Health inspection·September 27, 2023

F 0622 transfer was for 07/10/23 at 8AM. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #74's progress notes, dated 07/10/23, revealed resident #74 was transferred to the behavioral facility for behaviors. Residents Affected - Few During an interview on 9/27/23 at 9:50 AM, the MDS Coordinator stated Resident #74 was marked on the MDS as having a planned discharge because Resident #74 went to the hospital, returned to the facility, and then transferred to a behavioral facility. The MDS Coordinator stated she did know who was responsible for completing the discharge summary, but planned discharges were reviewed in the IDT meetings. The MDS Coordinator stated Resident #74 required a referral to transfer to a psychiatric facility and therefore it was a planned discharge. During an interview on 9/27/23 at 9:07 AM the DON stated Resident #74 was transferred to a psychiatric hospital and not expected to return to the facility and Resident #74 would have been an unplanned discharge. The DON stated going to a psychiatric hospital could not be planned, even though the facility had to send a referral and the MDS assessment should have indicated a non-planned discharge. The DON stated the floor nurse would have been responsible for completing the discharge summary and then medical records would have been responsible for making sure the physician signed it. The DON stated discharges were reviewed in the IDT meeting. The DON stated the importance of making sure the MDS was correct, was to make sure everything was done correctly and to make sure residents had everything they needed once they were discharge home. During an interview on 9/27/23 at 5:06 PM, the ADM stated he expected Resident #74 to have a discharge summary to ensure proper documentation and continuity of care. Record review of the facility's policy titled, Criteria for Transfer and Discharge, revised 1/2022, indicated, If a transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility, the resident's physician shall document the following in the resident's medical record: a) The specific resident need that cannot be met; b) Facility attempts to meet the resident needs; and c0 The service available a the receiving Facility to meet the needs. The policy also indicated, The physician will sign the Discharge Summary of the form for the physician to sign when a person is discharged or transferred. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675808 If continuation sheet Page 2 of 19 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 675808 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Rehabilitation and Healthcare 250 W British Flying School Blvd Terrell, TX 75160 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 observation, interview and record review, the facility failed to ensure an accurate MDS was completed for 1 of 18 residents reviewed for MDS assessment accuracy. (Resident #55) Residents Affected - Few The facility failed to accurately reflect Resident #55's restraint status on the MDS assessment. This failure could place residents at risk for not receiving care and services to meet their needs. Findings included: Record review of Resident #55's physician summary report indicated an [AGE] year-old male admitted on [DATE] with a diagnosis of dementia (brain disorder), depression (low mood) and acute kidney failure (not able to filter waste from the blood). Record review of Resident #55's quarterly MDS assessment dated [DATE] indicated Resident #55 was usually understood and usually understood others. The MDS indicated Resident #55 had a BIMS score of 7 indicating severely impaired cognition. Section P of the MDS indicated Resident #55 used trunk restraints (a restraint that aimed to to avoid compensatory trunk movement and to facilitate the developement of normal motor patterns in the affected upper limbs) less than daily in the bed. Record review of Resident #55's care plan dated 8/22/22 did not indicate restraints. During an observation and interview on 09/25/23 at 10:43 AM, Resident #55 was lying in bed with grab bars up on the upper part of the bed. Resident #55 stated the grab bars helped him with getting out of the bed and denied having any complaints. During an observation on 09/26/23 at 09:58 AM, Resident #55 was in bed sleeping bed. The bed was in low position and grab bars were up on the bed. During an interview on 09/27/23 at 9:50 AM, the MDS Coordinator stated Resident #55 should not have been marked as having a trunk restraint on the MDS assessment. The MDS Coordinator stated she was responsible for completing the MDS and corporate randomly checks the MDS assessments 3 times a month. The MDS coordinator stated she had received training on the MDS from a sister facility. The MDS Coordinator stated the importance of making sure the MDS assessment was accurate was so it reflected the residents' true care and if it was not correct, then the patient could have lost some of their benefits. During an interview on 9/27/23 at 3:07 PM, the DON stated she expected the MDS assessment to be completed accurately and it should not have been marked as a trunk restraint. The DON stated not completing the MDS assessment accurately could make it look like the facility was restraining Resident #55 and that could look like abuse. During an interview on 09/27/23 at 5:06 PM, the ADM stated he expected the MDS assessments to be completed accurately. The ADM stated the importance of making sure the MDS was accurate was so the facility was reporting it properly and to reflect what was going on with the residents. The ADM stated if the MDS was not accurate, it could also be a billing error (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675808 If continuation sheet Page 3 of 19 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 675808 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Rehabilitation and Healthcare 250 W British Flying School Blvd Terrell, TX 75160 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 During an interview on 9/27/23 at 3:07 AM, the DON stated the facility did not have a policy for MDS assessment and they followed the RAI manual. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675808 If continuation sheet Page 4 of 19 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 675808 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Rehabilitation and Healthcare 250 W British Flying School Blvd Terrell, TX 75160 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 interview and record review, the facility failed to implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs, for 1 of 6 (Resident #326) residents reviewed for care plans. The facility failed to ensure staff followed Resident #326's care plan by not administrating her prescribed medication as ordered. This failure could place residents at risk of not receiving necessary medication and services. Findings included: Record review of Resident #326's face sheet, dated 09/27/23 indicated Resident #326 was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included congestive heart failure (a condition that develops when your heart doesn't pump enough blood for your body's needs), Atrial fibrillation (also known as A Fib - is an irregular and often very rapid heart rhythm), and hypertension (high blood pressure). Record review of Resident #326's entry MDS assessment, dated 05/31/23, did not indicate anything about cognition or memory. Resident #326 required total assistance with bathing, extensive assistance with toileting, and dressing, limited assistance with bed mobility, and personal hygiene, and set-up assistance with transfers and eating. The MDS indicated Resident #326 received an antibiotic medication. Record review of Resident #326's comprehensive care plan, dated 05/27/23 indicated Resident #326 had an infection. The intervention of the care plan was to give the antibiotic as ordered by the physician. Record review of Resident #326's physician order dated 05/27/23 indicated: Give Cephalexin Oral Tablet 500 MG (Cephalexin) Give 1 tablet by mouth three times a day for CELLULITIS (swelling in legs) for 6 days. Record review of Resident #326's medication administration (MAR) record dated 05/01/23 through 05/31/23 revealed the following orders: Cephalexin Oral Tablet 500 MG (Cephalexin) Give 1 tablet by mouth three times a day for CELLULITIS. The MAR did not indicate Resident #326 received her antibiotic on 05/27/23 or 05/28/23. She only received 2 doses on 05/29/23. During an interview on 09/27/23 at 10:06 a.m., LVN E said she was Resident #326's nurse on 05/29/23. She said she could not remember anything about her medications not being at the facility or any concerns about her medication. She said she was not aware of what Resident #326's care plan stated. She said they should have administrated Resident #326's medication as ordered. During an interview on 09/27/23 at 4:07 p.m., ADON B said she could not remember any concerns with Resident #326's medication. She said Resident #326 had an order for Cephalexin (antibiotic) and she (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675808 If continuation sheet Page 5 of 19 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 675808 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Rehabilitation and Healthcare 250 W British Flying School Blvd Terrell, TX 75160 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 should have received her medication. She said she was unaware of what Resident #326 care plan stated but could go review if needed. She said if Resident #326 had on her care plan for her antibiotics to be given as ordered then her medication should have been given. She said failure to follow the care plan could lead to missed medication. During an interview on 09/27/23 at 4:34 p.m., the DON said she was not aware of Resident #326 missing her medication. She said if Resident #326's care plan indicated she was to receive her antibiotic, she should have received her antibiotic. The DON said it was important to follow the care plan because it was a part of the resident's plan of care. During an interview on 09/27/23 at 4:50 p.m., the Adm said he expected the nurses to give all prescribed medication. He said the DON/ADONs were responsible for ensuring staff followed care plans. He said if care plans were not being followed then we could potentially not meet the resident's needs. A record review of the facility's Comprehensive Person-Centered Care Planning policy, dated 01/2022, revealed, Policy: It is the policy of this facility that the interdisciplinary team(IDT) shall develop a comprehensive person-centered care plan for each resident .The IDT will develop a baseline care plan for each resident within 48 hours of admission, that includes minimum healthcare information necessary to properly care for each resident and instructions needed to provide effective and person-centered care that meets professional standards of quality care. A record review of the facility's Physician Orders policy, dated 05/2007, revealed, Policy: It is the policy of this facility that drugs and treatment shall be administered or carried out upon the order of a person duly licensed and authorize to prescribe such drugs and treatment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675808 If continuation sheet Page 6 of 19 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 675808 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Rehabilitation and Healthcare 250 W British Flying School Blvd Terrell, TX 75160 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 0694 Provide for the safe, appropriate administration of IV fluids for a resident when needed. 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 parenteral fluids were administered consistent with professional standards of practice and in accordance with physician orders for 1 of 2 (Resident #57) residents reviewed for intravenous fluids. Residents Affected - Few The facility failed to ensure Resident #57 received PICC (a soft, flexible catheter inserted into a central vein used for prolonged antibiotic therapy) line dressing changes as ordered. This failure could affect residents by placing them at risk for infection. Findings included: Record review of Resident #57's face sheet, dated 09/27/23 indicated Resident #57 was a [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included Pneumonia (an infection that affects one or both lungs), Methicillin-resistant Staphylococcus aureus (MRSA-a cause of staph infection that is difficult to treat because of resistance to some antibiotics), Chronic obstructive pulmonary disease (COPD- an inflammatory lung disease that gets worse over time), Diabetes mellitus (DM-a disease of inadequate control of blood levels of glucose), and hypertension (high blood pressure). Record review of Resident #57's admission MDS assessment, dated 08/20/23, indicated Resident #57 was understood and understood others. Resident #57's BIMS score was 15, which indicated she was cognitively intact. Resident #57 required supervision with toileting, personal hygiene, transfers, dressing, bed mobility, bathing, and eating. The