Health inspection·June 11, 2024

F 0584 residents who were starting to receive their lunches. There were two dead crickets on the dining room floor. Level of Harm - Minimal harm or potential for actual harm In an interview on 06/11/2024 at 1:35 PM LVN A stated she would expect dead bugs to be swept up in the dining room. Residents Affected - Some In an interview on 06/11/2024 at 1:50 PM the DON stated her expectation was for there to be no pests in the facility and for the rooms to be clean. In an interview on 06/11/2024 at 3:50 PM the ADM in training stated his expectation was for the facility to maintain livable conditions and there should be daily rounds to ensure cleanliness. He stated roaches and other insects on the dining room floor could affect the dignity of the residents. Record review of an undated facility Policy and procedure titled General Housekeeping Policies : The facility provided sufficient housekeeping and maintenance personnel, equipment and supplies to maintain the interior and exterior of the facility in a safe, clean, orderly, and attractive manner. All housekeeping personnel utilize the accepted practices and procedures to keep the facility free form offensive odors, accumulation of dirt, rubbish, dust, and hazards as well as participate in ongoing education and training to maintain their competency. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675356 If continuation sheet Page 2 of 11 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 06/11/2024 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 0732 Post nurse staffing information every day. Level of Harm - Potential for minimal harm Based on observation, interview, and record review, the facility failed to post required nurse staffing information in a prominent place readily accessible to resident and visitors. Residents Affected - Many The facility failed to ensure nurse staffing information was posted on 06/08/24 and 06/09/24. This failure could put residents, resident representatives, and visitors at risk of being unaware of actual staffing levels and available staff. Findings included: An observation on 06/09/24 at 10:29 AM revealed the posted staffing information was dated 06/07/24. During an interview on 06/11/24 at 9:50 AM, the DON stated the staffing information was to be posted daily and that she was responsible to post the papers. She stated the weekend charge nurse was responsible to ensure the posting was updated. She stated it did not meet her expectations that on 06/09/24, the document was dated 06/07/24. She stated there was no risk to the resident for not posting; the only risk was that the surveyor would cite them. Review of the facility policy, Nurse Staffing Posting Information, dated 10/24/22, reflected in part, It is the policy of this facility to make nurse staffing information readily available in a readable format to residents and visitors at any given time . 2. The facility will post the Nurse Staffing Sheet at the beginning of each shift. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675356 If continuation sheet Page 3 of 11 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 06/11/2024 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure PRN orders for psychotropic drugs are limited to 14 days unless the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order for 1 (Resident #23) 10 residents reviewed for pharmacy services. The facility failed to ensure Resident #23 had a stop date for PRN Ativan (a medicine used to treat the symptoms of anxiety). This failure could place residents at risk of being overmedicated or receiving unnecessary medications. Findings included: Review of Resident #23's annual MDS assessment, dated 04/03/24, Section A (Identification Information) reflected an [AGE] year-old female initially admitted to the facility on [DATE]. Section I (Active Diagnoses) reflected diagnoses that included Alzheimer's Disease (a type of dementia), cerebrovascular accident (stroke), arthritis (swelling and tenderness of joints), anxiety disorder (intense and excessive worry and fear), and depression (a mood disorder with persistent feeling of sadness and loss of interest). Section C (Cognitive Patterns) reflected a BIMS score of 00 indicating severely impaired cognition. Review of Resident #23's comprehensive care plan, revised 04/19/24, reflected the use of anti-anxiety medications and interventions to monitor for side effects. The care plan reflected the problem, [Resident #23] is at risk for digestive/bowel problems, headaches/migraines, rapid heartbeat, infections, substance misuse, insomnia, heart disease, isolation, frustration, and constant fear secondary to diagnosis of anxiety. Interventions included Administer medications as ordered. Behavioral health consults as needed. Monitor/record/report to MD prn mood patterns, signs and symptoms of depression, anxiety, sad mood . Review of Resident #23's physician's order dated 06/01/24 reflected, Ativan Oral Tablet 1 Mg (Lorazepam) Give 1 tablet by mouth every 4 hours as needed for anxiety related to anxiety disorder. The order had no end date. Review of Resident #23's Medication Administration Record for June 2024, reflected Ativan 1 mg was administered on both 06/09/24 and 06/10/24. During an interview on 06/11/24 at 9:50 AM, the DON stated all their PRN psychotropic medication orders were limited to 14 days. She stated they did not use PRN antipsychotic medications. She stated it did not meet her expectations that there was a PRN Ativan order without an end or stop date. She stated she was responsible for monitoring psychotropic medications and she was responsible for