Health inspection·June 27, 2025

F 0552 Ensure that residents are fully informed and understand their health status, care and treatments. 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 resident had the right to be informed in advance of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options, and to choose the alternative or option he preferred for 1 of 3 Residents (Resident #91) whose records were reviewed for informed consent. Residents Affected - Few The facility failed to ensure psychoactive medication consents for Resident #91's were signed and dated by his Guardian for the use of Zyprexa (antipsychotic medication), Haldol (antipsychotic medication), Perseris (atypical antipsychotic), Zoloft (anti-depressant) and Trazodone (anti-depressant). This failure could place residents at risk for receiving psychoactive medications without consent and knowledge of side effects. The findings were: Record review of Resident #91's admission Record dated 6/27/2025 revealed a [AGE] year-old-man admitted [DATE] and re-admitted on [DATE] with diagnoses which included: Schizoaffective Disorder (a mental health condition including schizophrenia and mood disorder symptoms); Anxiety Disorder (condition with intense, excessive, and persistent worry and fear about everyday situations) and Major Depressive Disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities). Further review revealed Resident #91 had a legal guardian. Record review of Resident #91's annual MDS assessment dated [DATE] revealed he had a BIMS score of 14 indicating intact cognition and was taking anti-psychotic, anti-anxiety, and anti-depressant medications. Record review of Resident #91's Order Summary dated 6/27/2025 revealed orders which included: - Haloperidol Lactate Oral Concentrate 2mg/ml - Give 2 ml by mouth two times a day related to Schizoaffective Disorder, Bipolar Type. - Perseris Prefilled Syringe 120mg (Risperidone ER). Inject 120 mg subcutaneously one time a day starting on the last day of month and ending on the last day of month every month related Schizoaffective Disorder, Bipolar Type. - Trazodone HCL Oral Tablet 150mg. Give 1 tablet by mouth at bedtime for insomnia. - Zoloft Oral Tablet 50 mg (Sertraline HCL) Give 1 tablet by mouth one time a day related Page 1 of 22 675409 675409 06/27/2025 Windsor Mission Oaks 3030 S Roosevelt Ave San Antonio, TX 78214

F 0552 Schizoaffective Disorder, Bipolar Type; Anxiety Disorder. Level of Harm - Minimal harm or potential for actual harm - Zyprexa Zydis Oral Tablet Disintegrating 15mg (Olanzapine) Give 1 tablet by mouth at bedtime related Schizoaffective Disorder, Bipolar Type. Residents Affected - Few Record review of Resident #91's Care Plan initiated 04/05/2021 revealed problem areas which included: -use of antipsychotic medications (Zyprexa, Perseris, Haldol) r/t Schizoaffective disorder bipolar type; -use of anti-anxiety medications (Ativan) r/t Anxiety disorder; -use of antidepressant medication (Trazodone, Zoloft) r/t insomnia, depression. Interventions on these problem areas of the Care Plan included intervention to Educate the resident/family/caregivers about risks, benefits and the side effects and/or toxic symptoms of psychotropic medication drugs being given Interview was attempted with Resident #91 on 06/24/2025 at 12:00 p.m. but he was unable to answer any questions about the medications he takes. Record review of Resident #19's Consent for Antipsychotic or Neuroleptic Medication Treatment for Zyprexa, Haldol and Perseris reflected it was signed by the Health Care Professional recommending treatment on 4/15/2021, but the signature of the Legal Guardian was not dated. Record review of Resident #19's Informed Consent for Psychoactive Medications for the medications Zoloft and Trazodone reflected it did not include the dates of the signature of the facility representative providing the information or the date telephone consent was obtained from the Legal Guardian. During an interview on 06/26/2025 at 2:56 p.m., ADON-C stated she was the facility representative who signed the Informed Consent and obtained the telephone consent from Resident #19's Legal Guardian for his Zoloft and Trazodone and confirmed she had not dated her signature or the telephone consent from the Legal Guardian. ADON-C further stated she failed to ensure the signature of the Legal Guardian was dated for his combined consent for the Zyprexa, Haldol and Perseris. ADON-C stated she must have just forgotten to date the signatures on the consents, and stated that it was important to have signatures dated on the consents to show that proper consent was obtained prior to starting the medication or treatment. Record review of the facility policy titled use of Psychotropic medications dated 03/05/2025 revealed: - Prior to initiating or increasing a psychotropic medication, the resident, family, and/or resident representative must be informed of the benefits, risks, and alternatives for the medication, including any black box warnings for antipsychotic medications, in advance of such initiation or increase; and -The facility will document that the resident or resident representative was informed in advance of 675409 Page 2 of 22 675409 06/27/2025 Windsor Mission Oaks 3030 S Roosevelt Ave San Antonio, TX 78214

F 0552 Level of Harm - Minimal harm or potential for actual harm the risks and benefits of the proposed care, the treatment alternatives or other options and the preferred option to accept or decline in a format the facility deems to use (e.g., written consent form, narrative note, etc.). . Residents Affected - Few 675409 Page 3 of 22 675409 06/27/2025 Windsor Mission Oaks 3030 S Roosevelt Ave San Antonio, TX 78214

