Health inspection·August 21, 2023

F812 Residents Affected - Many Abreviations: lbs- pounds, DM- Dietary Mananger, Admin- Administrator, DD- Dietary Director Based on observation, interview and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 2 of 2 kitchens (Kitchen A, Kitchen B) reviewed for proper protocols. 1. The facility failed to ensure stored foods are properly labeled and dated putting residents at risk for foodborne illness. 2. The facility failed to ensure proper temperature of hot and cold food items putting residents at risk for foodborne illness. 3. The facility failed to serve residents food that was at the proper holding temperature putting residents at risk for foodborne illness. Findings Include: Observation of Facility Fridge A in Kitchen A on 8/21/2023 at 11:16AM revealed the following: 1. 5lb container of garlic opened with no open date 2. 5lb container of jalapenos opened with no open date 3. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 3 Event ID: 675904 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 08/21/2023 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 0812 5lb container yellow mustard opened with no open date Level of Harm - Minimal harm or potential for actual harm 4. 5lb container tartar sauce opened with no open date, expired on 7/30/2023 Residents Affected - Many Observation of hot holding temperatures on the facility steam table in Kitchen B on 8/21/2023 at 11:38AM taken by surveyor revealed the following: 1. ham and cheese sandwiches, 55 degrees Fahrenheit 2. premade pureed packaged vegetables, 120 degrees Fahrenheit 3. vegetable soup, 127 Degrees Fahrenheit 4. ham and cheese sandwiches 2nd tray, 50 degrees Fahrenheit Observation of the Facility Fridge B in Kitchen B on 8/31/2023 at 11:51AM revealed the temperature to be 52 degrees Fahrenheit. Observation of the Facility Fridge B in Kitchen B on 8/31/2023 at 12:09PM revealed the temperatures of the food items inside the fridge taken by surveyor: pickles were 42 degrees Fahrenheit, mixed fruit was 45 degrees Fahrenheit and cheese slices were 44 degrees Fahrenheit. Observation of the Facility Fridge B in Kitchen B on 8/31/2023 at 12:13PM revealed the temperature to be 56.7 degrees Fahrenheit. Interview with DM on 8/21/2023 at 11:59AM, the DM was asked what the protocol is for foods do not come to the correct temperature at the steam table and DM stated, We put it in the microwave to warm it up. When asked if the DM thought the food on the steam table that was not temping appropriately was safe to serve to residents DM stated No, it's not safe. The DM stated, Part of the problem is when we open the fridge the temperature drops. When asked if the DM is familiar with the facility's policies and procedures for the kitchen, the DM said Yes I've had training on them. The foods that were not holding appropriate temperature was served to residents. In an Interview with the Admin on 8/21/2023 at 12:34PM, the Admin was asked what the process is for receiving food for mealtimes, Admin stated it comes here from across the street in insulated carts and goes on the steam table to reheat to the proper temperature. When asked what a negative outcome would be of food not reaching the correct temperature and being served to residents Admin stated, they could get a bellyache, diarrhea or get sick. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675904 If continuation sheet Page 2 of 3 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 08/21/2023 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete In an Interview with the DD on 8/21/2023 at 3:00PM, the DD was asked what a negative outcome would be of food not reaching the correct temperature and being served to residents and the DD stated, They would get sick. When asked if DD is familiar with the facility's policies and procedures for the kitchen, DD said Yes. Record Review of the facility policy for Receiving and Storage dated 2014 reflected, Refrigerated foods must be stored below 41 degrees unless otherwise specified by law. The policy reflected, acceptable ranges are 35 degrees to 40 degrees for refrigerators. The policy also reflected all food shall be appropriately dated to ensure proper rotation by expiration dates. Received dates (dates of delivery) will be marked on cases and on individual items removed from cases for storage. Use by dates will be completed with expiration dates on all prepared food in refrigerators. Expiration dates on unopened food will be observed and use by dates indicated once food is opened. The policy reflected supervisors will be responsible for ensuring food items in pantry, refrigerators, and freezers are not expired or past perish dates. Event ID: Facility ID: 675904 If continuation sheet Page 3 of 3