ensuring follow up on the pharmacist's recommendations. During an interview on 06/11/24 at 3:06 PM, the ADON stated PRN psychotropic medications should be (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675356 If continuation sheet Page 4 of 11 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 06/11/2024 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 0758 limited to 14 days to ensure the medications was still necessary. Level of Harm - Minimal harm or potential for actual harm Review of the facility policy, Psychotropic Medication, dated 08/15/22, reflected in part, 9. PRN orders for all psychotropic drugs shall be used only when the medication is necessary to treat a diagnosed specific condition that is documented in the clinical record, and for a limited duration (i.e., 14 days). a. If the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she shall document their rationale in the resident's medical record and indicate the duration for the PRN order Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675356 If continuation sheet Page 5 of 11 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 06/11/2024 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 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 observations, interviews and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation. The facility failed to ensure the kitchen floors, food preparation surfaces, pantry shelves and refrigerator shelves were clean. The facility failed to ensure frozen meat was thawed and stored properly prior to preparation. The facility failed to ensure stored foods were properly stored, labeled, and dated. These failures could place residents who received prepared meals from the kitchen at risk for food borne illness and cross-contamination. Findings included: Observation on 06/09/2024 at 9:00 AM in the facility kitchen revealed there were spilled liquids and food debris on all areas of the kitchen floor. All of the food preparation countertops had food spills and food debris. The shelves under the area containing the hot food serving trays had food spills and debris on them. A lid to a hot food serving tray had food debris on it and was sitting on top of a dirty box under the counter. The dry pantry floor had loose food debris on it and one of the shelves had pieces of dry cereal on it. A mop head in a plastic bag was on located on top of the canned goods. Observation on 06/09/2024 at 9:05 AM revealed a 10-pound roll of hamburger meat sitting on the countertop. The meat was soft and warm at one end and cooler toward the other end. It did not feel frozen. Observation on 06/09/2024 at 9:08 AM revealed the refrigerator in the kitchen contained an undated box of moldy green peppers with holes in them. The refrigerator shelves had food debris on them. There was a large container of undated cooked rice. There was a quart size container of liquid egg whites that was opened and not dated with an open date. A bottle of ranch dressing was opened, and the opened date was illegible. In an interview on 06/09/2024 at 9:10 AM the [NAME] stated she had worked at the facility for one year. She stated the hamburger meat was frozen when she got it out at 5 am that morning and she had put it on the counter to make a meatloaf for later. She stated it should not be sitting out on the counter and it had to be at a specific temperature, but she did not know what that was. She removed the hamburger meat from the counter and placed it in a container in the sink under cold running water. She stated the mop head should not have been on top of the canned goods and she removed the bag containing it. She further stated she had been off of work for two days. She stated she only had one worker on the 1-8 PM shift and her manager would come in on the night shift to clean the floors. She further stated the facility maintenance person was supposed to power wash the floors, but the facility maintenance person had only been employed for three days. In an interview on 06/11/2024 at 2:03 PM the Dietary Manager stated he had worked at the facility (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675356 If continuation sheet Page 6 of 11 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 06/11/2024 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many for four months. He stated he expected routine cleaning in the kitchen. He stated the kitchen was a little understaffed and they were missing two dietary aides. He stated he worked the morning shift for breakfast and assisted with lunch shift. He stated he would take a break and then return to the facility to work as a dietary aide in the evenings. He stated they had ads out to hire more staff but getting staff to stay had been an issue. He stated cleaning the kitchen would fall on everyone employed there and if a staff member saw something they should do something about it. He stated he tried to in-service and educate the staff. He stated food should be dated with the opened date and the date should be legible. He stated spoiled food should have been discarded. He stated when staff arrived in the morning or left for the night kitchen cleanliness and food labeling should have been checked. He stated there was no checklist or way to ensure accountability, but he would have to implement a checklist or duty sheet. He stated the moldy peppers in the refrigerator should have been discarded. He stated if closing duties had been implemented they would have caught the issues noted in the morning. He stated the 10-pound roll of hamburger meat should not have been left out on the countertop. He stated the potential risk to the residents