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure a comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments for 1 of 29 residents (Resident #49) reviewed for care plans. 1. The facility failed to revise Resident #49's comprehensive care plan to include a diagnosis of depression.2. The facility failed to revise Resident #49's comprehensive care plan to include the resident's use of a psychotropic medication (Sertraline).These failures could place residents at risk of not receiving appropriate interventions to meet their current health needs.The findings were: 1. Record review of Resident #49's face sheet dated 06/25/2025 revealed the resident was a [AGE] year old male with diagnoses that included: Type II diabetes with hyperglycemia (a chronic condition when the body cannot use insulin correctly and sugar builds up in the blood), fracture of surgical neck of right humerus (a break in the upper arm bone where it connects to the shoulder joint), hypertensive heart disease (heart conditions that develop as result of high blood pressure) and major depressive disorder, single episode (a severe depressive episode lasting at least two weeks marked by persistent sadness, loss of interest in previously enjoyed activities, and significant impairment in daily functioning).Record review of Resident #49's significant change MDS dated [DATE] revealed a BIMS score of 10/15, indicating the resident had moderately impaired cognition. Section I - Active Diagnoses revealed I5800, Depression (other than Bipolar) was checked.Record review of Resident #49's quarterly MDS dated [DATE] revealed a BIMS score of 15/15, indicating the resident had intact cognition. Section I - Active Diagnoses revealed I5800, Depression (other than Bipolar) was checked.Record review of Resident #49's Active Diagnoses List dated 06/26/2025 revealed a diagnosis of Major Depressive Disorder, Single Episode, Unspecified. The date of the diagnosis was 02/07/2025.Record review of Resident #49's comprehensive care plan, revised 06/24/2025, revealed a focus area noting Resident #49 had the potential to be physically aggressive, initiated 03/25/2025. Interventions included administering medications as ordered and psychiatric/psychogeriatric consult as indicated. There was no focus area indicating a diagnosis of depression, goals, or interventions for the diagnosis.2. Record review of Resident #49's Active Orders as of 06/26/2025 revealed an order for: Zoloft Oral Tablet 25 MG (Sertraline HCl) Give 1 tablet by mouth one time a day for depression. Active 02/07/2025, Start Date 02/08/2025. No end date was indicated.Record review of Resident #49's significant change MDS dated [DATE] and quarterly MDS dated [DATE] revealed both indicated in Section N0415. High-Risk Drug Classes: Use and Indication, C., Antidepressant was checked.Record review of Resident #49's comprehensive care plan, revised 06/24/2025, revealed there was no focus area indicating the use of a psychotropic medication, goals, or interventions for this medication.During an interview on 06/27/2025 at 1:05 PM, MDS RN O stated both Resident #49's diagnosis of depression and his use of a psychotropic medication were not noted as focus areas in his updated comprehensive care plan and should have been. He was responsible for updating care plans did not know why the diagnosis and medication were missed, as the resident received two MDS assessments since both the diagnosis was made and the medication was prescribed. He had a system for noting which residents required care plan updates and he simply missed updating Resident #49's care plan. MDS RN O stated it was important for the diagnosis of depression to be in the care plan so staff could monitor for signs and symptoms of depression, such as its potential effect on the resident's nutritional status and his interaction with others, and the for the psychotropic medication to be noted so staff could monitor for potential side effects.During an interview on 06/26/2025 at 1:30 PM, ADON C stated both Resident #49's 675409 Page 4 of 22 675409 06/27/2025 Windsor Mission Oaks 3030 S Roosevelt Ave San Antonio, TX 78214

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few diagnosis of depression and his order for the psychotropic medication Sertraline should have been noted in his comprehensive care plan, MDS RN O was responsible for updating resident care plans, and she could not explain the omissions in Resident #49's care plan.Record review of facility policy Care Plan Revisions Upon Status Change implemented 10/24/2022 revealed, The purpose of this procedure is to provide a consistent process for reviewing and revising the care plan for those residents experiencing a status change. 1. The comprehensive care plan will be reviewed, and revised as necessary, when a resident experiences a status change. 2. Procedure for reviewing and revising the care plan when a resident experiences a status change: a. Upon identification of a change in status, the nurse will notify the MDS Coordinator, the physician, and the resident representative, if applicable. b. The MDS Coordinator and the Interdisciplinary Team will discuss the resident condition and collaborate on intervention options. c. The team meeting discussion will be documented in the nursing progress notes. d. The care plan will be updated with the new or modified interventions. e. Staff involved in the care of the resident will report resident response to new or modified interventions. f. Care plans will be modified as needed by the MDS Coordinator or other designated staff member. 675409 Page 5 of 22 675409 06/27/2025 Windsor Mission Oaks 3030 S Roosevelt Ave San Antonio, TX 78214

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Based on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 2 of 3 residents (Residents #30 and #41) reviewed for incontinent care, in that: 1. The facility failed to ensure CNA I thoroughly cleaned Resident #30 while providing incontinent care. 2. The facility failed to ensure CNA N used the right technique to clean Resident #41 while providing incontinent care. This deficient practice could place residents at-risk for infection and skin break down due to improper care practices. The findings were: 1. Record review of Resident #30's face sheet, dated 06/26/2025, revealed an admission date of 05/01/2012, and a readmission date of 04/23/2022 with diagnoses which included: Type 2 diabetes mellitus (high level of sugar in the blood), Chronic obstructive pulmonary disease (progressive lung disease characterized by airflow limitation), Hypertension (High blood pressure), Hyperlipidemia (Elevated level of any or all lipids(fat) in the blood), Bipolar disorder (Mental disorder characterized by periods of depression and periods of abnormally elevated mood), Major depressive disorder (mental disorder characterized by at least two weeks of pervasive low mood, low self-esteem, and loss of interest or pleasure), Osteoporosis (Condition causing bones to become fragile and brittle). Record review of Resident #30's Quarterly MDS assessment, dated 06/16/2025, revealed Resident #30 has a BIMS score of 12, which indicated moderate cognitive impairment. Further review revealed Resident #30 required extensive assistance with ADLs and was indicated to frequently be incontinent of bladder and occasionally incontinent of bowel. Record review of Resident #30's care plan, dated 09/08/2020, revealed a problem of The resident has functional bladder incontinence r/t Confusion, with a goal of The resident will remain free from skin breakdown due to incontinence and brief use through the review date. Observation on 06/26/2025 at 1:10 p.m. revealed, while providing incontinent care for Resident #30, CNA I did not clean the buttocks and hips areas of the resident. During an interview on 06/26/2025 at 1:20 p.m. CNA I stated she did not clean the resident's buttocks' cheeks area or the hips area. CNA I stated she should have cleaned the buttocks and hips areas. CNA I stated she was nervous. CNA I stated she received training for infection control and incontinent care within the last year. During an interview with ADON C on 06/27/2024 at 2:05 p.m., ADON C stated the buttocks and hips areas had to be cleaned. The ADON stated the regional trainer was the one training the staff for infection control and incontinent care and that the ADONs and the regional trainer would check the staff skills annually and as needed if a problem was noted. 675409 Page 6 of 22 675409 06/27/2025 Windsor Mission Oaks 3030 S Roosevelt Ave San Antonio, TX 78214

