Health inspection·January 27, 2024

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of Resident #153's MDS Quarterly Assessment, dated 12/22/23, reflected a BIMS score of 8 out of 15, which indicated moderate cognitive impairment. Record Review of Resident #153's care plan reflected [Resident #153] is dependent on staff for meeting emotional, intellectual, physical, and social needs with interventions to include All staff to converse with resident while providing care, initiated 10/26/22. [Resident #153] has an ADL self-care performance deficit . with interventions to include EATING: The resident requires (supervision/set up assistance) by (1) staff to eat., revised 11/07/22. Record Review of the weights for Resident #19, Resident #153, and the other 2 residents at their table for 01/23/24 lunch did not have any recent weight loss for the last 3 months. During an interview and observation on 01/23/24 at 12:27 PM, Resident #153 was the only resident at a table of 4 that had his meal while lunch meal trays were being passed to other tables at the same time. Resident #153 was waiting to eat until Resident #19 received her meal. They shared that they were engaged and enjoyed eating together. Resident #19 told Resident #153 to eat his lunch so his food would not get cold. Resident #153 revealed that he felt bad for eating without Resident #19. Resident #153 and Resident #19 both revealed that this does occur often. At 12:43 PM (16 minutes after the start of this interview), Resident #19 continued to state, it breaks my heart and she got worried about the other residents at her table when they received their meals late. The other residents at her current table were unable to interview. During an interview and observation on 01/25/24 at 12:39 PM in the main dining room, CNAs were not serving one table at a time. There were 11 tables with about 33 residents and 8 CNAs passing out lunch meal trays. The FSS revealed that all the residents at each table should have received their plates before moving to the next table. The FSS revealed that he organized the trays so that they can be passed out to one table at a time. The FSS noted that this procedure was not happening at 01/25/24 lunch meal service and told ADON G to serve every resident at each table before moving on to the next table. During an interview on 01/26/24 at 03:42 PM, LVN II revealed all residents at each table are served their meal trays before moving to the next table. She stated that this was important because the residents wanted to eat at the same time to enjoy the meal together. 2. Record review of Resident #102's admission Record, dated 01/25/24, reflected a [AGE] year-old resident recently re-admitted [DATE] with diagnoses to include quadriplegia, post-traumatic stress disorder (a mental health condition that develops following a traumatic event characterized by intrusive thoughts about the incident, recurrent distress/anxiety, flash back and avoidance of similar situations), age related physical debility (physical weakness), lack of coordination, anxiety (a group of conditions characterized by two brain functions such as memory loss and judgement, and intense, excessive, and persistent worry), and major depressive disorder. Record review of Resident #102's MDS Quarterly Assessment, dated 12/08/23, reflected a BIMS score of 7 out of 15, which indicated severe cognitive impairment. Record Review of Resident #102's care plan reflected [Resident #102] has an ADL self-care performance deficit . with interventions to include All staff to converse with resident while providing care, initiated 10/26/22. [Resident #102] has an ADL self-care performance deficit . with interventions to include EATING: The resident total assist by staff to eat., revised 05/20/21. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675956 If continuation sheet Page 2 of 26 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 01/27/2024 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 0550 Record Review of Resident #102's weight history revealed no recent weight loss for the last 6 months. Level of Harm - Minimal harm or potential for actual harm During an interview and observation on 01/23/24 at 01:08 PM, Resident #102 was lying in bed with his 01/23/24 lunch meal tray to his side, untouched. Resident #102 had revealed that he had not eaten yet and had been waiting to be fed. He further revealed that he needed to be fed by a CNA. Resident #102's roommate, Resident #50, was able to request and was served more dessert from the FSS because he was done with his 01/23/24 lunch meal. Resident #102 said I need someone to come feed me. The FSS gave Resident #50 dessert and told Resident #102 that he would find someone to help him eat his lunch. Resident #50 revealed that sometimes he will finish his meal and Resident #102 would not be fed still. Resident #50 was a smoker and revealed that at times he would even go out to smoke after eating lunch and Resident #102 would still not be fed. Resident #50 revealed that he felt bad when his roommate was not fed. Residents Affected - Some During an interview on 01/24/24 at 11:57 AM, Resident #102 revealed that it made him feel bad when he was fed late, after his roommate has eaten and the food was cold. During an interview on 01/26/24 at 11:37 AM, the FSS revealed that Resident #102's roommate, Resident #50, had reported a few times (not able to quantify) to the FSS when Resident #102 had not been fed. Resident #102's roommate would ask the FSS to get a CNA to help Resident #102 eat. The FSS revealed that since he was made aware of Resident #102 not being fed timely, he saved Resident #102's meal tray to be passed out last in his hall to prevent Resident #102's meal to be cold. During an interview on 01/26/24 at 03:42 PM, LVN II revealed that Resident #102 was the only resident on his hall that needed total assistance so the CNAs would be able to get to him after the meals were passed out to the other residents in the hall. She further revealed she had not heard about any problems with the CNAs feeding Resident #102, except that he would refuse breakfast at times. On 1/26/24 at 03:42 PM, the DON stated the facility did not have a policy regarding dignity. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675956 If continuation sheet Page 3 of 26 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 01/27/2024 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 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the resident's right to request, refuse, and/or discontinue treatment, and to formulate an advance directive for 1 (Resident #68) of 35 residents reviewed for clinical records, in that: Resident #68's clinical record contained two OOH-DNR forms, both of which were invalid. This deficient practice could place residents at-risk of having their end of life wishes dishonored, and of having CPR performed against their wishes. The findings were: Record review of Resident #68's face sheet, dated [DATE], revealed the resident was admitted to the facility on [DATE] with diagnoses including: Unspecified Dementia, Chronic Obstructive Pulmonary Disease, and Type 2 Diabetes Mellitus. Record review of Resident #68's Quarterly MDS assessment, dated [DATE], revealed a BIMS score of 5, which indicated severe cognitive impairment. Record review of Resident #68's care plan, revised [DATE], revealed [Resident #68] is a DNR, facility will cooperate with [Resident #68]/family wishes, Ensure signed DNR is in medical record. If resident has a cardiac arrest, do not call 911 or initiate CPR. Notify MD/RP and follow instructions after notification. Keep resident as comfortable as possible at all times. [NAME] chart and all pertinent documents with DNR status. Send copy of DNR paperwork upon transfer from facility. Social services consult if resident/family want to change code status. Record review of Resident #68's OOH-DNR dated [DATE] revealed the executor's signature was illegible and he or she had not printed his or her name. Additionally, the executor had not signed a second time. Finally, the copy of the form was missing a portion of the bottom section which resulted in the witnesses' signatures only partially seen. Record review of Resident #68's OOH-DNR dated [DATE] revealed the physician's signature was illegible and he or she had not printed his or her name nor added his or her license number. During an interview with the Social Worker on [DATE] at 10:27 a.m., the Social Worker confirmed that both OOH-DNR forms in Resident #68's clinical record were invalid due to missing or illegible information. During an interview with the Social Worker on [DATE] at 10:47 p.m., the Social Worker stated that Resident #68's OOH-DNR dated [DATE] was in a paper file and had been completely filled in correctly, and confirmed the paper and electronic copies of the OOH-DNR did not match. Record review of the Texas Health and Human Services webpage titled, Out of Hospital Do Not Resuscitate Program, updated [DATE], revealed, Frequently Asked Questions for DNR: What happens if the form is not filled out correctly or EMS has doubts about any of the information? Health professionals can refuse to honor a DNR if they think: The form is not signed twice by all who need to sign it or is (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675956 If continuation sheet Page 4 of 26 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 01/27/2024 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 0578 filled out incorrectly. Level of Harm - Minimal harm or potential for actual harm A facility policy regarding Advance Directives was requested but not received by the time of exit. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675956 If continuation sheet Page 5 of 26 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 01/27/2024 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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care for 2 of 21 residents (Residents #396 and #190) reviewed for baseline care plan, in that: 1. The facility failed to ensure Resident #396's baseline care plan included information related to his foley catheter ( tube that helps drain urine from bladder). 2. The facility failed to initiate a baseline care plan within 48hours of admission date 1/8/2024 for resident #190 to include physical therapy for strengthening. These failures could affect newly admitted residents and place them at risk of not receiving continuity of care and communication among nursing home staff to ensure their immediate care needs are met. The findings are: 1. Record review of Resident #396's face sheet revealed was a [AGE] year-old male admitted on [DATE] with a diagnoses that included: [Dysuria] means you feel pain or a burning sensation when you pee, [Insomnia] is a sleep disorder that can make it hard to fall asleep or stay asleep, and [ Hypertension] is a condition in which the blood vessels have persistently raised pressure. Record review of Resident #396's Nursing home comprehensive MDS assessment dated [DATE] revealed a BIMS score of 15 suggesting cognition was intact, and under section H, Bowel and Bladder section A was selected, indicating the resident had an indwelling catheter. Record review of Resident #396's physicans orders for January 2024, revealed an order for Foley catheter. Record review of Resident #396's Baseline care plan, dated 1/19/24, did not reveal a focus area or instructions for the resident's use of an indwelling urinary catheter. Observation and interview on 01/24/24 at 10:38 AM revealed Resident #396's foley catheter tubing was attached to movable part of the bed frame with a dignity bag present. Resident #396 stated, I have a foley because sometimes I have problems emptying my bladder. During the interview on 01/25/24 at 9:45 AM, the MDS nurse stated Resident #396 had a Foley catheter. The MDS nurse stated she was responsible for care plans and has yet to have an opportunity to complete the baseline care plan but would by the end of day. She stated staff risked not being on the same page with care if something is not care planned. During an interview on 1/24/24 at 11:02 AM with ADON A , she stated that Resident #396 had been admitted on [DATE] with a condom catheter and then transitioned to a Foley catheter due to urinary retention. She believes that this transition from condom catheter to foley catheter is what might have caused the delay in the updated care plan. It was her expectation that the MDS nurses follow the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675956 If continuation sheet Page 6 of 26 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 01/27/2024 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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 48-hour policy for baseline care plans in order for licensed nurses to be on the same page in regard to patient care. The ADON also stated that resident #396 risked the possibility of nursing staff needing to be on the same page when addressing care to resident #396. During an interview with the DON on 01/25/2024 at 8:25 AM, the DON confirmed that Resident #396 needs should have been addressed on his baseline care plans. He did not know why the Foley catheter was unplanned by the MDS nurse but would ensure it was moving forward. He stated the resident risked not receiving the care needed if it was not care planned. 