Inspection·April 14, 2023

F 0686 Level of Harm - Minimal harm or potential for actual harm Observation on 4/12/23 at 8:55 a.m., during wound care, LVN C applied Gentamycin to Resident #20's wound bed on the left hip. LVN C then took a pre-cut piece of Hydrofera Blue antibacterial Foam to place over Resident #20's wound bed on the left hip but dropped the Hydrofera Blue antibacterial Foam onto Resident #20's bed linens. LVN C then picked up the same pre-cut piece of Hydrofera Blue antibacterial Foam and placed it over the resident's wound. Residents Affected - Few During an interview on 4/12/23 at 9:33 a.m., LVN C stated, the Hydrofera Blue antibacterial Foam used on Resident #20 was used to help with wound healing. LVN C revealed he was aware he had dropped the Hydrofera Blue antibacterial Foam intended for Resident #20's wound bed on the left hip and at that point should have discarded it because it was considered dirty. LVN C revealed he was waiting for the surveyor to call him out on it but since that did not happen LVN C revealed he continued with the treatment. During an interview on 4/13/23 at 10:53 a.m., the DON stated, LVN C should have discarded the Hydrofera Blue antibacterial Foam because it was considered contaminated after it was dropped on Resident #20's bed linens and it would not be good for the resident because you can't use something contaminated because it's not usable. Record review of the competency training document titled, Wound Care Procedure for Major Wounds, dated 4/6/23 revealed in part, .PURPOSE: To provide guidelines for appropriate technique in completing wound care .NOTE: Clean technique is used. Sterile technique would be used per physician orders, such as with fresh surgery wounds. Care must be taken to prevent contamination of the supplies and surfaces used in wound care . Further review of the competency training document revealed LVN C had satisfied the requirements for appropriate technique in completing wound care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675414 If continuation sheet Page 2 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675414 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Nursing and Rehabilitation Center of Edinb 1505 S Closner Edinburg, TX 78539 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 3 residents (Resident #57) and 1 of 4 medication carts (200 hall medication cart) reviewed for medication administration and storage, in that: 1. Certified Medication Aide (CMA) D used her ungloved right index finger to take a pill from a medication bottle intended for Resident #57 2. LVN C had a loose pill in a medication cup inside the top drawer of the medication cart intended for Resident #14 These deficient practices could affect residents who received medication and place them at risk of infection, not receiving the appropriate amount of medication and drug diversion. The findings were: 1. Record review of Resident #57's face sheet, dated 4/13/23 revealed a [AGE] year-old male admitted on [DATE] with diagnoses that included type 2 diabetes (a chronic long lasting health condition that affects how your body turns food into energy) with foot ulcer (open sores or lesions that will not heal or that return over a long period of time), moderate protein-calorie malnutrition, Stage 3 pressure ulcer (full-thickness skin loss potentially extending into the subcutaneous tissue layer) of sacral region and acute kidney failure. Record review of Resident #57's admission MDS assessment, dated 3/27/23 revealed the resident was moderately cognitively impaired for daily decision-making skills and had a wound infection. Record review of Resident #57's Order Summary Report, dated 4/13/23 revealed an order for multivitamin with minerals, 1 tablet by mouth one time a day for supplement/risk for malnutrition, with order date 4/12/23 and no end date. Observation on 4/13/23 at 7:14 a.m. revealed CMA D, during the medication pass, placed 9 different medications into a medication cup and then took a stock bottle of multivitamin with minerals from the medication cart, opened the bottle and placed her right ungloved index finger into the bottle to retrieve one multivitamin with minerals pill. CMA D then took the multivitamin with minerals pill and placed it in the medication cup with the other 9 pills and administered to Resident #57. During an interview on 4/13/23 at 7:26 a.m., CMA D revealed the bottle of multivitamin with mineral pills used for Resident #57 was a stock bottle and was also used for other residents. CMA D stated, I had a hard time taking the pill out so I scooped it out but should not have done that because it was considered cross contamination. During an interview on 4/13/23 at 10:39 a.m., the DON revealed, CMA D should have used clean gloves, a spoon or a clean straw to scoop the pill out instead of using her bare finger because it would cause the bottle of pills to be contaminated and needed to be tossed out. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675414 If continuation sheet Page 3 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675414 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Nursing and Rehabilitation Center of Edinb 1505 S Closner Edinburg, TX 78539 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of the Medication Pass Evaluation, dated 1/19/23 revealed in part, .Medication Administration: a. Meds are properly removed from container/blister pack . Further review of the Medication Pass Evaluation revealed CMA D had satisfied the requirements for administering medications. 