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of the Facility's policy, titled Perineal care, dated 10/24/2022. revealed Cleanse buttocks and anus, front to back. 2. Record review of Resident #41's face sheet, dated 06/26/2025, revealed an admission date of 01/10/2014, and a readmission date of 10/31/2024 with diagnoses which included: Type 2 diabetes mellitus (high level of sugar in the blood), Hypertension High blood pressure), Dementia (decline in cognitive abilities), Chronic prostatitis (Inflammation of the prostate gland causing painful urination), Major depressive disorder (mental disorder characterized by at least two weeks of pervasive low mood, low self-esteem, and loss of interest or pleasure), Schizophrenia (mental disorder characterized by abnormal thought processes and an unstable mood). Record review of Resident #41's Quarterly MDS assessment, dated 06/09/2025, revealed Resident #41 has a BIMS score of 14, which indicated mild cognitive impairment. Further review revealed Resident #41 required extensive assistance with ADLs and was indicated to have an indwelling catheter and was always incontinent of bowel. Record review of Resident #41's care plan, dated 10/10/2018, revealed a problem of The resident has bowel incontinence r/t Dementia AEB confusion At risk for skin breakdown, with a goal of The resident will have no skin breakdown r/t incontinence through the review date. Observation on 06/26/2025 at 1:49 p.m. revealed, while providing incontinent care for Resident #41, CNA N used a back to front motion, from buttocks to scrotum, to clean the resident buttocks and scrotum area . During an interview on 06/26/2025 at 2:00 p.m. CNA N stated she used a back to front motion to clean Resident #41 and she should have used a front to back motion. She stated she was nervous. CNA N stated she received training for infection control and incontinent care within the last year. During an interview with ADON C on 06/27/2024 at 2:05 p.m., ADON C stated the staff should always use a front to back motion to clean residents to prevent the risk of cross contamination and infection for the residents. Review of the Facility's policy, titled Perineal care, dated 10/24/2022. revealed Cleanse buttocks and anus, front to back. Review of Peri-care: What Every Caregiver Needs to Know By mmLearn.org on Fri, Jun 14, 2019 revealed Moving from front to back, use warm water and a clean washcloth (or disposable wipes) to clean the perineal area. For females, this involves cleaning the inner legs, labia, and groin area while for men it requires cleaning the tip and shaft of the penis, along with the scrotum. Both men and women require cleaning of the anal area, which will involve turning the patient on his/her side. 675409 Page 7 of 22 675409 06/27/2025 Windsor Mission Oaks 3030 S Roosevelt Ave San Antonio, TX 78214

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that a resident who is fed by enteral means receives the appropriate treatment and services to prevent complications of enteral feeding for 1 of 1 resident (Resident #9 ) reviewed for enteral feeding (method to provide nutrition and fluids directly into digestive tract via a feeding tube): LVN Q failed to flush Resident #9's enteral feeding tube per physician's orders. This deficient practice could place residents who received enteral nutrition and medications at increased risk of aspiration, infection, bloating discomfort, and not receiving the full benefit of the medications administered. The findings included: Record review of Resident #9's admission Record dated 06/26/2025 revealed a [AGE] year-old man admitted on [DATE] with re-admission on [DATE], with diagnoses which included: Cerebral Infarction (stroke); Dysphagia (difficulty swallowing food or liquids); and Gastrostomy Status (a surgical procedure in which a tube is inserted directly into the stomach through the abdominal wall to provide a way to deliver nutrition, fluids, or medications). Record review of Resident #9's admission MDS assessment dated [DATE] revealed the resident was moderately cognitively impaired for daily decision-making skills and utilized an enteral feeding tube. Record review of Resident #9's Order Summary Report dated 06/26/2025 revealed the following Physician Orders: - Enteral Feed Order as needed Complete tube site care q shift. - Enteral Feed Order five times a day Flush with 130ml water before and after each feeding. - Enteral Feed Order five times a day related to APHASIA FOLLOWING CEREBRAL INFARCTION (169.320) Bolus with Two Cal HN 1 carton (237ml) 5x/day via Gtube. Provides 2375 Kcal, 99G protein, 830ml free water, 2130 total ml fluids + water flushes. Record review of Resident #9's comprehensive care plan with initiation date of 05/10/2024 revealed the resident required tube feeding related to Dysphagia, NPO, with interventions which included The resident is dependent with tube feeding and water flushes. See MD order for current feeding orders. Observation on 06/26/2025 at 11:00a.m. of Resident #9's bolus enteral feeding revealed LVN Q administered one-half carton of Two Cal HN formula without flushing Resident #9's G-tube with 130ml of water before administering the formula. LVN Q realized her mistake after pouring half the carton of formula into the syringe, and after the syringe was empty, LVN Q administered the 130ml of water, and then administered the last half of the Two Cal HN formula. During an interview on 06/26/2025 at 11:07 a.m., LVN Q stated she should have flushed Resident #9's g-tube with 130 ml of water prior to administering his bolus feeding of formula, but she was in a 675409 Page 8 of 22 675409 06/27/2025 Windsor Mission Oaks 3030 S Roosevelt Ave San Antonio, TX 78214

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few hurry and just forgot. She stated she realized her mistake after pouring the first half of his formula and tried to correct by administering the water midway through his bolus feeding. LVN Q stated not flushing the G-tube with water first could result in the G-tube not being cleared, and could cause clogging of the G-tube. During an interview on 06/26/2025 at 3:47 p.m., ADON-C stated LVN-Q should have followed physician orders and flushed the G-tube with the prescribed amount of water before administering Resident #9's formula, and that not flushing first could result in the tube becoming clogged. Record review of facility policy titled Enteral Tube Medication Administration dated 10/01/2019 revealed Check the medication administration record (MAR) to confirm the order: note the medication, dose, route (tube) and volume of water for flushing and Medication administration via tube requires flushing with water at several steps in the procedure . 675409 Page 9 of 22 675409 06/27/2025 Windsor Mission Oaks 3030 S Roosevelt Ave San Antonio, TX 78214