2. Record review of Resident #190's face sheet 1/26/2024 at 3:10PM revealed the resident was a [AGE] year old female, admitted [DATE], with diagnoses of diastolic hypertension (elevated blood pressure of the bottom number), hypothyroidism (under active thyroid that does not produce enough thyroid hormone that controls body temperature, heart rate, and all aspects of metabolism), status asthmaticus (chronic obstructive airway preventing the regular exchange of oxygen and carbon dioxide that can also be fatal) -revealed there was no baseline care plan for this resident within 48 hours of admission. In an interview with the DON on 1/26/2024 at 3:30 PM, the DON confirmed the baseline care plan for Residents #396 and #190 were not done within 48 hours of admission. He stated he understood the error and it should have been done in a timely manner. Record review of the facility's policy titled, Base Line Care Plan, dated 10/22/22 and revised 10/5/23, revealed, The base line care plan will be developed with in 48 hours of a resident admission. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675956 If continuation sheet Page 7 of 26 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 01/27/2024 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 0695 Provide safe and appropriate respiratory care 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 observations, interviews, and record reviews the facility failed to ensure that a resident who needs respiratory care for 2 of 26 residents (Residents #2 and #53) reviewed for care consistent with professional standards, in that: Residents Affected - Few 1. The facility failed to post signage for the room of Resident #53 while oxygen was in use. 2. The facility failed to clean the oxygen concentrator filter for Resident #2 while the oxygen was in use. These failures could place residents at risk for improper respiratory care. The findings included: 1. Record review of Resident #53's face sheet, dated 1/26/24, revealed the [AGE] year old resident was admitted to the facility on [DATE] with diagnoses including: unspecified dementia (a condition of progressive loss of memory and intellectual functioning), unspecified osteoarthritis (a condition in which the bones become brittle with age), and major depressive disorder (a condition of persistent mood impairment). Record review of Resident #53's MDS, dated [DATE], revealed a BIMS score of 0, indicating severe cognitive impairment. Record review of Resident #53's Physician's orders, dated 01/26/24, revealed an order for palliative care effective 1/19/24. During an observation of Resident #53 in her room on 1/23/24 at 1:30 PM revealed that she was using oxygen while laying in bed and there was no oxygen signage placed for the room. During an interview on 1/23/24 at 1:35 PM with ADON G stated Resident #53 had been using oxygen for several days and that oxygen signage should have been posted for her room to notify staff of the potential hazard intervention. 2. Record review of Resident #2's face sheet dated 1/26/24, revealed the [AGE] year old resident was admitted to the facility on [DATE] with diagnoses of chronic obstructive disease (a condition involving constriction of the airways causing difficulty in breathing), congestive heart failure (a chronic condition in which the heart does not pump blood as well as it should), and spondylosis (a condition of the age-related wear of the spinal disks). Record review of Resident # 2's MDS dated [DATE] revealed a BIMS score of 0, indicating severe cognitive impairment. Record review of Resident #2's Physician's orders, dated 1/26/24, revealed an order for oxygen use effective 8/19/20. During an observation of Resident #2 in her room on 1/24/24 at 4:10 PM noted that the resident's oxygen concentrator was in operation and that she had a filter attached to the back of the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675956 If continuation sheet Page 8 of 26 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 01/27/2024 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 0695 concentrator that was dated 1/12/21. Level of Harm - Minimal harm or potential for actual harm During an interview with the DON on 1/24/24 at 4:15 PM, the DON stated the oxygen filter for Resident #2 should have been changed and immediately removed the concentrator from the room. Residents Affected - Few During an interview with the DON on 1/25/24 at 9:55 AM, DON stated that oxygen signage should be placed on any room in which oxygen is in use to alert staff to the resident's needs. The DON stated the concentrator filter in use for Resident #2 should have been replaced by nursing staff. He stated that an unclean filter could contribute to a resident having a respiratory infection. Record review of the Oxygen Concentrator Supplies Shop informational sheet dated 5/3/22 stated an annual filter change was recommended for the Oxygen concentrator. Record review of the facility policy titled Oxygen Administration, revised on 07/2015, revealed, T-1 that an Oxygen in Use signage should be placed on the outside of the room entrance door. The policy stated that oxygen filters should be changed or cleaned on a regular basis. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675956 If continuation sheet Page 9 of 26 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 01/27/2024 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the drug regimen of 2 out of 40 residents (Resident #37 and Resident #102) were reviewed at least once a month by a licensed pharmacist, in that: 1. Resident #37 was missing monthly medication reviews documented for the months of October 2023 and July 2023. 2. Resident #102 was missing monthly medication reviews documented for the months from August 2023 to December 2023. These deficient practices could place residents at risk from harm related to unnecessary medications or dosages, could place them at risk for adverse consequences related to medication therapy, and impact residents' ability to achieve or maintain their highest practicable level of physical, mental, and psychosocial well-being. The findings included: 1. Record review of Resident #37's admission Record, dated 01/24/24, revealed the resident was a [AGE] year-old resident, re-admitted on [DATE], with diagnoses to include: dementia (a group of symptoms affecting memory, thinking, and social abilities), age related physical debility (physical weakness), muscle wasting and atrophy, and need for assistance with personal care. Record review of Resident #37's MDS Quarterly Assessment, dated 11/26/23, revealed the resident had a BIMS score of 12 out of 15, which indicated moderate cognitive impairment. Record Review of Resident #37's Active Orders as of 01/24/24 revealed, Orders will be reviewed and renewed every 45 days., order date 08/21/23. 