Health inspection·April 8, 2023

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 03/19/23 RN A noted Family Member H approached RN A and asked her about a bruise he found on Resident #1's forehead. RN A noted a faint receding discolored area near Resident #1's left eye-brow. RN A noted there was no bleeding and no falls had been reported. RN A noted she spoke to DON and ADON regarding the bruise. On 03/22/23 LVN B noted Resident #1's family was in the facility wanting to know about the bruise on her forehead. The family wanted to know if a CT scan had been done. LVN B noted she called the ADON and told her about the family's concerns. LVN B then noted resident bruise on the side of her head is turning yellow in color. On 03/23/22 LVN B noted Resident #1 had a bruise that was turning yellow on the left side of her forehead. On 03/23/23 LVN B noted a late entry for March 18th when a CNA told LVN B there was a bruise on the left hip and left knee of Resident #1. LVN B noted the bruises were turning yellow and the left knee had scabbed areas. During an interview on 04/07/23 at 11:26 AM Resident #1's Family Member I stated Family Member H noticed she [Resident #1] had a gigantic bruise that was on her hair line at her brow to her temple during a visit on 03/19/23. He stated when Family Member H asked the nurses about the bruise they did not have an answer to what had happened, no report, nor did they do anything about it. He stated Family Member J visited Resident #1 on 03/22/23 and noticed the bruise. He stated Family Member J asked for documentation of what happened to cause the bruise, and facility staff could not provide any documentation. He stated Family Member J got pictures of the bruise and he will email them to me. During an interview on 04/07/23 at 03:46 PM CNA C stated if she notices a new bruise on a resident, she reports the bruise to the charge nurse. During an interview on 04/07/23 at 03:48 PM CNAs C and D stated they did notice the bruise on Resident #1's forehead. They stated it happened over the weekend when they were off work. They stated the night shift asked them about it to see if they knew when it happened. When asked if they documented the bruise, they said they did not because a nurse was asking them about it so they knew the nurses already knew about the bruise. During an observation on 04/07/23 at 03:51 PM Resident #1 was lying in bed, asleep with her legs elevated under a blanket and her head turned to the right side. She did not have any bruising to her left temple. During an interview on 04/07/23 at 03:59 PM RN A stated normal procedure when a bruise was found on a resident was to put in an incident report about it. During an interview on 4/07/23 at 04:15 PM, LVN E stated protocol for an unexplained bruise on a resident was put it in your nurse's notes, get hold of family, and let my DON and on-call know. Call doctor and let them know. Do a good complete assessment on the resident. During an interview on 04/07/23 at 06:17 PM, RN F stated protocol for a new bruise found on a resident was to make a note and a 72-hour follow up and take it up the chain to the DON or ADON. He stated he did not notice a bruise on Resident #1's forehead. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675904 If continuation sheet Page 2 of 5 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675904 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windflower Health Center 5500 SW 9th Ave Amarillo, TX 79106 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 04/07/23 at 06:22 PM with CNA G she stated if she noticed a new bruise on a resident she would report it to my charge nurse and if nothing gets done, go to abuse coordinator. During an observation and attempted interview on 04/07/23 at 06:25 PM Resident #1 was lying in her bed with her legs elevated under a blanket, awake. She smiled and shook hands with this surveyor but was unable to answer any questions. During an interview on 04/08/23 at 02:47 PM, Family Member J stated she visited Resident #1 on 03/22/23 and noticed a big bruise on the side of her temple .it was real yellow all the way down to her jaw. Family Member J stated, I took pictures of the bruise on my phone, and I inquired about what happened. She stated LVN B looked at the notes and could not find any mention of what happened. Family Member J stated she then called Family Member H and found out he had noticed a bruise in the same area on 03/19/23. She stated the bruise was so extensive it affected the shape of her face right there where her temple was. Family Member J stated she spoke to the ADON and the ADON did not know anything about the bruise but told her she would begin looking into it and let her know what she found. She stated she had meeting with the ADON the next day and during the meeting she asked the ADON if a CT scan had been ordered for the head injury. Family Member J stated the ADON called the physician, and he ordered a CT scan for the following day 03/24/23. She then asked the ADON if there was an incident report for the head injury and was told there was not an incident report. Family Member J stated the ADON told her nobody saw her fall and didn't know she had the injury because her hair fell down in front of her face. Family Member J stated she was called late on 03/23/23 and told the CT scan could not be done until 03/27/23. She stated she was not comfortable with that wait and took Resident #1 to the emergency room for a CT scan. She stated the CT scan did not show any concerns. She stated the emergency room doctor told her It was just a concussion and .it was a very deep bruise and would just have to heal. During an interview on 04/08/23 at 03:06 PM, Family Member H stated he noticed the bruise on Resident #1's brow on 03/19/23 and it was a blue color and right above the left eye. He stated, I was rubbing her head-she likes me to rub her head-and her bangs covered it up, I guess that is why they (nurses) didn't see it. He stated he spoke to a nurse, and she told him there was nothing written up about it, but she would get to the bottom of it. He stated he was not sure which nurse he spoke to but thought it was RN A. Family Member H said the bruise stopped by her eyebrow; it went higher