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. Based on observations, interviews and record reviews the facility failed to ensure that CNAs were able to demonstrate competency in skills and techniques necessary to care for residents' needs for 2 of 3 residents (Residents #30 and #41 ) by 2 of 8 CNAs (CNA I and CNA N) reviewed for competent staff, in that: 1. The facility failed to ensure CNA I thoroughly cleaned Resident #30 while providing incontinent care. 2. The facility failed to ensure CNA N used the right technique to clean Resident #41 while providing incontinent care. This deficient practice could place residents at-risk for infection and skin break down due to improper care practices. The findings were: 1. Record review of Resident #30's face sheet, dated 06/26/2025, revealed an admission date of 05/01/2012, and a readmission date of 04/23/2022 with diagnoses which included: Type 2 diabetes mellitus (high level of sugar in the blood), Chronic obstructive pulmonary disease (progressive lung disease characterized by airflow limitation), Hypertension (High blood pressure), Hyperlipidemia (Elevated level of any or all lipids(fat) in the blood), Bipolar disorder (Mental disorder characterized by periods of depression and periods of abnormally elevated mood), Major depressive disorder (mental disorder characterized by at least two weeks of pervasive low mood, low self-esteem, and loss of interest or pleasure), Osteoporosis (Condition causing bones to become fragile and brittle). Record review of Resident #30's Quarterly MDS assessment, dated 06/16/2025, revealed Resident #30 has a BIMS score of 12, which indicated mild to moderate cognitive impairment. Further review revealed Resident #30 required extensive assistance with ADLs and was indicated to frequently be incontinent of bladder and occasionally incontinent of bowel. Record review of Resident #30's care plan, dated 09/08/2020, revealed a problem of The resident has functional bladder incontinence r/t Confusion, with a goal of The resident will remain free from skin breakdown due to incontinence and brief use through the review date. Observation on 06/26/2025 at 1:10 p.m. revealed, while providing incontinent care for Resident #30, CNA I did not clean the buttocks and hips areas of the resident. During an interview on 06/26/2025 at 1:20 p.m. CNA I stated she did not clean the resident's buttocks' cheeks area or the hips area. CNA I stated she should have cleaned the buttocks and hips areas. CNA I stated she was nervous. CNA I stated she received training for infection control and incontinent care within the last year. During an interview with ADON C on 06/27/2024 at 2:05 p.m., ADON C stated the buttocks and hips areas had to be cleaned. The ADON stated the regional trainer was the one training the staff for infection control and incontinent care and that the ADONs and the regional trainer would check the staff skills annually and as needed if a problem was noted. 675409 Page 10 of 22 675409 06/27/2025 Windsor Mission Oaks 3030 S Roosevelt Ave San Antonio, TX 78214

F 0726 Level of Harm - Minimal harm or potential for actual harm Review of Facility's competency check for CNA I, dated 9/13/2024, revealed CNA I passed competency for infection control and incontinent care. Review of the Facility's policy, titled Perineal care, dated 10/24/2022. revealed Cleanse buttocks and anus, front to back. Residents Affected - Some Review of Peri-care: What Every Caregiver Needs to Know By mmLearn.org on Fri, Jun 14, 2019 revealed Moving from front to back, use warm water and a clean washcloth (or disposable wipes) to clean the perineal area. For females, this involves cleaning the inner legs, labia, and groin area while for men it requires cleaning the tip and shaft of the penis, along with the scrotum. Both men and women require cleaning of the anal area, which will involve turning the patient on his/her side. 2. Record review of Resident #41's face sheet, dated 06/26/2025, revealed an admission date of 01/10/2014, and a readmission date of 10/31/2024 with diagnoses which included: Type 2 diabetes mellitus (high level of sugar in the blood), Hypertension High blood pressure), Dementia (decline in cognitive abilities), Chronic prostatitis (Inflammation of the prostate gland causing painful urination), Major depressive disorder (mental disorder characterized by at least two weeks of pervasive low mood, low self-esteem, and loss of interest or pleasure), Schizophrenia (mental disorder characterized by abnormal thought processes and an unstable mood). Record review of Resident #41's Quarterly MDS assessment, dated 06/09/2025, revealed Resident #41 has a BIMS score of 14, which indicated mild cognitive impairment. Further review revealed Resident #41 required extensive assistance with ADLs and was indicated to have an indwelling catheter and was always incontinent of bowel. Record review of Resident #41's care plan, dated 10/10/2018, revealed a problem of The resident has bowel incontinence r/t Dementia AEB confusion At risk for skin breakdown, with a goal of The resident will have no skin breakdown r/t incontinence through the review date. Observation on 06/26/2025 at 1:49 p.m. revealed, while providing incontinent care for Resident #41, CNA N used a back to front motion, from buttocks to scrotum, to clean the resident buttocks and scrotum area . During an interview on 06/26/2025 at 2:00 p.m. CNA N stated she used a back to front motion to clean Resident #41 and she should have used a front to back motion. She stated she was nervous. CNA N stated she received training for infection control and incontinent care within the last year. During an interview with ADON C on 06/27/2024 at 2:05 p.m., ADON C stated the staff should always use a front to back motion to clean residents to prevent the risk of cross contamination and infection for the residents. The ADON stated the regional trainer was the one training the staff for infection control and incontinent care and that the ADONs and the regional trainer would check the staff skills annually and as needed if a problem was noted. Review of Facility's competency check for CNA N, dated 07/06/2024, revealed CNA N passed competency for infection control and incontinent care. Review of the Facility's policy, titled Perineal care, dated 10/24/2022. revealed Cleanse buttocks and anus, front to back. 675409 Page 11 of 22 675409 06/27/2025 Windsor Mission Oaks 3030 S Roosevelt Ave San Antonio, TX 78214

F 0726 Level of Harm - Minimal harm or potential for actual harm Review of Peri-care: What Every Caregiver Needs to Know By mmLearn.org on Fri, Jun 14, 2019 revealed Moving from front to back, use warm water and a clean washcloth (or disposable wipes) to clean the perineal area. For females, this involves cleaning the inner legs, labia, and groin area while for men it requires cleaning the tip and shaft of the penis, along with the scrotum. Both men and women require cleaning of the anal area, which will involve turning the patient on his/her side. Residents Affected - Some 675409 Page 12 of 22 675409 06/27/2025 Windsor Mission Oaks 3030 S Roosevelt Ave San Antonio, TX 78214