2. Record review of Resident #102's admission Record, dated 01/25/24, revealed the resident was a [AGE] year-old resident, re-admitted on [DATE], with diagnoses to include: quadriplegia, post-traumatic stress disorder (a mental health condition that develops following a traumatic event characterized by intrusive thoughts about the incident, recurrent distress/anxiety, flash back and avoidance of similar situations), age related physical debility (physical weakness), lack of coordination, anxiety (a group of conditions characterized by two brain functions such as memory loss and judgement, and intense, excessive, and persistent worry), and major depressive disorder. Record review of Resident #102's MDS Quarterly Assessment, dated 12/08/23, revealed the resident had a BIMS score of 7 out of 15, which indicated severe cognitive impairment. Record Review of Resident #102's Active Orders as of 01/25/24 revealed, Orders will be reviewed and renewed every 45 days., order date 01/29/21. During an interview with the DON on 01/26/24 at 2:36 PM, the DON stated the best practice for medication regimen reviews would be for them to occur once a month to ensure resident safety. The DON brought the medication regimen reviews the facility had for the past 6 months for Residents #37 and #102. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675956 If continuation sheet Page 10 of 26 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 01/27/2024 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 0756 Level of Harm - Minimal harm or potential for actual harm Record review of the medication regimen reviews revealed the facility was missing a medication regimen review for July 2023 and October 2023 for Resident #37, and was missing a medication regimen review for each month from August 2023 to December 2023 for Resident #102. The Pharmacist was called on 01/26/24 at 06:29 PM with no answer and no call back. Residents Affected - Some Record review of the facility's policy titled, Medication Management, dated 10/01/19, revealed, In order to optimize the therapeutic benefit of medication therapy and minimize or prevent potential adverse consequences, facility staff, the attending physician/prescriber, and the consultant pharmacist perform ongoing monitoring for appropriate, effective, and safe medication use. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675956 If continuation sheet Page 11 of 26 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 01/27/2024 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure a medication error rate was not 5% or greater. The facility had a medication error rate of 12%, based on 3 errors out of 25 opportunities, which involved (Residents #61 and #165) and 1 of 2 staff (MA J ) reviewed for medication administration, in that: Residents Affected - Few The facility failed to ensure MA J administered medications according to the physician's orders and per professional standards for Residents #61 and #165, which resulted in a 12% medication administration error rate. This deficient practice could place residents at risk of not receiving the therapeutic effects of their medications and possible adverse reactions. The findings were: 1. Record review of Resident #61's face sheet, dated 1/25/24, revealed a [AGE] year-old female admitted to the facility on [DATE] with the diagnoses that included: [dementia] a general term for loss of memory, language, problem-solving, and other thinking abilities that are severe enough to interfere with daily life, [Hypothyroidism] occurs when the thyroid gland does not make enough thyroid hormone, and [Paranoid schizophrenia] a pattern of behavior where a person feels distrustful and suspicious of other people and acts accordingly. Record review of Resident #61's Quarterly MDS assessment, dated 10/24/23, revealed a BIMS score 03 indicating severe cognitive impairment. Record review of Resident #61's order summary report for January 2024 revealed the following orders at 6:00 a.m.: - Levothyroxine Sodium 125 mcg, give one tablet daily by mouth at 0600 for hypothyroid. 2. Record review of Resident #165's face sheet dated 1/25/24 revealed a [AGE] year-old female admitted to the facility on [DATE] with the diagnoses that included: [dementia] a general term for loss of memory, language, problem-solving, and other thinking abilities that are severe enough to interfere with daily life, [muscle atrophy] loss of muscle tissue, and [Anemia] is a condition that develops when a person's blood produces a lower-than-normal amount of healthy red blood cells. Record review of Resident #165's Quarterly MDS assessment, dated 10/19/23, revealed a BIMS score of 11 indicating moderate cognitive impairment. Record review of Residents 165's order summary report for January 2024 revealed the following orders at 6:00 a.m.: -Tylenol 500 mg, give two tablets by mouth every 6 hours (0000, 0600, 1200, 1800) for general pain. During an observation and interview of medication pass on 1/25/24 at 7:25 a.m. MA J was asked by the surveyor why the screen was red for Residents #61 and #165. MA J stated they were red because medications were late and scheduled at 6:00 a.m. and should be administered one hour before 6:00 a.m. or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675956 If continuation sheet Page 12 of 26 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 01/27/2024 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 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few one hour after 6:00 a.m. MA J stated she forgot to give the medications at the start of her shift today and residents risked absorption issues by the medication not being offered at the time ordered by the physician. During an interview with the DON on 01/26/24 at 10:48 a.m., the DON stated that it was his expectation for nursing staff to adhere to the medication administration policy one hour before the scheduled time or one hour after. The DON stated he did not know why MA J did not administer the medications to Residents #61 and #165 as ordered by the physician. The DON stated Residents #61 and #165 risked possible medication interactions if the physician's ordered times were not followed. Record review of the facility's policy titled, Medication Administration, dated 10/24/22, revealed, Administer medications within 60 minutes prior to on or after scheduled time. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675956 If continuation sheet Page 13 of 26 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 01/27/2024 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 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to accommodate residents' food preferences for 1 of 8 (Resident #11) residents reviewed for food preferences, in that: 1. The facility failed to ensure that Resident #79's lunch meal on 01/23/24 did not include pepper per her dislike and allergy to pepper. 