Health inspection·December 1, 2023

F 0880 with mood disorder, Dysphagia (difficult to swallow), and Vascular dementia, Level of Harm - Minimal harm or potential for actual harm Record review on 12/01/23 of Resident #2's initial MDS assessment dated [DATE], revealed that the BIMS score in Section C- Cognitive patterns, was not completed. Residents Affected - Some Review of Resident #2's care plan, dated 9/13/23, reflected that Resident#2 had hypertension and the relevant intervention was measuring BP. Record review on 12/01/23 of physician's order dated 12/20/2022 reflected: Lisinopril Tablet 20 MG Give 1 tablet by mouth one time a day for HTN, hold if pulse less than 60, and SBP less than 110. During an observation on 12/01/23 beginning at 9:30 AM, MA A was administering medications to the residents. MA A took the blood pressure of Resident #1 with a wrist blood pressure monitor and then administered the ordered medications. Once the medication administration to Resident#1 was completed, MA A moved on to Resident #2 who resides in the same hall and used the same blood pressure monitor on Resident #2 without sanitizing it. After the blood pressure was taken, she stored the blood pressure monitor on the medication cart. MA A failed to sanitize the wrist blood pressure monitor before and after using it on Resident #1 and before and after using it on Resident #2. During an interview on 10/24/23 at 11:45AM, MA A stated she was aware that the blood pressure monitor should be sanitized in between the residents. MA A said she simply forgot to sanitize it and then, she looked for the sanitizer at the bottom of the drawer. Since it was not available on that cart, she picked up one from another cart and sanitized the blood pressure cuff. MA A stated there was a danger of transmitting diseases from one resident to another if the equipment was not sanitized properly. MA A stated she had not received in-service on disinfection of medical equipment, in the recent past. Review of Resident #3's face sheet, dated 12/01/23, reflected Resident #3 admitted to the facility on [DATE]. He was a [AGE] year-old male diagnosed with Rheumatoid Arthritis of right knee (type of degenerative disorder), osteoarthritis of knee(Brittle bones), Muscle wasting, Chronic Obstructive Pulmonary Disease (difficult to breath due to a type of lung disease), Anemia (low level of red blood cells), Protein-calorie malnutrition, Hypertensive Heart Disease without heart failure, Age-related physical debility, Localized edema (Swelling), unsteadiness on feet , schizophrenia (a type of mental illness), and Lack of coordination. Record review on 12/01/23 of Resident #3's initial MDS assessment dated [DATE] revealed, a BIMS score of 09 indicating moderately impaired cognition. Review of Resident #3's care plan dated 10/05/23, had not reflected his diagnosis of hypertensive heart disease. Record review on 12/01/23 of physician's order dated 10/06/23 reflected: Amlodipine Besylate Oral Tablet 10 MG (Amlodipine Besylate) Give 1 tablet by mouth one time a day for HTN Hold for SBP<100 OR DBP<60 OR HR<60. Hydrochlorothiazide Oral Tablet 25 MG (Hydrochlorothiazide) Give 1 tablet by mouth one time a day (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675956 If continuation sheet Page 2 of 4 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 675956 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Nursing and Rehabilitation Center of Duval 5301 W Duval Rd Austin, TX 78727 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 for HTN Hold for SBP<110. Level of Harm - Minimal harm or potential for actual harm Review of Resident #4's face sheet, dated 12/01/23, reflected Resident #4 admitted to the facility on [DATE]. He was a [AGE] year-old male diagnosed with Hypertension, Impulse disorders, Hyperlipidemia( High fat level in blood), Unsteadiness on feet, Bipolar disorder, Type 2 diabetes mellitus, Lack of coordination, Age-related physical debility, Major depressive disorder, Muscle wasting, Dysphagia (Difficulty to swallow), Vitamin D deficiency, Anemia (low level of red blood cells), Schizoaffective Disorder- bipolar type ( a type of mental illness), and Dementia. Residents Affected - Some Record review on 12/01/23 of Resident #4's quarterly MDS assessment, dated 10/11/23, revealed a BIMS score of 13 indicating his cognition was intact. Review of Resident #4's care plan, dated 10/20/23, reflected he had hypertension (HTN), the risk for abnormal blood pressure, and the relevant intervention was obtain blood pressure readings as indicated. Record review on 12/01/23 of physician's order dated 09/07/22 reflected: Lisinopril Tablet 2.5 MG Give 1 tablet by mouth one time a day for renal issue, hold if systolic blood pressure less than 110. During an observation on 12/01/23 beginning at 10:00 AM, MA B was administering medications to the residents. MA B took the blood pressure of Resident #3 with a wrist blood pressure monitor and then administered the ordered medications. Once the medication administration to Resident#3 was completed, MA B moved on to Resident #4 and used the same blood pressure monitor on Resident #4 without sanitizing it. After the blood pressure was taken, she stored the blood pressure monitor on the top of the med cart. MA B failed to sanitize the wrist blood pressure monitor before and after using it on Resident #3 and before and after using it on Resident #4. During an interview on 10/24/23 at 11:45AM, MA B stated everything that she did related to medication administration was correct. When investigator pointed out that she did not sanitize the blood pressure cuff every time she used it on residents, MA B stated she was aware that the blood pressure monitor should be sanitized in between the residents. MA B stated she forgot as she was in a hurry. Then she looked for the sanitizer and picked up a packet from the bottom drawer of the med cart and sanitized the blood pressure cuff. MA B stated sanitizing medical equipment like blood pressure cuff minimizes the transmission of various diseases from one resident to another. MA A stated she worked at the facility for many years and had received an in-service on disinfecting medical equipment, but was unsure of the exact time period. During an interview on 12/01/23 at 3:00 PM, the DON stated his expectation was that the nursing staff must follow facility policy/procedure for handwashing and sanitization of medical equipment. That includes sanitizing blood pressure monitor, every time after the use on residents was essential to stop spreading transmittable diseases. When asked about how the facility identified deficient practice by nursing staff, he stated the DON and the ADON observe and/or participate in nursing care with the nurses, MAs, and CNAs. The DON stated the facility conducted in -services on standard precautions and other infection control policies and protocol, but not specifically on sanitizing medical equipment at the facility. Record review on 12/01/23 of facility in-services from 06/01/23 revealed there were no in-services (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675956 If continuation sheet Page 3 of 4 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 675956 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Nursing and Rehabilitation Center of Duval 5301 W Duval Rd Austin, TX 78727 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 on disinfecting medical equipment. Level of Harm - Minimal harm or potential for actual harm Review on 12/01/23 of facility policy Infection prevention and control program dated 05/13/23 reflected: 4.standard precautions: Residents Affected - Some a. All staff shall assume that all residents are potentially infected or colonized with an organism that could be transmitted during the course of providing resident care services 10. Equipment Protocol: a. All reusable items and equipment requiring special cleaning, disinfection or sterilization shall be cleaned in accordance with our current procedures governing the cleaning and sterilization of soiled or contaminated equipment . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675956 If continuation sheet Page 4 of 4