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observations, interviews, and record reviews the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls, for 1 of 3 nurse medication carts (Hall 500 medication cart) reviewed for security and supervision and for one of one medication room reviewed for safe storage of medications requiring refrigeration. 1. The facility failed to ensure that LVN-R did not leave out a vial of insulin on top of the medication cart and leave that medication cart unlocked and out of line of sight when she went inside Resident #15's room to administer his medication.2. The facility failed to store medications within recommended temperature range in the medication refrigerator in the medication storage room.These deficient practices could place residents at risk of medication misuse or drug diversion and of not receiving therapeutic affect from their medications.The findings included:Observation on 06/26/2025 at 4:26 p.m., revealed LVN-R prepared Resident #15's insulin, drawing up 2 units of Novolin R into a syringe, and then entered Resident #15's room to administer his insulin. LVN-R left the vial of Novolin R unsecured on top of the medication cart and the medication cart unlocked when she went in the room to administer the insulin. During an interview with LVN-R on 06/26/2025 at 4:36 p.m., LVN-R stated she should not have left the insulin vial unsecured on top of the medication cart and the medication cart unlocked when she went into Resident #15's room, as this could have resulted in another resident walking by and taking the insulin, or even getting into the medication cart.Interview on 06/26/2025 at 7:00 p.m. with ADON-C revealed she had already been informed of the incident by LVN-R, and stated LVN-R should not have left the insulin out unsecured, nor left the medication cart unlocked when she went into the resident's room, as this could have resulted in another resident taking the medication. The ADON stated that LVN-R had received training on medication administration, including keeping medications secure and locked.2. During an inspection of the medication refrigerator in the only medication room in the facility on 06/25/2025 at 8:47 a.m. with ADON-C, the temperature of the refrigerator was noted to be at 29 degrees Fahrenheit (F), and re-check 2 minutes later revealed a temperature of 30 degrees F. Inventory of medications stored in the refrigerator included:-22 vials of various insulin vials-8 Trulicity pens-9 containers of various eye drops including Latanoprost and Atropine-27 vials of Lorazepam (anti-anxiety medication)-1 container of Ciproflaxacin (antibiotic)- 4 vials of Perseris/Risperdal (anti-psychotic)-6 vials of Cogentin -2 suppositories of Bisocdyl-5 suppositories of APAP (Tylenol)Record review of the temperature log for medication refrigerator for the month of June 2025 revealed there were 17 of 25 daily entries which recorded a temperature below freezing (32 degrees F). There was no acceptable temperature range listed on the temperature log.During an interview with ADON-C on 06/25/2025 at 8:47 a.m. while inspecting the medication refrigerator revealed ADON-C was initially unable to state the recommended temperature range medications were supposed to be stored at and review of the June 2025 temperature log with ADON-C revealed that there was no temperature range listed on the refrigerator temperature log to provide guidance to the nurses checking the temperature when variances from that temperature should be reported and addressed. ADON-C stated that the temperature range should be on the refrigerator temperature log and she would ensure that it was added to the log and the Nurse's would be inserviced as to correct temperature and what to do if temperature out of range. During an interview on 06/26/2025 at 9:55 am. the Regional Nurse stated that medications stored in the refrigerator should not be stored at below freezing temperature, as this could affect the effectiveness and usability of the medications. She stated the pharmacist checked the medication storage monthly. Record review of the U.S. Food and 675409 Page 13 of 22 675409 06/27/2025 Windsor Mission Oaks 3030 S Roosevelt Ave San Antonio, TX 78214

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Drug Administration Guidelines at https://www.fds.gov, current as of 09/19/2017 revealed that according to the product labels from all three U.S. insulin manufacturers, it was recommended that insulin be stored in a refrigerator at approximately 36-46 degree F.Record review of the facility policy titled Medication Carts and Supplies for Administering Meds dated 10/01/2019 revealed Do not leave the medication cart unlocked or unattended in the resident care area. The section of the policy titled Supplies revealed a temperature log with acceptable temperature ranges for each area should be maintained at all times 675409 Page 14 of 22 675409 06/27/2025 Windsor Mission Oaks 3030 S Roosevelt Ave San Antonio, TX 78214

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interviews and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation.1. The facility failed to label, date, and seal an opened bag of toasted oats cereal and three opened bags of pasta in the dry storage room. 2. The facility failed to store a mop, broom, and multiple mop heads in a sanitary manner in the utility closet.3. The facility failed to store three cases of water bottles off the floor in the storage area outside the kitchen.4. DA P failed to cover all his facial hair with a facial hair restraint while preparing food in the kitchen on 06/29/2025.These failures could place residents who received meals and snacks from the kitchen at risk for food borne illness.The findings included:1. Observation on 06/24/2025 at 9:30 AM in the dry storage room revealed an opened 35-oz. bag of toasted oats cereal on a shelf. The bag was approximately half-full, rolled down, and secured closed with two white labels. There was no marking on the bag indicating the date it was received or a use-by date, and the bag was not in a sealed in a zip-locked bag or sealed container. There were also three 10-lb. bags of pasta (egg noodles, macaroni noodles and tri-color pasta) that had been opened and closed by tying the tops of the bags in knots. The opened bags of pasta were not stored in zip-locked bags or sealed containers.During an interview on 06/24/2025 at 9:34 AM, the FSS stated the bag of cereal should have been labeled with a use-by date and sealed in a zip-locked bag or container and the bags of pasta should have been stored in zip-locked bags or containers. All dietary staff were trained by the DM on labeling, dating, and properly storing opened food upon hire and periodically throughout the year. Failing to store opened food in sealed containers could lead to the proliferation of pests and the potential of contamination with bacteria causing foodborne illness.2. Observation on 06/24/2025 at 9:39 AM in the utility closet revealed a soiled mop and a broom were stored head-side down on the floor inside the closet. There was also one used mop head on the floor and multiple used mop heads on top of a trash bag inside the closet.During an interview on 06/25/2025, the FSS stated the mop and broom should have been stored it in an upright position on the hooks inside the utility closet. The other mop heads should have been sent to laundry for cleaning and sanitizing. 3. Observation on 06/24/2025 at 9:48 AM revealed three cases of 0.5 L bottles of water (24 bottles/case) stacked on top of each other on the floor in the small dry storage area located outside the kitchen.During an interview on 06/24/2025 at 9:49 AM, the FSS stated the water bottles were on the floor of the storage area and should not have been. The facility had received a food delivery that morning, but the bottles of water were not delivered that day and should not have been on the floor. 4. Observation on 06/26/2025 at 9:35 AM in the kitchen revealed DA P stood next to the preparation table and used a spatula to transfer pieces of cake from a pan on the table to a blender on a table near the wall. DA P had a facial hair approximately 1/4 in length on his upper lip that extended the length of his mouth and approximately 1/2 in length that covered his chin and extended to his ears. DA P wore a facial hair restraint that only covered his chin. During an interview on 06/26/2025 at 9:36 AM, DA P stated he knew his facial hair restraint did not cover all his facial hair and should have. He had worked at the facility since 2003 and had been trained to cover his facial hair during food preparation. DA P stated he had just returned from the dish room as a reason his facial hair was not completely covered. He understood it was important to have all facial hair covered by a facial hair restraint to prevent potential cross contamination during food preparation.During an interview on 06/26/2025 at 9:38 AM, the FSS stated DA P's facial hair restraint should have covered all his facial hair and he had been trained upon hire to ensure it did.Record review of the 675409 Page 15 of 22 675409 06/27/2025 Windsor Mission Oaks 3030 S Roosevelt Ave San Antonio, TX 78214

