Health inspection·March 31, 2023

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview and record review on [DATE] at 2:22 p.m., the DON stated DNR forms started with the SW in getting completed. The DON stated he was unaware of Resident #7's DNR being incomplete. The DON stated the potential harm to the resident was doing the wrong code instruction. During an interview on [DATE] at 2:31 p.m., the Administrator, agreed with the DON, that the DNR form started with the SW in getting completed. The Administrator was also unaware that Resident #7's DNR was not completely signed. The Administrator stated the potential harm to resident was not following the correct code instructions. Record review of the facility's policy titled, Cardiopulmonary Resuscitation (CPR), dated [DATE] , which read It is the policy of this facility to adhere to residents' rights to formulate advance directives. In accordance to these rights, this facility will implement guidelines regarding cardiopulmonary resuscitation (CPR). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675409 If continuation sheet Page 2 of 21 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 675409 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Mission Oaks 3030 S Roosevelt Ave San Antonio, TX 78214 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 0583 Keep residents' personal and medical records private and confidential. 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 ensure residents have a right to personal privacy for 1 of 6 resident (Resident #57) reviewed for privacy, in that: Residents Affected - Few CNA A and CNA B did not completely close Resident #57's privacy curtain while providing incontinent care for the resident. This deficient practice could place residents at-risk of loss of dignity due to lack of privacy. The findings include: Record review of Resident #57's face sheet, dated 03/30/2023, revealed an admission date of 02/07/2019, and a readmission date of 04/05/2021, with diagnoses which included: Dementia(loss of cognitive functioning - thinking, remembering, and reasoning), Parkinson's disease (Progressive disorder that affect the nervous system), Type 2 diabetes mellitus(blood glucose, also called blood sugar, is too high.), Chronic kidney disease(gradual loss of kidney function), Chronic obstructive pulmonary disease(a chronic inflammatory lung disease that causes obstructed airflow from the lungs) Record review of Resident #'57's Annual MDS, dated [DATE], revealed the resident had a BIMS score of 10 indicating moderate impairment. Resident #57 required limited to extensive assistance and was always incontinent of bladder and, frequently incontinent of bowel. Observation on 03/30/23 at 01:46 p.m. revealed CNA A and CNA B provided incontinent care for Resident #57, CNA A and CNA B did not pull the curtains completely around Resident #57's bed to offer privacy to the resident during care. Resident #57's genitals and buttocks were exposed during care. Resident #57's roommate was laying down in his bed. Further observation revealed the privacy curtain was too short and partially broken and could not offer complete privacy. The end of the bed was partially exposed. Anybody opening the room's door and entering would have been able to seen the resident. During an interview with CNA A on 03/30/2023 at 1:54 p.m., CNA A confirmed the staff was supposed to provide complete privacy during care and close completely the privacy curtain. She confirmed the end of bed was partially uncovered. She stated the privacy curtain was broken and needed to be replaced. She revealed they had told the housekeeping department in the morning but the curtain still had to be changed. She confirmed receiving training about privacy during care. During an interview with the Housekeeping Supervisor on 03/31/23 12:10 PM, the Housekeeping supervisor confirmed housekeeping had been told about the broken curtain in Resident #57's room. They were not able to change it right away because all the curtain were locked in the maintenance office. During an interview with the DON on 03/31/2023 at 1:28 p.m., the DON confirmed the curtain should have been closed during care to provide privacy. The DON confirmed the staff received training on resident rights. The facility did annual skill checklists with the staff. The ADON did audits every weekend on different staff to check their knowledge and skills. The DON revealed the facility had ordered new curtains to replace the broken curtains but they were too short. Review of the facility's policy titled Perineal care, dated 10/24/2022, revealed, Provide privacy by pulling privacy curtain or closing room door if a private room. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675409 If continuation sheet Page 3 of 21 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 675409 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Mission Oaks 3030 S Roosevelt Ave San Antonio, TX 78214 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 0640 Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the interview and record review, the facility failed to transmit the resident assessment within the required time frame for 1 of the 3 discharged residents reviewed for data encoding and transmission. (Resident # 120). Residents Affected - Few The facility did not submit a discharge not anticapated MDS for Resident # 120. This failure could put residents discharged from the facility at risk of not having their assessments transmitted acurately . Findings included: 1.Record review of the face sheet for Resident # 120, dated 3/30/2023, revealed a [AGE] year-old male admitted to the facility on [DATE] and discharged on 12/28/22 with diagnosis that included: [Dementia] (a condition characterized by progressive or persistent loss of intellectual