2. Record review of Resident #14's face sheet, dated 4/13/23 revealed a [AGE] year old male admitted on [DATE] with diagnoses that included dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), psychosis (any clinical symptom that entails a marked loss of contact with reality, notably including delusions, hallucinations, disorganized speech, or disorganized behavior) not due to a substance or known physiological condition and recurrent depressive disorders (mood disorder that affects how you feel, think and behave and can lead to a variety of emotional and physical problems). Record review of Resident #14's most recent quarterly MDS assessment, dated 2/8/3 revealed the resident was severely cognitively impaired for daily decision-making skills and was treated with anti-anxiety medications. Record review of Resident #14's comprehensive care plan, revision date 12/21/22 revealed the resident was treated with the anti-anxiety medication klonopin related to anxiety disorder with interventions that included to administer anti-anxiety medications, klonopin as ordered by physician. Record review of Resident #14's Order Summary Report, dated 4/13/23 revealed an order for klonopin 0.5 mg, give 0.25 mg by mouth in the morning related to anxiety disorder, with order date 3/8/23 and no end date. During an observation and interview with LVN C on 4/13/23 at 1:23 p.m., during inspection of the 200 hall medication cart revealed a loose pill in a medication cup inside the top drawer of the medication cart. Upon further inspection, the loose pill in the medication cup had Resident #14's name written in black marker on the cup. LVN C identified the loose pill in the medication cup as a klonopin pill intended for Resident #14. LVN C revealed he had taken the klonopin pill from the lock box in the 200 hall medication cart and documented in Resident #14's Individual Resident's Controlled Substance Record which indicated the pill was dispensed to the resident at 8:00 a.m. LVN C stated Resident #14 was scheduled to receive the klonopin pill at 9:00 a.m. but forgot to give it to the resident because Resident #14 was asleep at the time and did not want to wake him. LVN C revealed he got busy and forgot about the pill but had still intended on administering the klonopin pill to Resident #14 more than 4 hours after it was due. LVN C revealed he was not supposed to store medications in a cup inside the 200 hall medication cart because somebody else could take it by mistake or could potentially lead to a drug diversion. LVN C revealed, the klonopin pill, a controlled substance, would need to be wasted (disposed of) but had to be witnessed by a second nurse and then the incident needed to be reported to the DON. Record review of the Individual Resident's Controlled Substance Record for Resident #14 revealed LVN C documented he removed one klonopin pill from the blister package on 4/13/23 at 8:00 a.m. During an interview on 4/13/23 at 1:35 p.m., LVN A revealed, klonopin was a controlled medication stored in the lock box of the medication cart. LVN A stated, once the klonopin pill was removed from the package, there had to be documentation on the Individual Resident's Controlled Substance Record and immediately administered to the resident. LVN A revealed, the next step after administering the klonopin would be to document in the computer in Resident #14's electronic medication administration record. LVN A stated, controlled medications could not be taken out of the package and not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675414 If continuation sheet Page 4 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675414 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Nursing and Rehabilitation Center of Edinb 1505 S Closner Edinburg, TX 78539 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few administered because it could fall out and mistakenly be given to somebody else. LVN A revealed, controlled medications not tracked could result in a drug diversion. During an interview on 4/13/23 at 1:40 p.m., the DON stated, once pills are taken out of the package, they have to be administered otherwise then the pills need to be disposed. Medications need to be given on time to avoid a mistake. There could have been a drug diversion and to me it's a medication error. Record review of the Medication Pass Evaluation, dated 4/5/23, revealed LVN C had satisfied the requirements for performing the medication pass. Record review of the policy and procedure titled, Medication Administration, revision date 10/1/19 revealed in part, .Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so .D. 10 Rights of Medication Administration .There is always a risk of giving the wrong pill, the wrong dose, or the wrong person's medication .harm to the person can occur and some reactions can be deadly .5. Right Time .the time a medication is given is important .check the frequency of the ordered medication .Double-check that you are giving the ordered dose at the correct time .Confirm when the last dose was given . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675414 If continuation sheet Page 5 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675414 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Nursing and Rehabilitation Center of Edinb 1505 S Closner Edinburg, TX 78539 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, interview, and record review, the facility failed to dispose of garbage and refuse properly, for 2 of 2 dumpsters in that: Residents Affected - Many 1. Dumpster #1 did not have a drain plug. 2. Dumpster #2 did not have a drain plug. These failures posed a sanitary and safety hazard that could result in the attraction of vermin and affect all resident residing in the facility by exposing them to germs and diseases carried by vermin and rodents. The findings were: During an interview and observation on 4/13/2023 at 8:01 a.m., while viewing the dumpsters, the Dietary Manager said the dumpsters are supposed to be closed everywhere. The Dietary Manager said, they do not have stoppers, they haven't had them that I know of and I think