2. The facility failed to ensure that Resident #37's lunch meal on 01/24/24 included soup as was reflected on her lunch meal tray ticket. These failures could affect residents with food preferences and could result in a decrease in resident choices and diminished interest in meals. The findings included: 1. Record review of Resident #79's admission Record, dated 01/23/24, revealed the resident was 61-years old resident, re-admitted to the facility on [DATE], with diagnoses to include: dementia (a group of symptoms affecting memory, thinking, and social abilities), age related physical debility (physical weakness), anxiety (a group of conditions characterized by two brain functions such as memory loss and judgement, and intense, excessive, and persistent worry), and post-traumatic stress disorder (a mental health condition that develops following a traumatic event characterized by intrusive thoughts about the incident, recurrent distress/anxiety, flash back and avoidance of similar situations). Record review of Resident #79's MDS Quarterly Assessment, dated 11/26/23, revealed the resident had a BIMS score of 12 out of 15, which indicated moderate cognitive impairment. Record review of Resident #79's care plan revealed the resident had a, Disturbed thought process ., with an intervention of, Show empathy regarding the residents feelings; reassure the resident of your presence and acceptance, which was initiated on 03/09/21. During an interview and observation on 01/23/24 at 12:55 PM, revealed Resident #79's lunch meal tray ticket for 01/23/24 read, Dislikes: Condiments (NO PEPPER). During an interview with CNA R on 01/23/24 at 12:58 PM, CNA R confirmed Resident #79's lunch meal ticket had, no pepper, on the resident's ticket, and CNA R stated she had not realized this when she passed the lunch meal trays out. She further revealed Resident #79 would let her know if there was any problem with her meal trays. During an interview with Resident #79 on 01/26/24 at 11:43 AM, Resident #79 stated she broke out in rash when she had black pepper, and further stated she still asked for black pepper knowing this. 2. Record review of Resident #37's admission Record, dated 01/24/24, revealed the resident was 79-years old, re-admitted to the facility on [DATE], with diagnoses to include: dementia (a group of symptoms affecting memory, thinking, and social abilities), age related physical debility (physical weakness), muscle wasting and atrophy, and need for assistance with personal care. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675956 If continuation sheet Page 14 of 26 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 01/27/2024 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 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of Resident #37's MDS Quarterly Assessment, dated 11/26/23, revealed the resident was a BIMS score of 12 out of 15, which indicated moderate cognitive impairment. Record review of Resident #37's care plan revealed, [Resident #37] is at risk for imbalanced nutrition ., with interventions to include, Give the resident supplements as ordered. Alert nurse/dietitian if not consuming on a routine basis, initiated on 11/11/21. During an interview and observation on 01/24/24 at 12:32 PM, CNA J confirmed Resident #37 did not have soup on her 01/26/24 lunch meal tray and CNA J further confirmed the resident's lunch meal tray ticket should have had a soup. During an interview with the FSS on 01/24/24 at 12:35 PM, the FSS stated soup was not given to Resident #37 for the resident's lunch. The FSS further stated nurses should check the residents' meal tray tickets before they gave the resident their meals. During an interview with the FSS on 01/26/24 at 10:54 AM, the FSS stated Resident #37's lunch meal tray ticket read, ADD SOUP LUNCH/DINNER. The FSS stated following residents' allergies and preferences were important for quality of life and the residents could feel like they could make choices, and further stated adding foods or supplements could help prevent weight loss of the residents. During an interview with [NAME] P on 01/26/24 at 11:47 AM, [NAME] P stated she was trained to follow tray tickets for allergies and preferences and if the kitchen staff forgot something on the tray ticket, then the nursing staff would come back to the kitchen to adjust accordingly. Record review of the facility's policy titled, Diet Order, revised 05/2007, revealed, The Dietary Department shall prepare the tray identification card to correspond to the diet transmittal/order. The tray care is to be individualized as needed to assist food service personnel in serving the diet accurately. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675956 If continuation sheet Page 15 of 26 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 01/27/2024 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 0921 Level of Harm - Immediate jeopardy to resident health or safety Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observations, interviews, and record reviews, the facility failed to ensure that the resident environment remains as free of accident hazards as is possible for 1 of 1 facility reviewed for physical environment, in that: Residents Affected - Many The facility failed to ensure no open flames are near oxygen cylinders, store cylinders in the upright position, and secure the cylinders from residents and the public. An Immediate Jeopardy (IJ) was identified on 01/26/24 at 10:25 AM While the IJ was removed on 01/27/24 at 10:27 AM, the facility remained out of compliance at a scope of widespread and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy because the facility needed to monitor their corrective actions. These failures could place residents at risk of injury or death due to improper or unsafe smoking. The findings included: Observation on 01/23/24 at 01:47 PM revealed that 2 of 2 outdoor storage spaces for oxygen cylinders, enclosed with chain link fencing, had unlocked doors. 1 outdoor storage space was located more than 10 feet away from the main dining room and right outside of the kitchen. The other outdoor storage space was located more than 10 feet away from the therapy room. The outdoor storage space near the main dining room and kitchen included about 10 empty oxygen cylinders and about 30 full oxygen cylinders. There was 1 empty oxygen cylinder stored upside down and 1 empty oxygen cylinder laying sideways under other empty oxygen cylinders. There was debris stuck in between cylinders, including 3 pieces of paper and some leaves. During an interview on 01/24/24 at 02:49 PM, the DON stated the extent of what the nursing staff knew was where the oxygen tanks were and to bring the oxygen cylinders when the oxygen ran out. The DON stated the oxygen cylinders should be stored upright. The DON stated the public did technically have access to the oxygen tanks as someone could walk behind the building and even cut the chain linked fence to access the oxygen cylinders. During an interview and observation on 01/24/24 at 01:54 PM, CNA B was smoking a cigarette in the no smoking area that surrounded the outside oxygen storage area, about 9 feet away from the full oxygen cylinders. CNA B stated she was smoking a cigarette and the staff smoked here when the weather was bad. During an interview and observation on 01/24/24 at 01:57 PM, the Floor Tech confirmed there were 2 CNAs who were smoking cigarettes there and they should not be smoking there. The Floor Tech further stated the 2 CNAs may be new and not know that they should not be smoking near the oxygen tanks. Only 