility failed to ensure resident rooms had the required 80 square feet per resident. This deficient practice placed residents at risk for having a diminished quality of life. Findings included: Observations on 04/26/23 at 10:15 AM revealed two residents were in a room that did not have 80 square feet per resident . In an interview on 04/27/2023 at 10:53 AM the ADM stated all of the facility's double occupancy rooms measured less than 80 square feet per resident. She said the maintenance man told her the rooms measured approximately 158 square feet each. She said the facility was not planning on changing anything and there was no possible way to make any changes. She stated a waiver was requested when the facility submitted the plan of correction from last year's citation and the plan of correction was accepted. She stated this was the way she had always requested a room size waiver. She stated she wished to continue the room waiver and there was no room waiver policy. She stated she did not feel that there was any possibility for potential harm to residents. Record review of the facility map (undated) reflected 48 rooms were of the smaller size. Record review of the Bed Classification form dated 04/27/23 revealed all the resident rooms were licensed for double occupancy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675356 If continuation sheet Page 8 of 8