MDS indicated Resident #57 received intravenous (IV) medications. Record review of Resident #57's comprehensive care plan, dated 08/24/23 indicated Resident #57 required IV medication related to infection. The interventions of the care plan were for staff to provide IV medications as ordered, check dressing at the site daily, monitor/document/report to the physician as needed for any signs or symptoms of infection and manage all IV equipment with aseptic technique. Record review of Resident #57's physician orders dated 9/13/23 indicated: Peripheral intravenous care, change IV dressing every 7 days on Sunday night shift and as needed if wet, soiled, saturated, or loose. During an observation and interview on 09/25/23 at 5:15 p.m., Resident #57 was sitting at the dining room table. Resident #57's PICC line dressing had a date of 09/07/23, no identified initials of a nurse who last changed the dressing, and was partially peeled away from her arm on all four sides. Resident #57 said she could not remember when her dressing was changed but said it needed to be changed because it was coming loose. During an interview on 09/27/23 at 9:59 a.m., Resident #57 said LVN K changed her PICC line dressing the previous night (09/26/23) because it had not been changed according to the date since 09/07/23. LVN E was in the room and heard Resident #57 say her last PICC line dressing was dated 09/07/23. LVN E said PICC line dressings should be changed every 7 days or every 3 days if they do not have a Bio patch (a protective Disk with CHG protects the insertion site and releases CHG, a powerful skin (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675808 If continuation sheet Page 7 of 19 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 675808 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Rehabilitation and Healthcare 250 W British Flying School Blvd Terrell, TX 75160 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 0694 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few antiseptic over a 7-day period). She said the risk of not changing the PICC line dressing as ordered could lead to infection or complications. During an attempted phone interview on 09/27/23 at 2:59 p.m., LVN K did not answer the phone. During an interview on 09/27/23 at 04:07 p.m., ADON B said nurses should follow the order for PICC line dressing changes. She said she was not sure what their policy said but expected nurses to change a PICC line dressing every 7 days and as needed. She said it was important to look at the site daily to ensure no infection or issues with the lines. ADON B said administration nurses were to ensure nurses were changing PICC line dressing as ordered. She said if the PICC line dressing were not changed it could lead to complications or infection. During an interview on 09/27/23 at 4:07 p.m., the DON said Resident #57 told her that the date on her PICC line dressing was dated 09/07/23. She said PICC line dressing changes were supposed to be changed every 7 days and as needed if soiled or dislodged. She said she was responsible for ensuring all nurses were competent in IVs and dressing changes. She said she had not asked nurses prior to 09/27/23 if they had IV training. She said going forward, she would ensure all nurses had IV training prior to working with residents who required IV services. She said if nurses were not changing dressing as ordered it could cause complications and lead to infections. During an interview on 09/27/23 at 4:38 p.m., the Adm said he expected nurses to have the training they needed for any IVs. He said the DON/ADON was responsible for ensuring nurses were certified in IV therapy. The Adm said without proper training a nurse could cause infection or a negative outcome. A record review of the facility's policy IV Medication Administration, dated 05/2007 indicated, It is the policy of this facility to provide venous access for the administration of fluids and or medication. It is the policy of this facility that IV drugs shall be administered by a registered nurse or IV-certified licensed nurse. All solutions must be labeled in accordance with established procedures governing all labeled IV solutions. All dressings should be labeled with the date, time, and nurse's initial. Central vascular access dressing: the transparent dressing is a preferred type for ease of observation this should be changed twice a week unless it becomes solid or nonadherent to the skin. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675808 If continuation sheet Page 8 of 19 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 675808 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Rehabilitation and Healthcare 250 W British Flying School Blvd Terrell, TX 75160 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that licensed staff were able to demonstrate the specific competencies and skill sets necessary to care for residents' needs for 1 of 2 licensed staff (LVN D) reviewed. The facility failed to ensure LVN D, was competent in providing care for the peripherally inserted central catheter (PICC - a soft, flexible catheter inserted into a central vein used for prolonged antibiotic therapy) for Resident #57. This failure could potentially affect residents by placing them at an increased and unnecessary risk of exposure to staff who lack the appropriate skills and competencies to provide safe care and minimize infections. Findings included: Record review of Resident #57's face sheet, dated 09/27/23 indicated Resident #57 was a [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included Pneumonia (an infection that affects one or both lungs), Methicillin-resistant Staphylococcus aureus (MRSA-a cause of staph infection that is difficult to treat because of resistance to some antibiotics), Chronic obstructive pulmonary disease (COPD- an inflammatory lung disease that gets worse over time), Diabetes mellitus (DM-a disease of inadequate control of blood levels of glucose), and hypertension (high blood pressure). Record review of Resident #57's admission MDS assessment, dated 08/20/23, indicated Resident #57 was understood and understood others. Resident #57's BIMs score was 15, which indicated she was cognitively intact. Resident #57 required supervision with toileting, personal hygiene, transfers, dressing, bed mobility, bathing, and eating. The MDS indicated Resident #57 received intravenous (IV) medications. Record review of Resident #57's comprehensive care plan, dated 08/24/23 indicated Resident #57 required IV medication related to infection. The interventions of