1 CNA was observed smoking. The other CNA was not present at this time. During an interview on 01/24/24 at 02:56 PM, the Administrator stated there should be no smoking around the oxygen storage area outside and the staff are trained on this. During an interview and observation on 01/24/24 at 04:13 PM, the FSS confirmed there were 10 cigarette butts on the floor in the no smoking area that was near full oxygen cylinders. One cigarette (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675956 If continuation sheet Page 16 of 26 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 01/27/2024 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 0921 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Many butt was only ¾ of the way done and found in a cardboard box that was 9 feet away from full oxygen cylinders. The FSS further stated staff had smoked in this area when the weather was bad but had been told to stop smoking in this area. During an interview and observation on 01/24/24 at 04:18 PM, ADON A revealed there was an oxygen cylinder that was stored upside down and one that was laying on its side on the ground. ADON A stated this was not how the oxygen cylinders should be stored. ADON A confirmed there were cigarette butts on the floor in the no smoking area that was near full oxygen cylinders and should not be here. She revealed she had not seen these cigarette butts before or had seen anyone smoking in this area before. During an interview on 01/25/24 at 10:23 AM, the Administrator stated, no one should be smoking near the oxygen cylinders, if that's what you saw. During an interview on 01/25/24 at 10:28 AM, LSC revealed the following: Oxygen storage can present specific risks in the context of a fire emergency or explosion. If there is an explosion in a facility where oxygen is stored, whether it's a medical facility, industrial site, or any other location, several additional hazards can arise: 1. Increased Fire Intensity: o Oxygen supports combustion, and if stored oxygen is involved in a fire or explosion, it can significantly increase the intensity and spread of the fire. This is because oxygen can act as an oxidizer, accelerating the combustion of other materials. 2. Pressure Vessel Rupture: o Oxygen is often stored under pressure in tanks or cylinders. In the event of an explosion, the pressure vessels containing the stored oxygen may rupture, leading to the release of high-pressure gas. This can cause additional hazards, including flying debris and potential injuries. 3. Oxygen Enrichment: o The release of oxygen can lead to oxygen enrichment in the surrounding air. While oxygen is essential for human respiration, elevated oxygen levels can increase the risk of fires and make materials more combustible. This can create an environment where fires are easier to ignite and more challenging to control. 4. Risk of Flash Fires: o If oxygen is released rapidly in a confined space, it can create conditions for flash fires. A flash fire is a sudden and intense fire that occurs when a flammable substance comes into contact with a source of ignition in the presence of an oxidizer like oxygen. 5. Potential for Explosions: o If there are other flammable materials present, the combination of oxygen and these materials can create explosive mixtures, increasing the risk of secondary explosions. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675956 If continuation sheet Page 17 of 26 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 01/27/2024 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 0921 6. Inhalation Hazards: Level of Harm - Immediate jeopardy to resident health or safety o In the aftermath of an explosion involving oxygen storage, there may be a risk of inhaling high concentrations of oxygen, which can lead to respiratory issues and other health concerns. 7. Specialized Firefighting Challenges: Residents Affected - Many o Fires involving oxygen storage require specialized firefighting techniques. Traditional water-based firefighting methods may not be effective, and in some cases, they can exacerbate the situation. Firefighters may need to use specialized extinguishing agents to control the fire. Given these risks, it's essential for facilities storing oxygen to adhere to strict safety protocols, including proper storage, handling, and emergency response procedures. Staff should be well-trained in the safe management of oxygen, and facilities should have appropriate safety measures in place, such as fire suppression systems, ventilation, and the use of flame-resistant materials. During an interview with the National Director of Sales for [company who supplied the facility's oxygen storage] on 01/26/24 at 09:25 AM and 09:45AM, he stated empty oxygen cylinders should not be stored upside down because this could damage the valve of the empty oxygen cylinder. He further revealed that the empty oxygen cylinders were refilled and a damaged valve increased the chance of a full oxygen cylinder to, shoot off like a rocket, because it made the full oxygen cylinder unstable. He further stated people had been killed by oxygen cylinders. The National Director of Sales further revealed if a fire started next to full oxygen cylinders, these oxygen cylinders, can turn into missiles, and move in any direction. During an interview on 01/26/24 at 11:30 AM, a confidential staff member stated when staff smoked cigarettes near the storage of oxygen cylinders, they were told to stop. The confidential staff member stated that they had reported this to the Administrator before. They further stated that residents did not have access to the oxygen cylinder storage area. The confidential staff member also revealed that they do fire drills monthly and they were taught to not go through the exit door that is near the oxygen cylinder storage area. They further revealed that if there was a fire in this area that spread to the kitchen, the fire could get bigger due to grease and ovens. Follow up call for further questions for the National Director of Sales for [company who supplied the facility's oxygen storage] was made on 01/26/24 at 04:15 PM with no answer nor response back. Record Review of USA Food Code 2022 revealed, 4-301.14 Ventilation Hood Systems, Adequacy. The accumulation of grease and condensate mat contaminate food and food-contact surfaces as well as present a possible fire hazard. Record Review of Health Care Facilities Code, 2012 Edition, revealed Smoking, open flames, electric heating elements, and other sources of ignition shall be prohibited within storage locations and within 20ft of outside storage locations. The Administrator revealed that they used this policy, and the facility did not have their own policy for the outside oxygen storage. Record review of the product label for Oxygen, Compressed USP UN1072, produced by Air Liquefaction, undated, indicated DANGER: MAY CAUSE OR INTENSIFY FIRE: OXIDIZER. CONTAINS GAS