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many facility's policy 03.003 Food Storage revised 06/01/2019 revealed, Policy: To ensure that 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. d. To ensure freshness, store opened and bulk items in tightly covered containers. All containers must be labeled and dated. h. Store all items at least 6 above the floor with adequate clearance between goods and ceiling to protect from overhead pipes and other contamination.Record review of the facility's policy 04.020 Janitor's Closet approved 10/01/2018 revealed, Policy: The facility will maintain the janitor's closet in a sanitary manner to minimize the risk of food hazards. The janitor's closet will be cleaned once per week or more often as needed. 1. Remove contents. Take dirty mop heads and cloths to laundry after each use. 8. Mops and brooms must be stored head up.Record review of the facility's policy 04.001 Employee Sanitation approved 10/01/2018 revealed, Policy: The Nutrition & Foodservice employees of the facility will practice good sanitation practices in accordance with the state and US Food Codes in order to minimize the risk of infection and food borne illness. 3. Employee Cleanliness Requirements. B. Hairnets, headbands, caps, beard coverings or other effective hair restraints must be worn to keep hair from food and food-contact surfaces.Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed, 3-305.11, Food Storage, (A) Food shall be protected from contamination by storing the food: (1) In a clean, dry location; (2) Where it is not exposited to splash, dust, or other contamination; (3) At least 15 cm (6 inches) above the floor. 6-501.16 Drying Mops. After use, mops shall be placed in a position that allows them to air-dry without soiling walls, equipment, or supplies. 2-402. Hair Restraints. 2-402.11 Effectiveness. (A) .Food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils, and linens; and unwrapped single service and single-use articles. 675409 Page 16 of 22 675409 06/27/2025 Windsor Mission Oaks 3030 S Roosevelt Ave San Antonio, TX 78214

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interviews, and record reviews, the facility failed to 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 disease and infection for 3 of 6 residents (Residents #23, #41 and, #46)) reviewed for infection control, in that: Residents Affected - Some 1. While providing transfer assistance for Resident #23, CNA H failed to use proper infection control. 2. While providing catheter care for Resident #41, CNA N and CNA M failed to use proper infection control. 3. While providing incontinent care for Resident #46, CNA K failed to use use proper infection control. These deficient practices could place residents at-risk for infection due to improper care practices. These findings included: 1. Record review of Resident #23's face sheet, dated 06/26/2025, revealed an admission date of 05/07/2025, with diagnoses which included: Dementia (decline in cognitive abilities), Hypothyroidism (under active thyroid), Bipolar disorder (Mental disorder characterized by periods of depression and periods of abnormally elevated mood), Parkinson's disease (movement disorder of the nervous system that worsens over time), Hypertension (High blood pressure), Hyperlipidemia (Elevated level of any or all lipids(fat) in the blood). Record review of Resident #23's MDS Quarterly assessment, dated 05/22/2025, revealed the resident had a BIMS score of 15, indicating no cognitive impairment. Resident #23 required extensive assistance with his activities of daily living and was always incontinent of bowel and bladder. Record review of Resident #23's care plan revealed a care plan initiated 05/07/2025 with a problem of The resident has an ADL self-care performance deficit r/t Dementia, Limited Mobility, Limited ROM, Stroke., and an intervention of TRANSFER: The resident requires Extensive assist and at times Mechanical Lift with 2 staff assistance for transfers. Observation on 06/26/25 at 12:58 p.m., revealed while providing transfer assistance for Resident #23, CNA H touched the bedroom's door to close it with her bare hands. CNA H did not sanitize or wash her hands before putting her gloves on, then, started to provide care for Resident #23. During an interview on 06/26/2025 at 1:05 p.m., CNA H stated the bedroom's door was considered dirty and she should sanitized her hands prior to putting gloves on and starting care. CNA H confirmed receiving training on infection control within the year. During an interview on 06/27/2025 at 2:05 p.m., ADON C stated the staff should have sanitize or wash their hands before putting gloves on and prior to start providing care for the resident. She stated it could cause a risk of cross contamination and infection for the resident. She revealed they provided training on infection control at least once a year and as needed. She revealed they checked 675409 Page 17 of 22 675409 06/27/2025 Windsor Mission Oaks 3030 S Roosevelt Ave San Antonio, TX 78214