functioning, especially with memory impairment and abstract thinking. [Hypertension] (is blood pressure that is higher than normal) and [Schizophrenia] (is a serious mental illness that affects how a person thinks, feels, and behaves). Record review of discharge MDS dated [DATE] revealed that discharge MDS was completed and submitted for a return anticipated. Record review of nurses' notes for 12/28/2022 revealed that Resident # 120 was picked up by van from another facility. During an interview on 03/29/23 at 10:11 a.m., the MDS nurse stated that Resident #120 was discharged from the facility on 12/28/22. The discharge MDS was marked as return anticipated because, at times, discharged residents return before 30 days. During an interview on 03/29/23 at 10:57 a.m., the DON said the MDS was transmitted within the required timeframes and was unaware of marking it return anticipated he was unable to provide a copy of a policy for transmitting MDS as the facility uses the RAI manual. During an interview on 03/29/23 at 02:30 p.m., the administrator said the MDS was transmitted within the required timeframes and was unaware of marking it return anticipated. CMS's RAI Version 3.0 Manual CH 2: Assessments for the RAI, Resident Transfers: It has been determined that the resident will not return to the evacuating facility, the evacuating provider will discharge the resident return not anticipated, and the receiving facility will admit the resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675409 If continuation sheet Page 4 of 21 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 675409 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Mission Oaks 3030 S Roosevelt Ave San Antonio, TX 78214 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 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the assessment accurately reflected the resident's status for 2 of 28 residents (Residents #48 and, #33) whose assessments were reviewed, in that: Residents Affected - Few 1. Resident #48's Quarterly MDS incorrectly documented the resident as receiving an insulin injection. 2. Resident #33's Quarterly MDS did not indicate he had experienced a significant weight loss. This deficient practice could place residents at-risk for inadequate care due to inaccurate assessments. The findings were: 1. Record review of Resident #48's face sheet, dated 03/31/2023, revealed an admission date of 01/10/2014 and a readmission date of 04/02/2018 with diagnoses that included: Type 2 diabetes mellitus (A chronic condition that affects the way the body processes blood sugar), Hypertension(high blood pressure), Hyperlipidemia(blood has too many lipids (or fats), such as cholesterol and triglycerides), Hepatic failure (slow decline in liver function) Record review of Resident #48's Medication administration record for February 2023 revealed orders for: - TRULICITY 1.5 MG/0.5 ML PEN Inject 0.5 ml subcutaneously in the evening every Sat for DIABETES INJECT SUBCUTANEOUSLY EVERY SATURDAY Record review of Resident #48's Annual MDS, dated [DATE], revealed the assessment indicated Resident #48 received an injection of insulin. During an interview with the MDS nurse D on 03/31/2023 at 11:47 a.m., the MDS nurse confirmed she had completed the MDS. The MDS nurse confirmed Resident #48's Annual MDS was coded as the resident having received an insulin injection when Resident #48 had only received Trulicity(medication used for the treatment of type 2 diabetes in combination with diet and exercise) . The MDS nurse revealed she did not know Trulicity should not be coded as an insulin. During an interview with the DON on 03/31/23 at 01:25 p.m., the DON confirmed Trulicity was a non insulin injection pen and should not have been coded as an insulin injection. The DON revealed the RAI was used as reference for the MDS and the MDS nurses had access electronically to the RAI on their computer. Record review of, Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Version 1.17.1, October 2019, revealed, Enter in Item N0350A, the number of days during the 7-day look-back period (or since admission/entry or reentry if less than 7 days) that insulin injections were received 2. Review of Resident #33's face sheet, dated 3/31/23, revealed he was admitted to the facility on [DATE] with diagnosis to include Dementia, Diabetes and Renal insufficiency. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675409 If continuation sheet Page 5 of 21 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 675409 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Mission Oaks 3030 S Roosevelt Ave San Antonio, TX 78214 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 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident #33's quarterly MDS, dated [DATE], did not reflect that Resident #33 had experienced a significant weight loss. Review of Resident #33's weights from [DATE] to March 2023 revealed Resident #33 experienced a 91.43 weight loss from October 2022 to March 2023. Further review a revealed he experienced a 12.4 % weight loss in 3 months. Interview on 03/31/23 at 10:37 AM weight MDS Coordinator E confirmed Resident #33's quarterly MDS, dated [DATE], did not indicate a weight loss. He stated Resident #33 had a 12.4 % weight loss in 3 months. He stated he depended on PCC to flag a significant weight loss. MDS Coordinator E stated it was important to provide an accurate description of resident changes and care needs. MDS Coordinator E stated he used the RAI as a reference to complete MDS assessments. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675409 If continuation sheet Page 6 of 21 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 675409 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Mission Oaks 3030 S Roosevelt Ave San Antonio, TX 78214 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights meet a resident's mental and psychosocial needs for 1 of 6 Residents (Resident #19) whose records were reviewed for care plans. Resident #19's Care Plan did not reflect she was a hoarder affecting her daily living. This deficient practice could affect any resident and contribute to resident needs not being met. The findings were: Review of Resident #19's face sheet, dated 3/23/23, revealed she was admitted to the facility on [DATE] with diagnoses including Seizure Disorder, Anxiety Disorder, Depression, Psychotic Disorder and Schizophrenia. Review of Resident #19's quarterly MDS, dated [DATE] revealed Resident #19's BIMS score was 8 (out of 15) reflective of moderate cognitive disorder. Further review revealed Resident #19 experienced hallucinations and delusions. Review of Resident #19's Care Plan revised on 3/13/23 revealed it did not reflect that Resident #19 was a hoarder which impacted her daily living. Observation on 03/29/23 at 10:07 AM revealed clutter around Resident #19's bed impeding a clear path to the bathroom or anywhere else in her room. Further observation revealed 2 storage bins, a straw basket with items in it including a blanket and other bags and items by her bedside. There was also a wheelchair next to her bed and a rolling walker at the foot of her bed. Observation on 03/30/23 at 10:24 AM revealed Resident #19 lying in bed. There were 2 storage bins, a straw basket with items in it including a blanket and other bags and items by her bedside. There was also a wheelchair next to her bed and a rolling walker at the foot of her bed. Interview with Resident #19 presented as being alert with confusion. She stated she was moving which was why the items were stacked by her bedside. Interview on 03/31/23 at 10:25 AM with MDS Coordinator D and MDS Coordinator E revealed they should have identified Resident #19's behavior as a safety concern and implemented safety measures. MDS Coordinators D and E stated they did not realize the resident was a hoarder. Interview on 3/31/23 at 1:36 PM with LVN G revealed Resident #19 had been a hoarder since the resident's admission to the facility and the family would bring items in. LVN G stated Resident #19 would get mad if staff moved her items but had never tried talking to her about safety concerns. Interview on 03/31/23 at 1:45 PM with the DON revealed he understood how the clutter around Resident #19's bed would potentially be a safety hazard. The DON further stated the facility's IDT had not discussed interventions that would address the residents hoarding behaviors and ensure her environment remained free of hazards. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675409 If continuation sheet Page 7 of 21 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 675409 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Mission Oaks 3030 S Roosevelt Ave San Antonio, TX 78214 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of facility policy, Comprehensive Care Plans, dated 1024/22, read in part: 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 timeframe's to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. 3. The comprehensive care plan will describe at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being. Review of facility policy, Fall Prevention Program, read in part: Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. 7. Each resident's risk factors and environmental hazards will be evaluated when developing the resident's comprehensive plan of care. a. Interventions will be monitored for effectiveness. b. The plan of care will be revised as needed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675409 If continuation sheet Page 8 of 21 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 675409 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Mission Oaks 3030 S Roosevelt Ave San Antonio, TX 78214 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible for 1 of 1 residents (Resident #19) whose records were reviewed for falls, in that: Staff failed to identify Resident #19's hoarding behavior as a safety hazard and to implement safety measures. This deficient practice could affect any resident and contribute to avoidable falls. The findings were: Review of Resident #19's face sheet, dated 3/31/23, revealed she was admitted to the facility on [DATE] with diagnoses including Seizure Disorder, Generalized Anxiety Disorder, Major Depressive Disorder, unspecified Psychosis, Obsessive-Compulsive Disorder and Schizoaffective Disorder. Review of Resident #19's quarterly MDS, dated [DATE] revealed Resident #19's BIMS score was 8 (out of 15) reflective of moderate cognitive disorder; she required extensive assistance by 1 person for bed mobility, toileting, transfers, locomotion on and off the unit. Further review revealed Resident #19 had 2 falls including one with a major injury. Review of Resident #19's Care Plan, revised on 3/13/23, revealed she had a fall and dislocated her right shoulder on 2/20/23 due to weakness, poor balance and unsteady gait. Further review revealed the resident's Care Pan did not identify Resident #19's clutter, related to her hoarding behaviors, in her room as a potential safety hazard. Further review revealed Resident #19 had impaired vision due to history of cataracts, she had a seizure disorder and she was receiving psychotropic medications which all made her vulnerable for falls. Review of Resident #19's fall risk evaluation, dated 3/3/23, revealed she was a high risk for falls. Review of Resident #19's incident and accident history from January to March 2023 revealed she fell twice on 2/14/23 and on 2/20/23 in her room. Review of incident report dated, 2/14/23, revealed an unidentified CNA reported Resident #19 attempted to transfer to bed and mattress slipped to floor. Resident #19 was on the floor