Health inspection·July 17, 2025

F 0804 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete turn out right because of the shredded chicken. She stated she understood if food was not appealing how, it could affect a Resident, and they would not eat and possible loss weight. During an interview on 07/17/2025 at 11:11AM with the Administrator, he stated his expectations was for meals to be appealing. He stated he was not pleased with the food (Arroz Con [NAME]) presentation. He stated all food served is to be palatable to ensure Residents are getting a nutritionist meal. Record review of facility test tray policy dated October 1, 20218 reflected, The facility recognizes the importance of routine quality assurance monitoring to ensure that its residents are provided food that is appealing, palatable and served at the correct temperatures. Routine test trays will be evaluated by the Nutrition & Foodservice Manager or designated employee. Event ID: Facility ID: 675356 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 675356 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/17/2025 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 - Some FORM CMS-2567 (02/99) Previous Versions Obsolete 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 storage, preparation and sanitation.The facility failed to ensure the kitchen dry pantry shelves were clean. The facility failed to ensure frozen foods were properly 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: Kitchen Observation on 07/15/2025 beginning at 10:12 AM revealed the following items in freezer were not dated, labeled or sealed : *4 bags of French toast stick, not labeled and dated;*2 bags of waffles, not labeled and dated;*1 opened bag of waffles, not labeled, dated and sealed Observation on 07/15/2025 at 10:10:17 AM in the facility kitchen revealed there was food debris on the dry storage shelf .Observation on 07/15/2025 at 10:12AM revealed cooked biscuits in a plastic bag, sitting on top of the can goods. During an interview on 07/18/2025 at 11:00 AM, [NAME] A, said she was in-serviced to label and date desserts and drinks before they were placed in the refrigerator or dry storage. He said all food items and drinks in the kitchen should be labeled and dated on the date the items were opened. She stated she began an in-service with her staff on labeling and dating. The risk of not labeling and dating items could have led to staff giving expired food to residents, and the residents could have gotten sick.During an interview on 07/18/2025 at 11:05AM, the Dietary Manager said the expectation was for all foods to be labeled, dated and all food items that had been opened should be labeled and dated. She stated it was every dietary staff responsibility to ensure food items was labeled. She stated on 07/16/2025 she had completed an in-service regarding all labeling and dating food items in the kitchen. She said the risk of storing unlabeled items could have led to food-borne illnesses in residents. During an interview on 07/18/2025 11:11AM, the administrator said his expectation was for all food items to be dated and labeled . He said the risks associated with unlabeled and undated food items in the refrigerator or the dry storage area could have led to infection and illness in residents.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 Code dated 2022 revealed the following: Pathogens can contaminate and/or grow in food that is not stored properly. Event ID: Facility ID: 675356 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 675356 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/17/2025 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 establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections and follow accepted national standards for one of five residents (Resident #48). reviewed for infection control practices. The facility failed to ensure that staff wore a gown during medication administration via g-tube (a tube inserted into the stomach) for Resident #48. This failure could place the resident at risk for cross contamination.Findings Included: Review of Resident #48's Face sheet reflected a [AGE] year-old female, admitted on [DATE]. Diagnoses included Huntington's Disease (a genetic condition affecting the brain's nerve cells, causing gradual loss of function and cell death), dysphagia (difficulty swallowing), aphasia (difficulty using or comprehending language), and Alzheimer's disease (dementia that damages the brain). Review of Resident #48's Annual MDS dated [DATE] reflected the resident is rarely or never understood. The Functional Abilities section reflected she is dependent for all care. For section K0520 Nutritional Approaches, it indicated she used a feeding tube only for nutrition at the time of the assessment. Review of Resident #48's Orders reflected at order dated 04/16/2025 for Place on Enhanced Barrier Protection. Review of Resident #48's Care Plan reflected a Problem initiated on 05/28/2024 stating, [Resident #48] has the need for Enhanced Barrier Precautions due to: g-tube. Is at risk for infection, depression, feelings of isolation, and decline in physical activity. The Interventions dated 05/28/2024 included, Place on Enhanced Barrier Precautions, ensure a sign is placed on the door to notify staff and visitors of the precautionary measures: Gown and gloves only for high-contact resident care activities (dressing, bathing/showering, personal hygiene, changing linens, assisting with toileting, perineal/incontinent care, medical device care or use, wound care). Observation of medication administration with LVN A on 07/16/2025 at 08:40AM, revealed LVN A did not wear a gown while administering medications via G-tube for Resident #48. In an interview with LVN A on 07/16/2025 at 08:54AM, she stated that she should have worn a gown to administer medications via g-tube for Resident #48. She stated that potential impact to the resident of not wearing a gown while administering medications via g-tube could be the potential spread of infection to the resident. In an interview with IP on 07/17/2025 at 11:32AM, she stated that she was the Infection Preventionist for the facility. She stated it was her responsibility to monitor and educate staff regarding EBP (Enhanced Barrier Precautions). She stated that it was her expectation that staff wear gowns and gloves when providing care to residents with PEG (type of g-tube) tubes, during wound care, and during medication administration. She stated that not wearing a gown and gloves during g-tube medication administration would put the resident at potential risk for infection. In an interview on 07/17/2025 at 12:56PM with the DON, she stated that staff are supposed to wear and gown and gloves during medication administration with a g-tube. She stated that the risk to the resident of not wearing a gown and gloves during medication administration with a g-tube is the potential to cause infection for the resident. In an interview on 07/17/2025 at 12:58PM with ADMIN, he stated it was his expectation that staff follow precautions per the signage on the door. He stated he would defer to nursing regarding the specific cares that require the precautions. He stated that not following EBP when indicated would increase the risk of infection for the resident receiving care. Review of facility Infection Control Program policy dated 05/13/2023 reflected, Policy: This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675356 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 675356 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/17/2025 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 FORM CMS-2567 (02/99) Previous Versions Obsolete standards and guidelines.5. Isolation Protocol (Transmission-Based Precautions):a. A resident with an infection or communicable disease shall be placed on transmission-based precautions as recommended by current CDC guidelines. Review of the CDC guidelines for Enhanced Barrier Precautions in Nursing Homes dated 05/20/2024 reflected, EBP are indicated for residents with any of the following: Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO.Indwelling medical device examples include central lines, urinary catheters, feeding tubes, and tracheostomies. A peripheral intravenous line (not a peripherally inserted central catheter) is not considered an indwelling medical device for the purpose of EBP.EBP should be used for any residents who meet the above criteria, wherever they reside in the facility. Event ID: Facility ID: 675356 If continuation sheet Page 5 of 5