F 0880 the skills of the staff annually and as needed with the assistance of her ADONS and the Regional Trainer. Level of Harm - Minimal harm or potential for actual harm Review of facility policy, titled Handwashing/Hand Hygiene, dated January 2018, revealed Perform hand hygiene before applying non-sterile gloves. Residents Affected - Some 2. Record review of Resident #41's face sheet, dated 06/26/2025, revealed an admission date of 01/10/2014, and a readmission date of 10/31/2024 with diagnoses which included: Type 2 diabetes mellitus (high level of sugar in the blood), Hypertension High blood pressure), Dementia (decline in cognitive abilities), Chronic prostatitis (Inflammation of the prostate gland causing painful urination), Major depressive disorder (mental disorder characterized by at least two weeks of pervasive low mood, low self-esteem, and loss of interest or pleasure), Schizophrenia (mental disorder characterized by abnormal thought processes and an unstable mood). Record review of Resident #41's Quarterly MDS assessment, dated 06/09/2025, revealed Resident #41 had a BIMS score of 14, which indicated mild cognitive impairment. Further review revealed Resident #41 required extensive assistance with ADLs and was indicated to have an indwelling catheter and be always incontinent of bowel. Record review of Resident #41's care plan, dated 10/10/2018, revealed a problem of The resident has bowel incontinence r/t Dementia AEB confusion At risk for skin breakdown, with a goal of The resident will have no skin breakdown r/t incontinence through the review date. Observation on 06/26/25 at 1:49 p.m., revealed while providing catheter care for Resident #41, the catheter strap bag fell on the floor, CNA M picked it from the floor and placed it on the side table. CNA M, later used the catheter strap on the resident. CNA M touched the bed and bed remote with her gloved hands and started providing care without changing her gloves. CNA M changed her gloves after cleaning the resident buttocks but did not sanitize her hands before putting clean gloves on. CNA N touched the gown on herself she was going to use during care before washing her hands ( the resident was on EBP). During an interview on 06/26/2025 at 2:00 p.m., CNA N stated she should have not touched the gown before washing her hands. CNA M stated the environment around the resident was considered dirty. CNA M confirmed she should not have picked the catheter strap from the floor and should have changed gloves and sanitized her hands before proving care after touching the bed and bed remote. CNA M stated she should have sanitized her hands between change of gloves. CNA N and CNA M confirmed receiving training on infection control within the year. During an interview on 06/27/2025 at 2:05 p.m., ADON C stated the staff should have sanitized or washed their hands before putting gloves on and prior to start providing care for the resident. She stated supply that had fallen to the floor should not be picked up and used. She stated it could cause a risk of cross contamination and infection for the resident. She revealed they provided training on infection control at least once a year and as needed. She revealed they checked the skills of the staff annually and as needed with the assistance of her ADONS and the Regional Trainer. Review of the Facility's policy, titled Handwashing - Hand Hygiene, dated January 2018, revealed Use an alcohol-based rub [ .] After contact with blood or bodily fluids, after handling used dressing, contaminated equipment, etc, after contact with objects in the immediate vicinity of the resident, after removing gloves 675409 Page 18 of 22 675409 06/27/2025 Windsor Mission Oaks 3030 S Roosevelt Ave San Antonio, TX 78214

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 3. Record review of Resident #46's face sheet, dated 06/26/2025, revealed an admission date of 08/29/2024, and a readmission date of 02/15/2025 with diagnoses which included: Schizoaffective disorder (mental disorder characterized by abnormal thought processes and an unstable mood), Vascular dementia (decline in cognitive abilities due to reduce blood flow in the brain), Type 2 diabetes mellitus (high level of sugar in the blood), Hypertension (High blood pressure), Hyperlipidemia (Elevated level of any or all lipids(fat) in the blood), Meniere's disease (chronic inner ear disease resulting in dizziness and problem hearing). Record review of Resident #46's Quarterly MDS assessment, dated 06/02/2025, revealed Resident #46 has a BIMS score of 12, which indicated moderate cognitive impairment. Further review revealed Resident #46 required extensive assistance with ADLs and was indicated to be frequently incontinent of bladder and be always incontinent of bowel. Record review of Resident #46's care plan, dated 09/10/2024, revealed a problem of The resident has FUNCTIONAL, MIXED bladder incontinence r/t Dementia, Impaired Mobility, with a goal of The resident's risk for septicemia (blood infection) will be minimized/prevented via prompt recognition and treatment of symptoms of UTI through the review date. Observation on 06/26/25 at 1:23 p.m., revealed while providing incontinent care for Resident #46, CNA K touched the privacy curtain to close it, with her bare hands. Then without sanitizing her hands and putting gloves on, she touched the clean supplies. CNA K touched the bed remote and the bed with her gloved hands. Without changing gloves and sanitizing her hands, she touched the cleaning wipes and started providing care for Resident #46. During an interview on 06/26/2025 at 1:30 p.m., CNA K stated the environment around the resident was considered dirty. CNA K confirmed she should have changed gloves and sanitized her hands before providing care after touching the bed and bed remote. She stated she was nervous and forgot. CNA K confirmed receiving training on infection control within the year. During an interview on 06/27/2025 at 2:05 p.m., ADON C stated the staff should have sanitized or washed their hands before putting gloves on and prior to start providing care for the resident. She stated it could cause a risk of cross contamination and infection for the resident. She revealed they provided training on infection control at least once a year and as needed. She revealed they checked the skills of the staff annually and as needed with the assistance of her ADONS and the Regional Trainer. Review of the Facility's policy, titled Handwashing - Hand Hygiene, dated January 2018, revealed Use an alcohol-based rub [ .] After contact with blood or bodily fluids, after handling used dressing, contaminated equipment, etc, after contact with objects in the immediate vicinity of the resident, after removing gloves 675409 Page 19 of 22 675409 06/27/2025 Windsor Mission Oaks 3030 S Roosevelt Ave San Antonio, TX 78214