in sitting position next to her bed with mattress next to her. X-rays were ordered for right elbow, right lumbar and right shoulder. Findings revealed right shoulder dislocation. Review of incident report dated 2/20/23 revealed Resident #19 was observed on the floor in her room. Upon assessment Resident #19 complained of pain to right arm, right lumbar and right shoulder.dislocated her right shoulder on 2/20/23. Observation on 03/29/23 at 10:07 AM revealed clutter around Resident #19's bed impeding a clear path to the bathroom or anywhere else in her room. Further observation revealed 2 storage bins, a straw basket with items in it including a blanket and other bags and items by her bedside. There was also (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675409 If continuation sheet Page 9 of 21 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 675409 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Mission Oaks 3030 S Roosevelt Ave San Antonio, TX 78214 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 0689 a wheelchair right next to her bed and a rolling walker at the foot of her bed. Level of Harm - Minimal harm or potential for actual harm Observation and interview on 03/30/23 at 10:24 AM revealed Resident #19 lying in bed. There were 2 storage bins, a straw basket with items in it including a blanket and other bags and items by her bedside. There was also a wheelchair right next to her bed and a rolling walker at the foot of her bed. Interview with CNA F revealed she had seen Resident #19 take a few steps in her room. She stated Resident #19 had slid down in the shower but had not seen her fall in her room. CNA F stated the clutter was a risk for tripping. She stated Resident #19 would get upset when staff moved anything. Residents Affected - Some Observation and interview on 03/30/23 at 10:27 AM revealed Resident #19 woke up during the conversation with CNA F. Interview with Resident #19 revealed she presented as being alert with confusion. Resident #19 stated she was moving which was why the items were stacked by her bedside. Observation on 3/31/23 at 11:37 AM revealed Resident #19 lying in bed asleep. There were 2 storage bins, a straw basket with items in it including a blanket and other bags and items by her bedside. There was also a wheelchair right next to her bed and a rolling walker at the foot of her bed. Interview with CNA P revealed Resident #19 was a fall risk. She required assistant with transfers and close supervision. CNA P stated Resident #19 was able to bare weight but was not always steady. CNA P stated she knew Resident #19 had a history of falls but was not sure if she sustained any injuries. CNA P stated Resident #19's was barricaded to her bed because of her personal belongings by the dresser and the wheelchair located right next to her bed. CNA P stated the resident did not like it when staff moved her belongings but further stated she had not tried talking to Resident #19 about moving them. She stated Resident #19 was on fall precautions including a low bed, her wheelchair was supposed to be locked when not in use especially because she would transfer herself without assistance. CNA P stated the wheelchair was not locked and the environment should be free of clutter which she stated it was not. CNA P stated the right brake did not work and she would usually tell the DOR because he would repair faulty parts on the wheelchairs. CNA P stated she had not noticed the brake did not work and had not reported it to the DOR. Interview on 3/31/23 at 1:36 PM with LVN G revealed Resident #19 had been a hoarder since the resident's admission to the facility and the family would bring items in. LVN G stated Resident #19 would get mad if staff moved her items but had never tried talking to her about safety concerns. LVN G stated she was aware Resident #19 had a history of falling and she had dislocated her right shoulder. LVN G stated fall precautions in place included a low bed; the wheelchair should be locked when not in use, but stated it was not locked. LVN G stated Resident #19 wanted to independent and would try to walk on her own. LVN G stated Resident #19 did not always ask for assistance and was able to bare weight but at times was not steady. LVN G stated there was limited walking space around Resident #19's bed because of her personal belongings and could potentially become a trip hazard for Resident #19. LVN G stated the clutter definitely impeded her path to the bathroom or to the doorway. Interview on 03/31/23 at 1:45 PM with the DON revealed Resident #19 had a history of falls, history of infections including UTI's but mostly pneumonia. The DON stated Resident #19 had been a hoarder for years and he had discussed it with the family. The DON stated he was aware she had storage bins by her bed including her wheelchair and rolling walker. The DON stated Resident #19 was difficult to re-direct and would become angry when staff attempted to move her belongings which would affect her mood. The DON stated he understood how the clutter would potentially be a safety hazard. he DON further stated the facility's IDT had not discussed interventions that would address the residents hoarding behaviors and ensure her environment remained free of hazards. The DON he stated he wrestled with wanting to keep Resident #19 safe and respecting her rights. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675409 If continuation sheet Page 10 of 21 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 675409 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Mission Oaks 3030 S Roosevelt Ave San Antonio, TX 78214 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Review of facility policy, Fall Prevention Program, read in part: Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. 