up from her left eye. It looks like she might have run into a wall or a door or I don't know because nobody saw it happen. During an interview on 04/08/23 at 03:43 PM, RN A stated she remembered speaking to Family Member H regarding a bruise to Resident #1's brow. She stated, Nobody knows how she got that bruise. She stated she observed the bruise, when Family Member H brought it to her attention and it wasn't a big bruise, it was just a faint bruise; faint blue right at the outside edge of her eyebrow. RN A stated the bruise was the size of a nickel. She stated, I looked at it and I filed a report of what I saw and what he [Family Member H] told me. She stated the report she referred to was her progress note from 03/19/23. RN A stated her note indicated she spoke to the DON and the ADON about the bruise on 03/19/23. During an interview on 04/08/23 at 04:13 PM, the ADON stated she spoke to RN A regarding the bruise and asked LVN B to file an incident report on 03/22/23 because LVN B spoke to Family Member J about the bruise. She stated she did not know if the incident report was filed. She stated, .the DON follows up with incident reports and the DON does the investigation and all of that. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675904 If continuation sheet Page 3 of 5 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675904 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windflower Health Center 5500 SW 9th Ave Amarillo, TX 79106 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 04/08/23 at 04:22 PM, the ADM reviewed the printed incident report for the last three months and noted there was not record of an incident involving Resident #1 on 03/19/23 or 03/22/23. He stated he would call the ADON and try to find that report. During an interview on 04/08/23 at 04:48 PM, the ADM had a regional staff member on speaker phone explaining the system that kept track of incidents was down and the help desk was closed until after Easter. During an interview on 04/08/23 at 05:58 PM the ADM stated the usual procedure when a resident has an injury of unknown origin was, We investigate. He stated this investigation just didn't happen in the case of Resident #1's injury of unknown origin. During an interview on 04/10/23 at 08:28 AM the Interim DON stated she has worked for the facility for three weeks. She stated on her first day [she could not remember the exact date] in the facility she saw a light bruise on the left side of her [Resident #1's] forehead. She stated the bruise was oval in shape, an inch and a half long, light greenish in color. The Interim DON stated the bruise was brought to her attention by the family. When asked if an incident report was filed regarding the bruise, she stated, I was told there was an incident report made but, I have to be honest, I had just started, and I did not follow up at that point. During an interview on 04/10/23 at 02:36 PM, LVN B said of the bruise to Resident #1's brow, I came back to work, and it was there. They told me an incident report was made for it. She said it was RN F who told her an incident report was already made. Record review of printed incident report for the last three months of the facility, dated 04/07/23, mentioned Resident #1 only two times. The first mention was 01/31/23 when a behavior was noted for Resident #1. The second mention of Resident #1 was 03/30/23 when Resident #1 was visually observed on the floor. Record review of an email from Family Member I, received on 04/08/23 at 02:03 PM, revealed two images of Resident #1. In the images a hand is holding Resident #1's hair back on the left side of her head. There is a bruise extending from the hairline to the brow and down the outside of the eye. The bruise is dark reddish-purple along the brow and extending up from the brow and down to the side of the eye. The bruise is yellow with some mottled blue tinges along the outer edges of the bruise to the top and sides. According to the email these pictures were taken by Family Member J on her phone during her visit with Resident #1 on 03/22/23 and sent to Family Member I via text message. Record review of facility policy titled, Abuse Investigations and dated 04/2014 revealed the following: All reports of resident abuse, neglect and injuries of unknow source shall be thoroughly and promptly investigated by facility management. 1. Should an incident or suspected incident of resident abuse, mistreatment, neglect or injury of unknown source be reported, the Administrator, or his/her designee, will appoint a member of management to investigate the alleged incident. 3. The individual conducting the investigation will, as a minimum; . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675904 If continuation sheet Page 4 of 5 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675904 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windflower Health Center 5500 SW 9th Ave Amarillo, TX 79106 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 10. The Administrator will keep the resident and his/her representative (sponsor) informed of the progress of the investigation. 11. The results of the investigation will be recorded on approved documentation forms. 13. The Administrator will inform the resident and his/her representative (sponsor) of the results of the investigation and corrective action taken. 14. The Administrator will provide a written report of the results of all abuse investigations and appropriate action taken to the sate survey and certification agency, the local police department, the ombudsman, and others as may be required by state or local laws, within five (5) working days of the reported incident. 16. Inquiries concerning abuse reporting and investigation should be referred to the Administrator or to the Director of Nursing Services. Record review of facility policy titled, Abuse Prevention Program and dated 12/2016 revealed the following: . As part of the resident abuse prevention, the administration will: . 6. Identify and assess all possible incidents of abuse; 7. Investigate and report any allegations of abuse within timeframes as required by federal requirements; . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675904 If continuation sheet Page 5 of 5