they ordered them but I am not sure. The Dietary Manger was unable to state or provide any additional information regarding how long the stoppers were missing from the dumpster drain hole. During an interview and observation on 4/13/2023 at 8:06 a.m., while viewing the facility dumpsters, the administrator said, the holes in the bottom of the dumpster are supposed to be closed so whatever we put in there does not run out of the dumpster and on the ground. The Administrator stated he did not know how long the plugs had been missing from the dumpsters . Review of facility policy Garbage Receptacles, (Revised June 1, 2019), revealed, Outdoor Receptacles: It shall be constructed to have tight fitting lids, doors or covers and stored in a manner that is inaccessible to insect and rodents with doors/lids kept closed and no waste outside of the receptacle. All Shall be maintained in good repair. Review of the U.S. Public Health Service FDA U.S. Food & Drug Administration Food Code 2017, Section 5-501.114 revealed, Using Drain Plugs: Drains in receptacles and waste handling units for refuse, recyclables, and returnables shall have drain plugs in place. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675414 If continuation sheet Page 6 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675414 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Nursing and Rehabilitation Center of Edinb 1505 S Closner Edinburg, TX 78539 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 2 residents (Resident #20) reviewed for infection control practices, in that: Residents Affected - Few LVN C failed to utilize appropriate hand hygiene during wound care and skin treatment to Resident #20 This failure could place residents at risk for infection, slow wound healing and or a decline in health. The findings were: Record review of Resident #20's face sheet, dated 4/12/23 revealed a [AGE] year-old male admitted on [DATE] and re-admitted on [DATE] with diagnoses that included elevated white blood cell count (also known as leukocytosis; usually occurs because of an infection or inflammation in the body), cutaneous abscess of left lower limb (localized collection of pus in the skin), heart disease and respiratory failure with hypoxia (not enough oxygen in the blood). Record review of Resident #20's most recent annual MDS assessment, dated 1/20/23 revealed the resident was severely cognitively impaired for daily decision-making skills and had a Stage 3 pressure ulcer (full-thickness skin loss potentially extending into the subcutaneous tissue layer). Record review of Resident #20's comprehensive care plan, revision date 4/11/23 revealed the resident had been receiving treatment with antibiotic therapy for wound infection effective 4/7/23 with interventions that included to administer treatments as ordered and observe for effectiveness. Further review of Resident #20's comprehensive care plan revealed the resident had a rash to the face with interventions to apply/administer anti-pruritic medication/topical as ordered by the physician. Record review of Resident #20's Order Summary Report, dated 4/12/23 revealed the following orders: -Hydrofera Blue Foam Dressing External Pad (Wound Dressings) apply to left hip topically every day shift for wound care for 30 days, cleanse wound with Dakins 0.25% and gauze, dry with gauze, apply skin prep to peri wound, apply Santyl and gentamycin 0.1%, place Hydrofera Blue Foam, cover with gauze and secure with tape, with order date 4/8/23 and no end date. -Ketoconazole External Cream 2%, apply to face topically every day and evening shift for fungal infection of face for 14 days. Apply topically to face and LOTA (left open to air), with order date 4/7/23 and end date 4/21/23. Observation on 4/12/23 at 8:55 a.m., after completing wound care to Resident #20, LVN C applied skin prep to the perimeter of Resident #20's left hip wound, took off his gloves, did not perform hand hygiene and put on a new pair of gloves. LVN C then took the clean adhesive bandage with a dry gauze and placed it over Resident #20's left hip wound. LVN C then, with the same gloves, applied the Ketoconazole cream to Resident #20's face. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675414 If continuation sheet Page 7 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675414 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Nursing and Rehabilitation Center of Edinb 1505 S Closner Edinburg, TX 78539 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm During an interview on 4/12/23 at 9:33 a.m., LVN C revealed he realized he had not performed hand hygiene between glove changes because he did not have any hand sanitizer with him. LVN C stated he did not want to leave Resident #20's bedside to get hand sanitizer and decided to keep going. LVN C stated not sanitizing or washing his hands between glove changes was considered an infection control issue and cross contamination and could result in the resident being exposed to infection. Residents Affected - Few During an interview on 4/13/23 at 10:53 a.m., the DON revealed, it was best practice to either sanitize or wash hands between glove changes otherwise it was considered cross contamination. Record review of the policy and procedure titled, Administering Topical Medications, revision date 7/15 revealed in part, .The purpose of this procedure is to provide guidelines for the safe administration of topical medications .1. Perform hand antisepsis by either washing with soap and water or applying alcohol-based hand rub .Remove gloves. Wash and dry hands thoroughly . Record review of the Wound Care Procedure for Major Wounds competency, dated 4/6/23 for LVN C revealed in part, .17. Remove gloves .wash hands .18. Put on new gloves . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675414 If continuation sheet Page 8 of 8