5. High Risk Protocols: a. Provide interventions that address unique risk factors measured by the risk assessment tool: medications, psychological, cognitive status, or recent change in functional status. 7. Each resident's risk factors and environmental hazards will be evaluated when developing the resident's comprehensive plan of care. a. Interventions will be monitored for effectiveness. b. The plan of care will be revised as needed. Event ID: Facility ID: 675409 If continuation sheet Page 11 of 21 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 675409 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Mission Oaks 3030 S Roosevelt Ave San Antonio, TX 78214 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 6 resident (Resident #57) reviewed for incontinent care, in that: While providing incontinent care for Resident #57, CNA A used a back to front motion to clean Resident #57's genitals. This deficient practice could place residents at-risk for infection and skin break down due to improper care practices. The findings were: Record review of Resident #57's face sheet, dated 03/30/2023, revealed an admission date of 02/07/2019, and a readmission date of 04/05/2021, with diagnoses which included: Dementia(loss of cognitive functioning - thinking, remembering, and reasoning), Parkinson's disease (Progressive disorder that affect the nervous system), Type 2 diabetes mellitus(blood glucose, also called blood sugar, is too high.), Chronic kidney disease(gradual loss of kidney function), Chronic obstructive pulmonary disease(a chronic inflammatory lung disease that causes obstructed airflow from the lungs) Record review of Resident #'57's Annual MDS, dated [DATE], revealed the resident had a BIMS score of 10 indicating moderate impairment. Resident #57 required limited to extensive assistance and was always incontinent of bladder and, frequently incontinent of bowel. Review of Resident #57's care plan, dated 08/19/2020, revealed a problem of The resident has FUNCTIONAL bladder incontinence r/t Confusion, Dementia, Impaired Mobility Monitor/document for s/sx UTI: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse,increased temp, Urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. Observation on 03/30/2023 at 1:46 p.m. revealed while providing incontinent care for Resident #57, CNA A wiped Resident #57's penis starting at the base of the shaft in at upward motion, creating a back to front motion. She also clean the scrotum of Resident #57 before cleaning his penis. During an interview on 03/30/2023 at 1:54 p.m. with CNA A, she confirmed she had wiped Resident #57's scrotum first and wiped the penis in an upward motion. She said she thought she was using the correct technique. She confirmed receiving training on incontinent care from the facility. During an interview with ADON C on 03/30/2023 at 1:56 p.m., ADON C confirmed the right motion to clean the penis during perineal care is a circular motion around the head and wiping the shaft toward the Scrotum. She confirmed the staff was trained for incontinent care and their skills were checked periodically. During an interview with the DON on 03/31/2023 at 1:28 p.m., he confirmed the correct motion to clean the residents during perineal care was front to back to prevent fecal matter from contacting the urethra and possibly cause an infection. The DON reveled the staff received training on infection (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675409 If continuation sheet Page 12 of 21 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 675409 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Mission Oaks 3030 S Roosevelt Ave San Antonio, TX 78214 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 0690 Level of Harm - Minimal harm or potential for actual harm control and incontinent care at least annually. The staff skills were check yearly. The ADON spot check the staff while they provided care for infection control and quality of care. Review of annual skills check for CNA A revealed CNA A passed competency for Perineal care/incontinent care on 11/24/2022. Residents Affected - Few Review of facility policy, titled Perineal care, dated 10/24/2022, revealed [ .] Males [ .]g. Cleanse the shaft of the penis, using downward strokes toward the scrotum. [ .] h. Cleanse the scrotum. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675409 If continuation sheet Page 13 of 21 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 675409 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Mission Oaks 3030 S Roosevelt Ave San Antonio, TX 78214 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 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 revealed the facility failed to store, distribute and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen, in that: Residents Affected - Many 1. Kitchen staff stacked plates that were wet for meal service. 2. Kitchen staff failed to keep the two -compartment oven clean. 3. Kitchen staff failed to store chemicals off the floor. 4. Kitchen staff failed to cover 4 trays of regular diet pumpkin pie dessert plates and 1 tray of puree pumpkin pie dessert cups. 5. The DM and [NAME] O failed to ensure their hairnet covered all of their hair. These deficiencies could affect residents who ate meals prepared from the kitchen and could contribute to the spread of foodborne illness. The findings were: 1. Observation and interview during kitchen tour on 3/28/23 at 9:15 AM revealed a shelving unit beside the steam table on the left side. There were multiple plates and covers stacked that were dripping wet. Interview with the DM confirmed the plates and covers were wet and she instructed one of the dishwashers to place them on the rack to dry. The DM stated bacteria could form when plates were stacked and wet. The DM further stated most residents' immune systems were compromised, and kitchen staff had to be careful about following sanitation guidelines so the residents did not get sick. 2. Observation and interview on 3/28/23 at 9:20 AM revealed the stove with a two-compartment oven were both black on the bottom with what looked like burned food residue. Interview with the DM revealed the [NAME] and Dietary Aides were supposed to deep clean the ovens once a week but the ovens did not look like they had been cleaned in some time based on the black burned residue. 