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents for 4 of 5 units (unit 100, 200, 300, and 400) observed for environment, in that: 1. The facility failed to ensure furniture was in a good state of repair in resident rooms. 2. The facility failed to secure chemical cleaners. 3. The facility failed to ensure outside doors were in a good state of repair. These deficient practices could place residents at risk of a diminished quality of life due to an unsafe environment.The findings included:1. Review of Resident #98's face sheet dated 06/26/2025, revealed an admission date of 11/09/2022 with diagnostics which included: Schizoaffective disorder (mental disorder characterized by abnormal thought processes and an unstable mood), Epilepsy (Seizures), Hypertension (High blood pressure), Hyperlipidemia (Elevated level of any or all lipids(fat) in the blood), Hemiplegia (Paralysis of one side of the body), Intellectual disability, Difficulty in walking.Review of Resident #98's Quarterly MDS assessment dated [DATE], revealed Resident #98 had a BIMS score of 13, indicating mild to moderate cognitive impairment. Resident #98 was ambulatory and required limited to extensive assistance with his activity of daily living. Review of Resident #98's care plan dated 03/13/2023 revealed a problem of The resident is Low risk for falls r/t impaired balance, gait' and a goal of The resident will not sustain serious injury through the review date.Observation on 06/26/25 at 11:30 a.m.during colostomy care for Resident # 98 provided by LVN F, revealed the footboard of the bed was not properly affixed to the bed and was moveable. The surveyor pushed on the right side of the footboard and the left side came up and off the end of the bed. The resident was observed ambulating out of his room with a shuffle and leaning on one side. During an interview on 06/26/2025 at 11:36 a.m. with Resident #98, he revealed he did not think he ever put his hand on the footboard when he was walking by the bed. (the foot board of the bed is by the door of the room).During an interview on 06/26/2025 at 11:37a.m. with the LVN F, she stated the footboard was moveable and was a risk for fall and injury if the resident was using it for support. She revealed any repair needs could be communicated to the maintenance supervision using the TELLS system on their laptop. She was not able to say for how long the footboard had been a concern. During an interview on 06/27/25 at 02:05 p.m. with the Administrator, he stated broken furniture was a risk for accident and injury and broken furniture should be immediately repaired or replaced. He was not aware Resident #98's bed was broken. There was no policy about repair and maintenance of furniture and equipment. 2. Observation at 06/24/2025 at 10:06 a.m. of the housekeeping supply closet on 100 unit revealed the closet was unlocked and contained four, one-gallon containers of cleaning agents including: odor neutralizer, detergent disinfectant, glass and surface cleaner, and tub and tile cleaner. The detergent disinfectant was labeled Danger Keep out of Reach of Children Call Poison Control if Swallowed. Further observation revealed the electronic lock on the supply closet door appeared inoperable. During an interview with Housekeeper A on 06/24/2025 at 10:07 a.m., Housekeeper a confirmed the supply closet was unlocked and should not have been since it contained chemical cleaners that were potentially unsafe for residents to handle. Housekeeper A stated she did not know that the lock was inoperable and that she would have reported it to the Maintenance Director via the TELS communication system if she had known. Observation on 06/24/2025 at 10:56 a.m. revealed the Maintenance Director repairing the lock on the housekeeping supply closet. During an interview with the Maintenance Director on 06/24/2025 at 10:56 a.m., the Maintenance Director stated the electronic lock on the supply closet door utilized batteries which had become oxidized, causing the lock to become inoperable. The Maintenance Director stated he did not know how long the 675409 Page 20 of 22 675409 06/27/2025 Windsor Mission Oaks 3030 S Roosevelt Ave San Antonio, TX 78214

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some lock had been inoperable and confirmed he was in the process of repairing it. During an interview with ADON C on 06/26/2025 at 3:42 p.m., ADON C stated the facility had no policy regarding Physical Environment. During an interview with the Administrator on 06/26/2025 at 4:00 p.m., the Administrator confirmed the facility had no policy regarding Physical Environment and stated his expectation was that cleaning agents with warning labels be kept secure and away from residents. 3. Observation and interview with the Maintenance Director on 06/26/2025 at 10:55 a.m. revealed the Maintenance Director confirmed there were spaces underneath the doors leading to the patio at the end of both 300 and 400 units. The Maintenance Director stated the spaces measured ½ inch and that the issue had not before been brought to his attention. The Maintenance Director stated it was possible for flies to enter the facility via the spaces under the doors and for air conditioning to exit. During an interview with ADON C on 06/26/2025 at 3:42 p.m., ADON C stated the facility had no policy regarding Physical Environment. During an interview with the Administrator on 06/26/2025 at 4:00 p.m., the Administrator confirmed the facility had no policy regarding Physical Environment and stated his expectation was that the facility structures be kept in good repair. 675409 Page 21 of 22 675409 06/27/2025 Windsor Mission Oaks 3030 S Roosevelt Ave San Antonio, TX 78214

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 Based on observation, interview, and record review, the facility failed to maintain an effective pest control program for 3 of 5 units (unit 100, 300, and 400) reviewed for effective pest control in that: Residents Affected - Some Numerous flies were observed throughout the investigation period in and around units 100, 300, and 400. This deficient practice could result in diminished quality of life for residents die to living in an environment with pests. The findings were: Observations on 06/24/2025 between 10:10 a.m. and 11:30 a.m. revealed numerous flies in the hallway and in resident rooms on the 400 unit. Observation on 06/24/2025 at 11:49 a.m., during the lunchtime meal service, revealed numerous flies in the 100 unit dining room. Observation on 06/24/2025 at 11:55 a.m., during the lunchtime meal service, revealed numerous of flies in the dining room between units 300 and 400. During an interview with CNA B on 06/24/2025 at 11:56 a.m., CNA B confirmed there were numerous flies during the lunchtime meal service in the dining room between units 300 and 400. During a confidential interview with members of the Resident Council on 06/26/2025 at 10:30 a.m., the Resident Council stated flies were present throughout the facility and were very bothersome. Resident Council members stated they had observed flies in their rooms and in dining areas. Record review of the facility contracts revealed a contract, undated, for pest control service was in place. Record review of the pest control visit logs dated 02/01/2025 through 06/02/2025, revealed the pest control service visited the facility once per month. During an interview with ADON C on 06/26/2025 at 3:42 p.m., ADON C stated the facility had no policy regarding Pest Control. During an interview with the Administrator on 06/26/2025 at 4:00 p.m., the Administrator confirmed the facility had no policy regarding pest control. The Administrator stated that the pest control program had been ineffective regarding flies, and he planned to contact the pest control company and look for unorthodox solutions and was committed to keep trying until the pest control program was effective. 675409 Page 22 of 22