was being served spoiled food or hamburger meat then there could be a food poisoning, or a food borne illness. In an interview on 06/11/2024 at 3:45 PM the ADM in training stated the facility should ensure all food are was prepped in a safe and sanitary way. He stated all foods in the refrigerator should have been labeled and dated and all raw foods should have been handled per guidelines, either by being kept in the freezer, refrigerator or under cold running water. He further stated the potential risk was spoiled food could adversely affect the resident's health and lead to a food borne illness. Record review of a facility policy and procedure dated 2018 and titled General Kitchen Sanitation reflected The facility recognizes that food borne illness has the potential to harm elderly and frail residents. All Nutrition and Food service employees will maintain clean, sanitary kitchen facilities in accordance with the state and US Food Codes in order to minimize the risk of infection and food borne illness. Procedure 1. Clean and sanitize all food preparation areas, food contact surfaces, dining facilities and equipment. After each use, clean and sanitize all tableware, kitchenware and food contact surfaces of equipment, except cooking surfaces of equipment and pot and pans that are not used to hold or store food and are used solely for cooking purposes. 6. Clean nonfood contact surfaces of equipment at intervals as necessary to keep them free of dust, dirt, food particles and otherwise in a clean and sanitary condition. Record review of a facility policy and procedure dated 2018 and titled Food Storage reflected Policy: To ensure all food served by the facility is of good quality and safe for consumption, all food will be stored according to the state, federal and US Food Codes and HACCP guidelines. Procedure: 1. Dry storage rooms. i. Do not use or store cleaning materials where they might contaminate foods. Store in locked area away from any food products. 2. Refrigerators a. Keep fresh meat, in the refrigerator at an internal temperature of 41 degrees F or less. d. Date, label and tightly seal all refrigerated foods. 3. Freezers i. Once frozen food has been thawed, it must be maintained at 41 degrees F or less prior to cooking. Record review of fda.gov, FDA Food Code 2022, dated 2022 reflected: 3-501.13 Thawing. Except as specified in (D) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be thawed: (A) Under refrigeration that maintains the FOOD temperature at 5 degrees C (41degrees F) or less Pf; or (B) Completely submerged under running water: (1) At a water temperature of 21degrees C (70degrees F) or below Pf, (2) With sufficient water velocity to agitate and float off loose particles in an overflow Pf, and (3) For a period of time that does not allow thawed portions (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675356 If continuation sheet Page 7 of 11 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 06/11/2024 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete of READY-TO-EAT FOOD to rise above 5degrees C (41degrees F) Pf, or (4) For a period of time that does not allow thawed portions of a raw animal FOOD requiring cooking as specified under 3-401.11(A) or (B) to be above 5oC (41degrees F), for more than 4 hours including: (a) The time the FOOD is exposed to the running water and the time needed for preparation for cooking Pf, or (b) The time it takes under refrigeration to lower the FOOD temperature to 5degrees C (41degrees F) Pf; 4-602.13 Nonfood-Contact Surfaces. Nonfood-CONTACT SURFACES of EQUIPMENT shall be cleaned at a frequency necessary to preclude accumulation of soil residues. Event ID: Facility ID: 675356 If continuation sheet Page 8 of 11 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 06/11/2024 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 1 (Resident #37) of 14 residents reviewed for infection control. Residents Affected - Few LVN A failed to perform hand hygiene after removing her gloves and before putting on clean gloves while performing wound care to Resident #37 on 06/11/24. This failure could place residents at risk for cross contamination and the spread of infection. Findings included: Review of Resident #37's Significant change in status MDS assessment, dated 04/24/24, Section A (Identification Information) reflected a [AGE] year-old female initially admitted to the facility on [DATE]. Section I (Active Diagnoses) reflected diagnoses including cerebral infarction due to embolism (obstructed blood flow to the brain due to a clot causing brain tissue damage), hypertension (high blood pressure), peripheral arterial disease (narrowing of arteries which results in reduced blood flow to the legs), hemiplegia (paralysis of one side of the body), dysphagia (difficulty swallowing), schizophrenia (a mental health disorder characterized by delusions, hallucinations, and disorganized thoughts), legal blindness, and muscle wasting/atrophy( degeneration or shrinkage of muscle). Section C (Cognitive Patterns) reflected a BIMS score of 3 indicating severely impaired cognition. Review of Resident #37's comprehensive care plan, revised 06/09/24, reflected, The resident has actual impairment to skin integrity of right heel related to PAD . Resident's opening to her right heel will show signs of healing . Apply treatment per medical practitioner's orders . Another problem reflected, Resident has actual impairment to skin integrity of the left buttock . opening to left buttock will show signs of healing . assist with turning and repositioning every 2 hours and as needed . Subsequent problems reflected skin impairment