3. Observation and interview on 3/28/23 at 9:30 AM in the outside storage unit revealed multiple boxes of liquid cleaning bottles (20-25) on the floor. The bottom shelf of the shelving unit on the right side was caved down in the middle and the bottles of cleaning supplies were basically on the floor. Interview with the DM revealed chemicals were supposed to be 4 to 6 inches off the floor. She stated the boxes of cleaning supplies were supposed to be placed on top of a pallet. She stated the shelving unit had collapsed because of the weight. 4. Observation in the kitchen on 3/30/23 at 11:12 AM during meal service delivery revealed 4 trays with individual pumpkin pie on dessert plates and 1 tray of puree pumpkin pie dessert cups. All were on a food cart and uncovered. 5. Observation and interview on 3/30/23 at 11:17 AM revealed [NAME] O prepping lunch meal trays. There was a stack of plates placed on the shelf of the steam table. The inside center base of the plates were wet. Interview with [NAME] O confirmed the plates were wet but she continued to use them. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675409 If continuation sheet Page 14 of 21 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 675409 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Mission Oaks 3030 S Roosevelt Ave San Antonio, TX 78214 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 Further observation revealed [NAME] O's hair was coming down on her neck. The hairnet did not hold all of her hair in place. Further interview with [NAME] O revealed she was in a hurry this morning and she usually wore her bun higher so it did not fall out of her hairnet. She stated her hair could fall into the food and contaminate the food. Observation on 3/30/23 at 11:30 AM revealed the DM walked into the kitchen. The DM had hair sticking out of the hair net on the bottom and sides of her head. Interview with the DM revealed she would adjust her hair net multiple times a day but it would not stay in place. The DM stated her hair could fall into the food and contaminate the food. Interview on 3/31/23 at 12:20 PM with the DM revealed [NAME] O should have replaced the wet plates with dry plates. The DM stated bacteria could form and make the residents sick. Review of facility policy, Sanitation Procedures, revised January 2002, read in part: To serve in order to prevent contamination and foodborne illness. Serving: 6. Transport food to as follows to prevent contamination. a Cover or wrap food sent out to the floor or resident/patient room. Personal Hygiene: 3. Wear a hair restraint at all times. Cover all hair. Interview on 3/31/23 at 3:05 PM with the Administratot revealed, this is the extent of what we have, for kitchen policy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675409 If continuation sheet Page 15 of 21 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 675409 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Mission Oaks 3030 S Roosevelt Ave San Antonio, TX 78214 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 0814 Dispose of garbage and refuse properly. Level of Harm - Potential for minimal harm Based on observation and interview the facility failed to dispose of garbage and refuse properly including 1 of 2 garbage containers, in that: Residents Affected - Many The facility staff failed to keep the sliding door closed to prevent the harborage and feeding of pests. This deficient practice could affect any resident and contribute to the spread of diseases and infections. The findings were: Observation on 03/30/23 at 5:40 PM revealed the sliding door was open to the dumpster positioned on the left side. Interview on 3/30/23 at 5:45 PM with RN N confirmed the sliding door was open to the dumpster positioned on the left side. RN N stated the sliding door of the dumpster was open to any rodents, insects and other critters that could climb inside. RN N stated he had seen a possum sitting on the fence line located about 20 feet from the open dumpster. RN N further stated the rodents and insects carry diseases, bite a resident and infect the resident. RN N stated it was important to keep the doors closed to prevent this from taking place. Interview on 3/31/23 at 12:20 PM with the DM revealed any staff taking out trash was responsible for keeping the doors closed. The DM stated in addition, kitchen staff were responsible for ensuring the doors were kept closed and the area around the dumpsters were free of debris. The DM stated kitchen staff would make rounds periodically when they took out the trash and at the end of day. Interview on 3/31/23 at 12:26 PM with the Administrator revealed the facility did not have a policy for the dumpsters. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675409 If continuation sheet Page 16 of 21 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 675409 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Mission Oaks 3030 S Roosevelt Ave San Antonio, TX 78214 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 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician, and others participating in the provision of care for 1 of 5 residents (Resident #76) reviewed for hospice services, in that: Facility did not ensure Resident #76's hospice records were a part of their records in the facility This deficient practice could place residents who receive hospice services at-risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care and communication of resident needs. The findings were: Record review of Resident #76's face sheet, dated 03/31/2023, revealed the resident was admitted to the facility on [DATE] with diagnoses that included: major depressive disorder, lung cancer, chronic kidney disease, dementia, emphysema, nicotine dependence, anxiety disorder and insomnia. Record review of Resident #76's quarterly MDS, dated [DATE], revealed a BIMS score of 11 which indicated moderate cognitive impairment. Record review of Resident #76's physician orders, dated 03/31/2023, revealed an order entered 12/21/2022 which read Admit to [Hospice Name and Phone Number], DX: Lung Cancer. Record review of a list of hospice residents, dated as of 03/09/2023, revealed Resident #76 was admitted to hospice on 12/09/2022. Record review of Resident #76's EHR did not reveal any hospice related records to include: (a) the most recent hospice plan of care; (b) the hospice election form; (c) physician certification and recertification of the terminal illness; (d) names and contact information for hospice personnel involved in hospice care (e) hospice medication information; (f) hospice physician orders; and (g) any progress notes from any provider visits. During an interview on 03/31/2023 at 3:35 p.m., the Administrator verbally confirmed Resident #76's hospice documentation was not currently in the facility when he stated the hospice company was currently faxing all the required paperwork at that time. The Administrator stated the facility had a difficult time keeping a hospice resident binder at the nurse's station because the residents at this facility had a history of picking up items and then the staff were unable to find them. The Administrator stated the hospice company was responsible for ensuring the facility had all the required hospice documentation in the residents records. The Administrator stated he was aware of certain hospice documentation for hospice residents were required to be in the facility. Record review of [Hospice Name] contract, provided by the facility, originally signed 04/15/2015, revealed the hospice agency went through a name change on 03/31/2017. Further review revealed under 2.14 Providing information. HOSPICE shall promote open and frequent communication with FACILITY and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675409 If continuation sheet Page 17 of 21 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 675409 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Mission Oaks 3030 S Roosevelt Ave San Antonio, TX 78214 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 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few shall provide FACILITY with sufficient information to ensure that the provision of services under this Agreement is in accordance with the Hospice Plan of Care, assessments, treatment planning and care coordination. HOSPICE will respond promptly to any communications by FACILITY concerning changes in the condition of a Hospice Patient. HOSPICE will promptly inform FACILITY of any change in a Hospice Patient's condition which requires a modification to the Hospice Plan of Care. In addition, at a minimum, HOSPICE shall provide the following information to FACILITY for each Hospice Patient: a. Hospice Plan of Care, Medications and Orders. The most recent Hospice Plan of Care, medication information and physician orders specifically to each Hospice Patient residing at Facility; b. Election Form. The hospice election form and any advanced directives; c. Certification. Physician certification and recertifications of terminal illness. d. Contact Information. Names and contact Information for HOSPICE personnel involved in providing Hospice services; and e. On Call Information. Instructions on how to access HOSPICE's 24 hour on-call system. Record Review of the facility policy titled Hospice Policy, revised 12/2017, revealed, Our facility contracts for hospice services for residents who wish to participate in such programs. Our facility has entered into a contractual arrangement for hospice services to make sure that residents who wish to participate in a hospice program may do so. When a resident participates in the hospice program, a coordinated plan of care between the facility, hospice agency is developed. The resident's care plan should be revised and updated with changes. All hospice services are provided under contractual arrangement. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675409 If continuation sheet Page 18 of 21 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 675409 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Mission Oaks 3030 S Roosevelt Ave San Antonio, TX 78214 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 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to maintain an effective pest control program for 7 of 24 residents (Residents #8, #12, #21, #52, #75 #108, #115) reviewed for pests, in that: Residents Affected - Some Facility failed to ensure their pest control program was thoroughly working in all areas of the facility This failure could affect residents by increasing their risk of exposure to pests, vector-borne diseases, and infections. The findings were: 1. Record review of Resident #8's face sheet, dated 03/31/2023, revealed the resident was re-admitted on [DATE] with diagnoses that included: paranoid schizophrenia, age-related, physical debility, diabetes type 2, and HIV disease. Record review of Resident #8's annual MDS, dated [DATE], revealed a BIMS score of 08, which indicated moderate cognitive impairment. 