the care plan were for staff to provide IV medications as ordered, check dressing at the site daily, monitor/document/report to the physician as needed for any signs or symptoms of infection, and manage all IV equipment with aseptic technique Record review of Resident #57's physician orders dated 9/13/23 indicated: Peripheral intravenous care, change IV dressing every 7 days on Sunday night shift and as needed if wet, soiled, saturated, or loose. During an observation on 09/26/23 at 3:31 p.m., LVN D had hung Resident #57's IV Vancomycin antibiotic and was flushing her PICC line. LVN D said she could not remember if she had IV training but knew she had not received IV training since employed by this facility and does not remember anyone asking her about her IV certification. During an interview on 09/27/23 at 4:38 p.m., the DON said they had IV training at the facility back in June 2023 and LVN D was not employed during that time. She said she had not asked LVN D or any (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675808 If continuation sheet Page 9 of 19 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 675808 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Rehabilitation and Healthcare 250 W British Flying School Blvd Terrell, TX 75160 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few new hires prior to 09/27/23 if they had IV training. The DON said she was aware LVNs needed to be trained on IVs and going forward would ensure all nurses had IV training prior to working with residents who required IV service. She said they did competencies on hire, yearly, and as needed. The DON said it was important for LVNs to have the proper training on IVs to prevent infection. During an interview on 09/27/23 at 4:38 p.m., the Adm said he expected nurses to have the training they needed to give IV meds. He said he was aware LVNs had to be certified to administer medication or work with residents who required IV services. He said the DON/ADON was responsible for ensuring nurses were certified in IV therapy. The Adm said without proper training someone could mess up the IV medication or dressing changes and cause infection or negative outcomes. Record review of competencies skills revealed LVN D had been checked off on different types of skills on 08/04/23 but no IV competency or IV certification was in her file. Record review of a Competency of Nursing Staff policy dated 01/22 indicated, It is the policy of this facility to have sufficient nursing staff with the appropriate competencies and skill sets to provide nursing and related services to ensure residents safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessment and individual plans of care. #1 Within 30 days of the date of hire the nursing staff member shall complete the orientation competency assessment for the appropriate job category to meet the needs of the facility resident population in accordance with the facility assessment. #5 Each nursing staff member shall complete an annual competency assessment and additional competency assessment as needed based on the resident population's needs in accordance with the facility assessment. #8 Records of each staff development program shall be maintained. Record review of www.bon.texas.gov/practice_bon_position_statements_content.asp: It is the opinion of the Board that the LVN shall not engage in IV therapy related to either peripheral or central venous catheters, including venipuncture, administration of IV fluids, and/or administration of IV push medications, until successful completion of a validation course that instructs the LVN in the knowledge and skills applicable to the LVN's IV therapy practice. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675808 If continuation sheet Page 10 of 19 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 675808 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Rehabilitation and Healthcare 250 W British Flying School Blvd Terrell, TX 75160 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 - Some 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 interview and record review, the facility failed to ensure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for 1 of 3 residents (Residents #326) reviewed for medications. The facility failed to administer medications as prescribed for Resident #326. This failure could place residents at risk of not receiving the therapeutic effects of their medications including a diminished health status. The findings included: Record review of Resident #326's face sheet, dated 09/27/23 indicated Resident #326 was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included congestive heart failure (a condition that develops when your heart doesn't pump enough blood for your body's needs), Atrial fibrillation (A Fib - is an irregular and often very rapid heart rhythm), and hypertension (high blood pressure). Record review of Resident #326's entry MDS assessment, dated 05/31/23, did not indicate anything about cognition or memory. Resident #326 required total assistance with bathing, extensive assistance with toileting, and dressing, limited assistance with bed mobility, and personal hygiene, and set-up assistance with transfer and eating. Record review of Resident #326's comprehensive care plan, dated 05/27/23 indicated Resident #326 had an infection. The intervention of the care plan was to give the antibiotic as ordered by the physician. Record review of Resident #326's medication administration record (MAR) dated 05/01/23 through 05/31/23 revealed the following orders: Aspirin 81 Oral Tablet Chewable (Aspirin) Give 1 tablet by mouth one time a day for ANALGESICS. The MAR did not indicate Resident #326 received this medication on 05/28/23 or 05/29/23. Atorvastatin Calcium Oral Tablet 40 MG (Atorvastatin Calcium) Give 1 tablet by mouth at bedtime for CHOLESTEROL. The MAR did not indicate Resident #326 received this medication on 05/27/23 or 05/28/23. Cephalexin Oral Tablet 500 MG (Cephalexin) Give 1 tablet by mouth four times a day for CELLULITIS (swelling of the legs) for 6 days. The MAR did not indicate Resident #326 received her antibiotic on 05/27/23 or 05/28/23. She only received 2 doses on 05/29/23. Furosemide Tablet 20 MG Give 1 tablet by mouth one time a day for CHF (heart failure). The MAR did not indicate Resident #326 received this medication on 05/28/23 or 05/29/23. Lantus Solostar Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Glargine) Inject 30 units subcutaneously one time a day for DM (diabetic). The MAR did not indicate Resident #326 received this (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675808 If continuation sheet Page 11 of 19 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 675808 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Rehabilitation and Healthcare 250 W British Flying School Blvd Terrell, TX 75160 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 medication on 05/28/23 or 05/29/23. On 05/30/23 blood sugar reading was 250. Level of Harm - Minimal harm or potential for actual harm Lisinopril Oral Tablet 2.5 MG (Lisinopril) Give 1 tablet by mouth one time a day for HTN (high blood pressure). The MAR did not indicate Resident #326 received this medication on 05/28/23 or 05/29/23. Residents Affected - Some Myrbetriq Oral Tablet Extended Release 24 Hour 25 MG (Mirabegron) Give 1 tablet by mouth one time a day for BLADDER SPASM. The MAR did not indicate Resident #326 received this medication on 05/28/23 or 05/29/23. Plavix Oral Tablet 75 MG (Clopidogrel Bisulfate) 1 tablet by mouth one time a day for anticoagulant. The MAR did not indicate Resident #326 received this medication on 05/28/23 or 05/29/23. Potassium Chloride ER Tablet Extended Release 10 MEQ Give 1 tablet by mouth one time a day for a supplement. The MAR did not indicate Resident #326 received this medication on 05/28/23 or 05/29/23. Seroquel Oral Tablet 25 MG (Quetiapine Fumarate) Give 1 tablet by mouth two times a day for antipsychotics. The MAR did not indicate Resident #326 received this medication on 05/27/23, 05/28/23, or a 9 a.m. dose on 05/29/23. Trazodone HCI Oral Tablet 50 MG (Trazodone HCI) Give 1 tablet by mouth at bedtime for Insomnia. The MAR did not indicate Resident #326 received this medication on 05/27/23 or 05/28/23. During an interview on 09/27/23 at 9:53 a.m., the MA H said she remembered Resident #326 and something about her leg but could not remember anything about her medications. She said she worked Monday through Friday. She looked at the MAR and said she was not at the facility over the weekend of 05/27/23 and 05/28/23 but verified no initials for 05/27/23, 05/28/23, and some medication initials on 05/29/23. She said she gave all the medication on Tuesday 05/30/23. During an interview on 09/27/23 at 10:06 a.m., LVN E said she was Resident #326's nurse on 05/29/23. She said she could not remember anything about her medications not being at the facility or any concerns about her medication. She said the medication aides usually gave residents their medications. She looked at the MAR and verified Resident #326 did not receive her insulin on 05/29/23. She said if she did not give the insulin, it had to be a reason but she could not remember why since it was back in May 2023. LVN E looked at Resident #326's nurse notes and she did not see any indications as to why her medications or insulin was not given. During a phone interview on 09/27/23 at 2:15 p.m., admitting RN N said he could not recall Resident #326 because he was an agency nurse and he went to several facilities. He said the medication aides gave the medications and the nurses gave the insulin. He said he did not recall the medication aide letting him know anything about Resident #326's medication not being at the facility. He said the insulin was not scheduled on his shift. He said if a resident had an order for medications, then the medications should have been given. During an attempted phone interview on 09/27/23 at 3:40 p.m., attempted to reach LVN L the medication aide who worked on 05/27/23 and 05/28/23 with no answer. During an interview on 09/27/23 at 4:07 p.m., ADON B said she could not remember any concerns with Resident #326's medications. She said the hospice company was good about writing orders when a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675808 If continuation sheet Page 12 of 19 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 675808 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Rehabilitation and Healthcare 250 W British Flying School Blvd Terrell, TX 75160 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 - Some resident was admitted to the facility and providing medications. She said she was not sure why Resident #326 did not receive her medication. ADON B said she expected medication to be given as ordered. She said the resident could have adverse effects if medication orders were not followed correctly. During an interview on 09/27/23 at 4:34 p.m., the DON said Resident #326 was admitted on Saturday 05/27/23 and left on Wednesday 06/01/23. She said she did not remember any issues with Resident #326's medication. She said hospice usually provided hospice residents with their medication. She said if Resident #326 did not have her medications on admission, they should have reached out to hospice or pulled her medication out of the emergency kit located in the facility. She said either way, Resident #326 should not have missed her medications. The DON looked at Resident #326's MAR and verified she did not receive any of her prescribed medication on her first 2 days of stay at the facility. The DON said they usually run a medication report daily and review it during the standup meeting daily to ensure residents' medications were given. She said she did not know how they missed Resident #326's missing her medication. The DON said if residents missed medication, it could cause adverse effects on their health. During an interview on 09/27/23 at 4:50 p.m., the Adm said he expected the nurses to give all medication prescribed. He said the DON/ADONs were responsible for ensuring residents received their medication as ordered. He said if a resident does not receive their medication, they could potentially have a negative outcome. A record review of the facility's Physician Orders policy, dated 05/2007, revealed, Policy: It is the policy of this facility that drugs and treatment shall be administered or carried out upon the order of a person duly licensed and authorize to prescribe such drugs and treatment. A record review of the facility's Medication Administration policy, dated 05/2007, revealed, Policy Statement: It is the policy of this facility to accurately prepare, administer and document oral medications. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675808 If continuation sheet Page 13 of 19 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 675808 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Rehabilitation and Healthcare 250 W British Flying School Blvd Terrell, TX 75160 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 - Some 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 3 of 4 residents (Residents #21, #25, and #42) reviewed for hospice services. The facility did not ensure Residents #21, #25, and #42'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 included: 1.Record review of Resident #21's face sheet, dated 09/26/23, indicated she was a [AGE] year-old female that was admitted to the facility on [DATE] with a diagnosis of (COPD) Chronic obstructive Pulmonary Disease (lung disease that causes difficulty with breathing), Type 2 Diabetes (blood sugar disorder) and End Stage Renal Disease (gradual loss of kidney function). Record review of Resident #21's MDS assessment dated [DATE] indicated Resident #21 was usually understood and usually understood others. The MDS did not indicate a BIMS (Brief Interview for Mental Status) score. Special Treatments, Procedures, and Programs of the MDS did not indicate Resident #21 was on hospice care. Record review of Resident #21's care plan revised on 04/22/23 indicated she had a terminal prognosis related to Parkinson's and was on hospice care. The interventions included physician consult and social services for the resident while in the facility. Record review of Resident #21's order summary report dated 9/26/23 indicated no lab draws due to hospice status started on 02/06/23 and to notify hospice of any changes in condition dated 06/05/23. Resident #21's order summary revealed she was admitted to hospice on 3/21/23. Record review of Resident #21's hospice binder, accessed on 09/26/23, revealed no updated nursing visit since 05/09/23 and no updated plan of care since 5/15/23-07/13/23. 2. Record review of Resident #25's face sheet, dated 09/27/23 indicated Resident #25 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included Osteomyelitis (a serious infection of the bone that can be either acute or chronic), dementia (the loss of cognitive functioning thinking, remembering, and reasoning), and anxiety (feelings of nervousness, panic, and fear). Record review of Resident #25's quarterly MDS assessment, dated 06/15/23, indicated Resident #25 was usually understood and usually understood others. Resident #25 required total assistance with bathing, toileting, personal hygiene, and eating; extensive assistance with transfers, dressing, and bed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675808 If continuation sheet Page 14 of 19 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 675808 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Rehabilitation and Healthcare 250 W British Flying School Blvd Terrell, TX 75160 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 mobility. The MDS indicated Resident #25 received hospice service. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #25's comprehensive care plan, dated 06/07/23 indicated Resident #25 had a terminal prognosis related to senile degeneration of the brain and was on hospice. The interventions of the care plan were for staff to encourage the resident to express her feelings, encourage support of family, and work with the hospice team to ensure the resident's needs were met. Residents Affected - Some Record review of Resident #25's physician's order dated 06/02/23 indicated: Admit to hospice, diagnosis: Senile Degeneration of the Brain. Record review of Resident #25's hospice binder, accessed on 09/26/23, revealed no updated plan of care since 08/30/23. 3.Record review of Resident #42's undated face sheet indicated he was a male that admitted to the facility 6/29/22. Record review of the physician's orders dated 9/26/23 indicated Resident #42 had diagnoses that included: Dementia (loss of intellectual functioning, impairment of memory), paraplegia (paralysis of legs and lower body), major depression, severe with psychotic symptoms (persistent sadness and lack of pleasure, with a loss of reality). Record review of the quarterly MDS dated [DATE] indicated Resident #42 had no speech, was rarely or never understood by others, and sometimes understood others. Section C of the MDS indicated Resident #42 was unable to complete the BIMS interview, indicating severe cognitive deficits. Section O of the MDS indicated hospice care. Record Review on 9/26/23 of Resident #42's hospice binder did not contain an updated POR or nurse communications (visits). Record review of a physician's order dated 6/29/22 for Resident #42 indicated: Admit to [Name] Hospice, diagnosis: Senile Degeneration of the Brain. During an interview on 09/26/23 at 03:10 PM, Resident #21's hospice nurse stated the hospice liaison was responsible for making sure the hospice binder had current nursing notes and plan of care every 2 weeks. The hospice nurse stated the importance of updating the hospice binder was to make sure the facility had back up information and that the hospice staff member had spoken to the facility staff every visit to discuss the resident. During an interview on 09/26/23 at 2:50 PM, the DON stated she did not find any current nursing notes or plan of care in Resident #21's hospice binder. The DON stated the hospice nurse should have made sure the hospice binder was up to date and the facility's social worker was responsible for making sure the binder was up to date. The DON stated the importance of making sure the binder was current was to make sure the patient was taken care of, and things were not missed. During an interview on 09/26/23 at 8:26 AM, the SW stated she had just started working at the facility the previous week and admissions was responsible for making sure the binders were up to date prior to her starting. The SW stated she had not checked the binders to make sure they were current, and she had not received training at this time from a sister facility. The SW stated the importance of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675808 If continuation sheet Page 15 of 19 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 675808 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Rehabilitation and Healthcare 250 W British Flying School Blvd Terrell, TX 75160 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 - Some making sure the hospice binder was current was so they could verify patients were getting seen by the hospice company. During a record review and interview on 9/26/23 at 3:10 PM, LVN A said she did not see any communications or visit notes in Resident #42's hospice binder. She said she did not see an updated POC in his hospice binder and the most updated POC in his binder was dated 6/9/23 - 8/7/23. She said there were no nurses notes in Resident #42's binder from the RN Case Manager for his hospice company. LVN