to right buttock and coccyx. During an observation on 06/11/24 at 11:23 AM to 11:47 AM, revealed LVN A performed wound care on Resident #37. The ADON was present in the room and recorded the wound measurements. LVN A washed her hands and donned gloves. With the brief already removed and the buttocks exposed, she measured the wounds on the left buttock. She doffed the gloves and, without performing hand hygiene, donned a new pair of gloves. She measured the wound on the coccyx. She doffed the gloves and, without performing hand hygiene, donned a new pair of gloves. She measured the wound on the right buttock, doffed the gloves then washed her hands. She donned gloves and measured an area on the resident's knee. She removed the gloves and washed her hands. She donned gloves and cleansed the left buttock. She doffed the gloves, and without performing hand hygiene, donned new gloves. She used gauze to pat dry the area. She doffed her gloves and without performing hand hygiene, she donned new gloves. She applied ointment to the wound then doffed her gloves and, without hand hygiene donned new gloves. The same process continued for the wound on the coccyx and the wound on the left buttock. LVN A washed her hands then donned new gloves. She measured the wound on the right heel. LVN A doffed her gloves, and without performing hand hygiene, donned new gloves. She cleansed the heel wound. LVN A doffed her gloves, and without performing hand hygiene donned new gloves and used gauze to pat the wound dry. LVN A opened a package of a medicated gauze and placed the wrapper in the red trash bag (biohazard waste) touching the inside of the bag with her gloved hands. She proceeded to apply the dressing to the wound (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675356 If continuation sheet Page 9 of 11 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 06/11/2024 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few without changing her gloves. LVN A was observed changing her gloves 20 times throughout wound care process. LVN A was observed washing her hands 6 times throughout the process. During an interview on 06/11/24 at 1:52 PM, LVN A stated she had received training on wound care, hand hygiene, and infection control. LVN A stated she was supposed to change gloves when moving from one field to another. When asked if she was familiar with the facility policy on hand hygiene she stated, I am now because they just showed me. She stated she did not perform hand hygiene each time she changed gloves, but it should have been performed before donning gloves, at every glove change, and when doffing gloves. She stated not performing hand hygiene increased the potential for contamination. During an interview on 06/11/24 at 3:06 PM, the ADON stated hand hygiene should be completed with each glove change. She stated during her observation earlier of wound care, LVN A changed her gloves about 30 times during wound care but did not perform hand hygiene every time. She stated not performing hand hygiene when changing gloves increased the potential for infection. During an interview on 06/11/24 at 3:10 PM, the acting ADM stated had hygiene should be performed when hands or gloves are visibly soiled, when starting a new procedure, after toileting, and multiple other times. He stated LVN A had counted 20 glove changes but did not perform hand hygiene with each glove change. He stated not performing hand hygiene with each glove change had the potential to increase the risk of contamination or infection. Review of the facility policy, Hand Hygiene, implemented 10/24/22, reflected in part, Hand Hygiene is a general term for cleaning your hands by handwashing with soap and water, or the use of an antiseptic had rub, also known as alcohol-based hand rub . 6. a. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675356 If continuation sheet Page 10 of 11 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 06/11/2024 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 interview, and record review the facility failed to ensure the required 80 square feet per resident for 47 of 47 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: In an interview on 06/11/2024 at 10:53 AM the acting ADM stated all of the facility's double occupancy rooms measured less than 80 square feet per resident. He said the facility was not planning on changing anything as there was no possible way to make any changes. He 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. He stated he wished to continue the room waiver and the health and safety of the residents would not be affected. He stated there was no room waiver policy. Record review of the facility map (undated) reflected 47 rooms did not have 80 square feet per resident. were of the smaller size . Record review of the Bed Classification form dated 06/10/2024 and signed by the acting ADM revealed all the resident rooms were licensed for double occupancy. Record review of the Room Size Waiver for Facilities form dated 06/10/2024 and signed by the acting ADM reflected the facility met all four criteria for a waiver including 1. The minimum square footage allowed for a waiver is 72 square feet per resident in multiple-use rooms. 2. Residents are ambulatory and have sufficient space to meet their needs and/or residents with physical disabilities have adequate space to meet accessibility standards. 3. The health and safety of the residents will not be adversely affected. 4. There is not impediment to the resident attaining the highest practicable well-being. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675356 If continuation sheet Page 11 of 11