2. Record review of Resident #12's face sheet, dated 03/31/2023, revealed the resident was admitted on [DATE] with diagnoses that included: schizoaffective disorder, chronic kidney disorder, dementia, and major depressive disorder, and heart failure. Record review of Resident #12's quarterly MDS, dated [DATE], revealed a BIMS score of 14, which indicated borderline cognitive impairment. 3. Record review of Resident # 21's face sheet, dated 03/29/2023, revealed admitted to the facility on [DATE] with diagnosis that included: dementia (a progressive or persistent loss of intellectual functioning), bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration), and schizophrenia (a serious mental disorder in which people interpret reality abnormally). Record review of Resident #21's quarterly, MDS dated [DATE], revealed a BIMS of 12, indicating severe cognitive impairment. 4. Record review of Resident # 52's face sheet, dated 03/29/2023, revealed admitted to the facility on [DATE] with diagnosis that included: cerebral infarction (occurs because of disrupted blood flow to the brain due to problems with the blood vessels that supply it), bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration), and hypothyroidism (when the thyroid gland doesn't make enough thyroid hormones to meet your body's needs). Record review of Resident #52's quarterly MDS, dated [DATE], revealed a BIMS left blank, indicating Resident was unable to complete the interview. 5. Record review of Resident #75's face sheet, dated 03/31/2023, revealed the resident was re-admitted on [DATE] with diagnoses that included: paranoid schizophrenia, heart failure, major depressive (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675409 If continuation sheet Page 19 of 21 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 675409 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Mission Oaks 3030 S Roosevelt Ave San Antonio, TX 78214 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 0925 disorder, and anxiety disorder. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #75's quarterly MDS, dated [DATE], revealed a BIMS score of 12, which indicated moderate cognitive impairment. Residents Affected - Some 6. Record review of Resident # 108's admission face sheet dated 3/29/2023, revealed admitted to the facility on [DATE] with diagnosis that included: hypertension (blood pressure higher than normal), diabetes mellitus (A disease in which the body does not control the amount of glucose in the blood and the kidneys make a large amount of urine), and functional quadriplegia (complete immobility due to severe physical disability). Record review of Resident #108's quarterly MDS, dated [DATE], revealed a BIMS left blank indicating Resident was unable to complete interview. 7. Record review of Resident #115's face sheet, dated 03/31/2023, revealed the resident was admitted on [DATE] with diagnoses that included: schizophrenia, heart failure, hepatitis C, and chronic kidney disorder. Record review of Resident #115's quarterly MDS, dated [DATE], revealed a BIMS score of 12, which indicated moderate cognitive impairment. During an interview, in the resident group meeting, on 03/29/2023 at 10:27 a.m., Residents #8, #12, #75 and #115 all stated the facility has fruit flies in different areas of the facility. These residents also stated they see these flies around their food and in their rooms. The residents described seeing these flies as being unhabituated and gross. During an observation and interview on 03/29/2022 at 10:39 a.m., Resident #21 was observed lying in bed. There were four flies on his blankets and one fly on the wall near the head of his bed. When asked if the flies bothered him, (Resident #21), CNA K stated, Oh. well. yes. they are here sometimes. During an observation on 03/30/2023 at 12:28 p.m., multiple flies were noted in Resident #21's room as CNA K and CNA L provided incontinent care for Resident #21. During an observation on 03/30/2023 at 1:25 p.m., multiple flies were noted on the face of Resident #108, while in his room. During an interview on 03/31/2023 at 9:40 a.m., CNA K and CNA L stated, We have flies here all the time, it's because some of the residents are hoarders. During an interview on 03/31/2023 at 10:15 a.m., with LVN M she was asked if residents' rooms were checked for hoarding and unnecessary food items removed. She stated, CNA's and nurses check rooms each shift, and unnecessary items are removed if residents allow us to. During an interview on 03/31/2023 at 12:23 p.m., the MS said he was responsible for monitoring pests in the facility and notifying pest control. He stated that pest control comes out monthly and as needed. The MS, further, stated pest control serviced, this facility, at the begining of this month and flies were not treated. The MS stated Flies are an ongoing problem as residents don't wash their hands enough and run the sinks there for flies come from the pipes. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675409 If continuation sheet Page 20 of 21 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 675409 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Mission Oaks 3030 S Roosevelt Ave San Antonio, TX 78214 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 0925 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Record review of the pest control log revealed that pest control comes out monthly with last service was on 3/1/2023. Furrther review revealed flies was not written as a concern. During an interview on 03/31/2023 at 11:32 a.m., the Administrator stated flies are sometimes in his building and he contacted pest control services to help with the issue, and new tablets were provided to place in residents' sinks to help irradiate the pests. A policy for pest control was requested and per the administrator, they do not have a policy for pest control. Event ID: Facility ID: 675409 If continuation sheet Page 21 of 21