A said that was the only hospice binder she was aware of, and if they had communications/nurse visits or an updated POC, they would be in the binder, and they were not. During an interview on 9/26/23 at 3:20 PM, the DON said she could not find any hospice communications in Resident #42's hospice binder. She said when the hospice nurses came to see Resident #42, they did not leave documentation, but would communicate verbally with the staff nurses which was not documented in the hospice binder or facility notes. During an interview on 9/27/23 at 8:11 AM, the DON said the Hospice POC for Resident #42, in his hospice binder, was dated 6/9/23 - 8/7/23. She said there were no nurse's notes in the hospice binder. She said hospice communications were important for continuity of care for the resident. She said the SW was responsible for making sure the hospice updated the POC's and put the nurse's notes in the hospice binder. She said she did not oversee that the SW completed this, but the administrator did. During an interview on 09/27/23 at 8:16 AM, the DON said the prior admission person was supposed to keep the hospice books updated but had recently changed to the social worker being responsible. She verified the last plan of care for Resident #25 was 08/30/23. During a phone interview on 09/27/23 at 8:26 AM, the hospice nurse said they had a plan of care meeting every 2 weeks. She said she was responsible for ensuring Resident #25's facility's book was updated. She said she had Resident #25's most recent plan of care in her car, but did not realize the plan of care ended on 08/30/23. She said it was important to update the plan of care for continued care. During an interview on 9/27/23 at 8:35 AM, the Admissions Coordinator said she had worked at the facility for 8 days. She said she was not responsible and had not been told by anyone she was responsible for hospice POC's or hospice communications for residents. She said she did not know what the prior Admissions Coordinator's responsibilities were. During an interview on 9/27/23 at 10:15 AM, the CNA Coordinator who answered the phone for [Name] Hospice said the RN Case Manager for Hospice was responsible for making sure the nursing notes and updated POC's were in the hospice binder in the facility. During an interview on 9/27/23 at 10:23 AM, the RN Case Manager for Resident #42 for Hospice said she had not printed out the new Plan of Care (POC) for Resident #42 and did not realize the old one dated 6/9/23-8/7/23 was the newest one in the facility. She said it was her fault it had not been updated in the facility binder. She said having the updated POC in the facility was important because things changed quickly with hospice residents and all staff needed to know about any changes. She said in the absence of an updated POC in the facility, they would not know what to adhere to. The Hospice RN Case Manager said continuity of care was very important for the care of the resident. She said she did her nurse's notes every time she came to the facility, but they were electronic notes and only in their (hospice) computer system. She said she gave a verbal report every time she came in the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675808 If continuation sheet Page 16 of 19 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 675808 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Rehabilitation and Healthcare 250 W British Flying School Blvd Terrell, TX 75160 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 facility to Resident #42's nurse so that they knew about anything new or any changes. Level of Harm - Minimal harm or potential for actual harm During a phone interview on 09/27/23 at 10:31 AM, the prior admission person said she was not responsible for keeping the hospice charts together. She said she thought the ADON kept up with hospice charts. She said she did help correlate care with hospice and family but never the facility hospice charts. Residents Affected - Some During an interview on 9/27/23 at 12:38 PM, LVN D said written communication from hospice to the facility was important for continuity of care so the facility would know what was going on and to be aware of any changes. She said a verbal report would not be sufficient because it would not be communicated to all nursing staff. During an interview on 9/27/23 at 12:44 PM, ADON B and ADON C both said written communications were very important for the hospice nurse for a hospice resident because that was how they communicated orders or concerns to the facility. ADON B said the absence of written communication could cause missed communication on different levels of care regarding medications, treatment, or ADL care. ADON C said if a hospice nurse gave only a verbal report, things could be misinterpreted, and new information would not get to all staff. During an interview on 9/27/23 1:05 PM, the DON said written communications from hospice were also important to let them know the hospice nurses and their CNAs were going to the facility to see their residents. During an interview on 9/27/23 at 1:24 PM, the ADM said hospice should have kept their books updated for Resident #42 and Resident #21. He said it was important to have nurses notes and a current POC so that the staff knew what was going on with that resident. The ADM said not having those things could cause a slew of potential problems. The ADM said because one would not know if anything was new with hospice, the facility could provide services that were harmful without realizing it. He said the SW was responsible for making sure the hospice binders were up to date, but she just got that assignment. He said he doubted she had time to check or do them yet. He said before the SW, it was the Marketer's responsibility, but she walked out 9/18/23. He said he thought the SW was up to date on the hospice binders, but realized she did not. He said he expected hospice binders to be up to date. During a record review on 9/27/23 at 1:57 PM, the ADM provided a new Hospice POC dated 8/23/23 10/21/23 for Resident #42. During a record review on 09/27/23 at 4:01 PM, the ADM provided a new plan of care for Resident #25 dated 09/27/23 through 10/13/23. During an interview on 09/27/23 at 4:07 PM, ADON B said the facility should have a binder for all residents who were on hospice. She said the binders should contain when they were admitted to hospice, why they were admitted to hospice (such as diagnosis), code status (full code or do not resuscitate (DNR), a list of medications provided by hospice, progress notes, and their plan of care. She said she was not sure who was responsible for ensuring hospice charts were updated. She said it was important to have hospice charts updated for continuity of care. Record review of the facility's policy on End of Life Care; Hospice, revised 12/2019, revealed Collaboration with Hospice will include processes for orienting staff to facility policies and procedures which may include: resident rights, documentation and record keeping requirements . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675808 If continuation sheet Page 17 of 19 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 675808 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Rehabilitation and Healthcare 250 W British Flying School Blvd Terrell, TX 75160 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 infections for 1 of 2 residents reviewed (Resident #51) for infection control practices. Residents Affected - Few The facility failed to ensure CNA F and CNA G changed their gloves or performed hand hygiene appropriately while providing incontinent care for Resident #51. This failure could place any resident at the facility at risk for infection due to improper care practices. Findings included: Record review of Resident #51's face sheet, dated 09/05/23 indicated Resident #51 was a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Chronic obstructive pulmonary disease (COPD- an inflammatory lung disease that gets worse over time), Diabetes mellitus (DM-a disease of inadequate control of blood levels of glucose), and dementia (the loss of cognitive functioning - thinking, remembering, and reasoning). Record review of Resident #51's quarterly MDS assessment, dated 08/08/23, indicated Resident #51 was understood and understood others. Resident #51's BIMs score was 08, which indicated she was moderately cognitively impaired. Resident #51 required total assistance with bathing; extensive assistance with toileting, personal hygiene, transfers, dressing, bed mobility; and set-up assistance with eating. The MDS indicated Resident #51 was incontinent of bowel and bladder. Record review of Resident #51's comprehensive care plan, dated 06/03/23 indicated Resident #51 had an ADL self-care performance deficit related to muscle weakness, unsteady gait, COPD/asthma, and oxygen dependence. Resident #51 had the potential for bowel/bladder incontinence related to confusion, a history of urinary tract infection, and impaired mobility. The interventions of the care plan were for staff to provide dignity by ensuring privacy, check as required for incontinence, wash, rinse, and dry perineum, and monitor for any signs/symptoms of urinary tract infection. During an observation on 09/25/23 at 10:25 a.m., CNA F and CNA G were providing incontinent care for Resident #51 who had an incontinent episode. CNA F wiped Resident #51 using up and down and down and up strokes while cleaning the vaginal area and then changed gloves without sanitizing her hands. CNA G was observed to wipe the buttock down the center only and no other part of Resident #51's buttock which contained urine. CNA G applied barrier cream and applied a brief without changing her gloves or hand hygiene. During an interview on 09/25/23 at 10:49 a.m., CNA G said she did not realize she did not change her gloves or perform hand hygiene while performing incontinent care for Resident #51. CNA G said she knew she should have performed hand hygiene between clean and dirty sources to prevent infections. CNA G said she had been checked off by the ADON/DON for incontinent care and hand washing. During an interview on 09/25/23 at 3:49 p.m., CNA F said she did not realize she wiped front to back and then back to front while cleaning Resident #51's vaginal area. She said she should never wipe upward because she was pushing bacteria into Resident #51's vagina which could cause bacteria to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675808 If continuation sheet Page 18 of 19 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 675808 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Rehabilitation and Healthcare 250 W British Flying School Blvd Terrell, TX 75160 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few grow. CNA F said she did not perform hand hygiene in between each glove change. She said it was important to perform hand hygiene to prevent cross-contamination. She said she was checked off for incontinent care and handwashing by the teacher who taught the CNA program at the facility. During an interview on 09/27/23 at 4:07 p.m., ADON B said she expected staff to perform incontinence care the proper way. She said she expected staff to perform hand hygiene anytime they went from dirty to clean. ADON B said all administration nurses were responsible for ensuring residents were cleaned properly to prevent infection and skin issues. She said they did competencies upon hire, yearly, and as needed. During an interview on 09/27/23 at 4:34 p.m., the DON said she expected staff to change their gloves between clean and dirty and to use hand hygiene between glove changes. She said she was the overseer of CNAs. She said they did competencies upon hire, yearly, and as needed. The DON said failure to do appropriate incontinence care could cause skin issues and lead to infections. During an interview on 09/27/23 at 4:50 p.m., the Adm said he expected all staff to use proper hand hygiene techniques between dirty and clean areas with all care. The Adm said the DON/ADON was responsible for ensuring staff were trained on infection control. He said improper hygiene could place the resident at risk for skin issues and UTI infections. Record review of competencies skills revealed CNA F had been checked off on hand washing and peri-care on 03/29/23. Record review of competencies skills revealed CNA G had been checked off on hand washing and peri-care on 03/29/23. Record review of the facility policy titled, Hand Hygiene, dated 05/07 indicated, It is the policy of this facility to cleanse hands to prevent transmission of possible infectious material and to provide clean, healthy environment for residents and staff. Hand washing is considered the most single procedure for preventing nosocomial infection. Although antiseptics and other hand-washing agents do not sterilize the skin, they can reduce microbial contamination depending on the type and the amount of contamination, the agent used, the presence of residual activity, and the hand-washing technique followed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675808 If continuation sheet Page 19 of 19