UNDER PRESSURE: MAY (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675956 If continuation sheet Page 18 of 26 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 01/27/2024 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 0921 EXPLODE IF HEATED . Do not smoke . Keep/store away from clothing and other combustible materials. Level of Harm - Immediate jeopardy to resident health or safety This was determined to be an Immediate Jeopardy (IJ) and the Administrator was notified on 01/26/24 at 10:25 AM, an IJ Template was presented to the Administrator, and a Plan of Removal was requested to lift the immediacy. Residents Affected - Many The following Plan of Removal submitted by the facility was accepted on 01/26/24 at 03:52 PM. January 26, 2024 [Facility] LETTER OF CREDIBLE ALLEGATION FOR REMOVAL OF IMMEDIATE JEOPARDY Attention Sir or Madam: On January 26, 2024, the facility was notified by the surveyor, that an immediate jeopardy had been called and the facility needed to submit a letter of credible allegation. The Facility respectfully submits this Letter for Plan of Removal pursuant to Federal and State regulatory requirements. Submission of the Letter of Credible Allegation does not constitute an admission or agreement of the facts alleged or the conclusions set forth in the verbal and written notice of immediate jeopardy and/or any subsequent Statement of Deficiencies. The alleged immediate jeopardy allegations are as follows: Issue: [Citation Number and Title] No residents were identified as smoking in that area. No staff are identified, other than by CNA B. 1) As of 1/26/24, oxygen cylinders are secured with chain link fencing. Full and empty oxygen cylinders are stored upright. Debris and paper have been removed from the oxygen storage area. Oxygen storage areas were cleaned of cigarette butts by Maintenance Director and/ or designee. 2) To identify any other related oxygen storage concerns, the Maintenance Director and/ or designee made rounds to ensure all oxygen cylinders storage areas and oxygen used in resident care areas are properly stored. 3) An Oxygen Safety policy was developed on 1/26/24 and will be used for staff education on the below topics regarding oxygen. 4) On 1/26/24, All staff will be reeducated by the Administrator / designee on the following topics: Abuse and Neglect (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675956 If continuation sheet Page 19 of 26 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 01/27/2024 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 0921 Oxygen Storage Level of Harm - Immediate jeopardy to resident health or safety No smoking in oxygen storage area Residents Affected - Many Proper method to extinguish and discard smoking paraphernalia Designated smoking areas 5) The Maintenance Director and/ or designee will observe the oxygen storage areas daily to ensure the oxygen is stored upright and secured daily during rounds. The Director of Nursing and/ or designee will observe oxygen cylinders in resident care areas to ensure that oxygen is stored upright and secured properly daily during rounds. 6) The housekeeper / designee will monitor and clean the outside oxygen storage area daily and as needed. The Administrator / designee will monitor outside oxygen storage areas daily on various shifts and as needed rounding to ensure there are no people smoking in that area. The Administrator and/ or designee will monitor compliance that staff are rounding daily on various shifts to ensure oxygen is stored upright and secured and free of debris. An Ad Hoc QAPI meeting was completed on 1/26/24 to discuss the root cause and plan to correct attended by the Administrator, Director of Nursing, Maintenance Director, and the Medical Director. We respectfully submit this action plan for removal of Immediate Jeopardy. Sincerely, [The Administrator] POR Verification 1) Verified via Observation on 01/26/2024 at 5:18 p.m. Verified via Interview on 01/26/2024 at 5:20 p.m. with the Maintenance Director who stated he personally secured the oxygen cylinder area, added a sign which read Replace Lock After Removing Oxygen, personally ensured oxygen cylinders were in the upright position, removed debris from the cylinder storage area, and removed the cigarette butts. 2) Verified via Interview on 01/26/2024 at 5:20 p.m. with the Maintenance Director who stated he personally performed rounds throughout the facility to ensure all oxygen cylinders storage areas and oxygen used in resident care areas were properly stored. 3) Verified via Record Review of Oxygen Safety Policy Interview with the Administrator on 01/26/2024 at 4:15 p.m. revealed he assisted with the creation of the Oxygen Safety policy. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675956 If continuation sheet Page 20 of 26 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 01/27/2024 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 0921 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Many Interview with DON on 01/26/2024 at 4:12 p.m. revealed he assisted with the creation of the Oxygen Safety policy. 4) Completion date of re-education of all staff will be 1/26/24, in person or via telephone. Those that are PRN, Agency and/ or out on FMLA/ LOA will have the education completed prior to accepting assignment for their next scheduled shift. Any staff member not re-educated in person or via phone today (1/26/24), will be removed from the schedule until re-education is provided. Verification of 100% of staff re-education will be verified by the Administrator / designee. Interview with Administrator on 01/26/2024 at 4:15 p.m., the Administrator stated staff work a four-days on and 2 days off schedule so that there was no distinction between weekday and weekend staff. The Administrator further stated that he and 5 additional designees divided the list of staff members and educated each staff member present in the building in person. The Administrator further stated that he and his 5 designees called all staff members who were not present to share the Oxygen Safety Policy and documented each conversation on an individual One-on-One In-Service form. The Administrator identified designees as: HR L, HR M, the Admissions Director, and the DON Joint Interview with: HR L, HR M, the Admissions Director, and the DON on 01/26/2024 at 4:20 pm revealed they assisted the Administrator to educate the staff regarding the Oxygen Safety Policy o Verification via in person interviews with 9 staff members from 2 pm to 10 pm shift, telephone interviews with 7 staff members from 6 am to 2 pm shift, and telephone interviews with 6 members of 10 pm to 6 am shift. all staff listed below confirmed they received and understood the Oxygen Safety Policy to include keeping cigarettes and other open flames away from oxygen cylinders, storing cylinder in the upright position, and ensuring the oxygen storage area is locked at all times. o In-Person Interviews (2 pm to 10 pm shift) Activity Aide N 4:22 p.m. RN O 4:26 p.m. Cook P 4:28 p.m. CNA Q 4:30 p.m. CNA R 4:32 p.m. ADON G 4:34 p.m. Medication Aide S 4:36 p.m. CNA T 4:39 p.m. CNA U 4:42 p.m. Telephone Interviews (6 am to 2 pm shift): RN V 4:45 p.m. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675956 If continuation sheet Page 21 of 26 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 01/27/2024 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 0921 Receptionist W 5:26 p.m. Level of Harm - Immediate jeopardy to resident health or safety CNA X 5:09 p.m. Residents Affected - Many CNA Z 5:28 p.m. LVN Y 5:12 p.m. Cook AA 4:43 p.m. LVN BB 5:30 p.m. o Telephone Interviews (10 pm to 6 am shift): Medication Aide CC 5:24 p.m. CNA DD 5:00 p.m. CNA EE 5:16 p.m. LVN FF 5:03 p.m. CNA GG 4:49 p.m. CNA HH 4:53 p.m. Record review of 183 individual One-on-One In-Service forms revealed the in-service included: o Only smoke in designated areas (NOT near oxygen cylinders) o Oxygen cylinders should only be stored in the upright position o Oxygen storage should secure behind locked gate at all times 5) Verified via Interview on 01/26/2024 at 5:20 p.m. with the Maintenance Director. The Maintenance Director revealed that he would check the oxygen storage areas daily. He further revealed that he would check that the fence surrounding the oxygen storage was locked, the Empty and Full signs are posted appropriately, the No Smoking signs are posted, the oxygen cylinders were upright, and that the areas was clean and free from debris. Record review of the Housekeeping/Maintenance Log, dated 01/27/2024, revealed regular checks have been performed. 6) Verified via in person interview with the Housekeeper on 01/26/2024 at 4:37 p.m. who stated she and all the Housekeeping Staff had been instructed to monitor and clean the outside oxygen storage area on a daily basis and more often as needed o Interview on 01/26/2024 at 5:20 p.m., the Maintenance Director revealed that he would make sure that the outside oxygen storage area was clean and free from debris daily. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675956 If continuation sheet Page 22 of 26 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 01/27/2024 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 0921 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Many Record review of the Housekeeping/Maintenance Log, dated 01/27/2024, revealed regular checks have been performed. Verified via Interview with the Administrator on 01/26/2024 at 4:15 p.m. who stated he will perform rounds on a daily basis, across all shifts to ensure no one is smoking in the oxygen storage area Additional Interview with the Administrator on 01/27/2024 at 8:39 a.m. revealed he and the MOD during weekends perform rounds to check oxygen storage and record checks in Managers' Log. Record Review of Managers' Log, dated 01/27/2024, revealed regular checks have been performed. Verified via Interview with the Administrator on 01/26/2024 at 4:15 p.m. who stated he will perform rounds on a daily basis, across all shifts to ensure oxygen cylinders are stored in the upright position, the storage area is locked, and free of debris Verified via Interview with the Administrator on 01/26/2024 at 4:15 p.m. who confirmed a meeting was held and that he attended along with the Director of Nursing, the Maintenance Director, and the Medical Director. Verified via Interview on 01/26/2024 at 5:20 p.m. with the Maintenance Director who confirmed a meeting was held and that he attended along with the Director of Nursing, the Administrator, and the Medical Director. Interview with DON on 01/26/2024 at 4:12 p.m. who confirmed a meeting was held and that he attended along with the Administrator, the Maintenance Director, and the Medical Director. Record Review of Ad Hoc QAPI Sign-In Sheet which listed the Administrator, the Director of Nursing, the Maintenance Director, and the Medical Director as attendees An Immediate Jeopardy (IJ) was identified on 01/26/24 at 10:25 AM While the IJ was removed on 01/27/24 at 10:27 AM, the facility remained out of compliance at a scope of widespread and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy because the facility needed to monitor their corrective actions. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675956 If continuation sheet Page 23 of 26 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 01/27/2024 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 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews, and record reviews, the facility failed to maintain an effective pest control program within 1 of 1 facility reviewed for pest control revealed: Residents Affected - Some Live and dead pests were observed in the facility. This deficient practice could lead to contamination and/or infection due to an unsanitary environment. The findings were: Observation on 01/24/2024 at 3:00 p.m. in Resident #64's room revealed a pool noodle had been fitted around the bottom of the bathroom door. During an interview with Resident #64 on 01/24/2024 at 3:00 p.m., at the same time as the observation, Resident #64 stated his room had seen small, black roaches at night entering his room from under the bathroom door. During an interview with Health Aide E on 01/25/2024 at 9:38 a.m., Health Aide E had not seen roaches in residents' rooms but had seen them in the resident showers. During an interview with Student CNA H on 01/25/2024 at 10:58 a.m., Student CNA H stated he had seen a roach crawling on a pillow while a resident was sleeping and moving towards the resident's face, so he woke the resident up and changed the pillowcase. Student CNA H said he had not seen anyone exterminating. He said he had seen roaches in the ice room and in the dining room. Observation on 01/25/2024 at 3:28 p.m. revealed a live roach on a medication cart. During an interview with Medication Aide D on 01/25/2024 at 3:28 p.m., at the same time as the observation, Medication Aide D stated she had seen roaches elsewhere in the facility, but never on a medication cart. During an interview with Resident #95 on 01/26/2024 at 1:30 p.m., Resident #95 stated he had found a live roach in his nightstand and killed it. Resident #95 showed the dead roach to the state Surveyor. Record review of the facility pest sighting log, dated 09/12/2023 to 01/19/2024, revealed twenty-two entries noting the presence of roaches in locations throughout the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675956 If continuation sheet Page 24 of 26 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 01/27/2024 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 0926 Have policies on smoking. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure it formulated, adopted, and enforced policies regarding smoking, smoking areas, and smoking safety that also take into account non-smoking residents for 3 of 40 residents (Residents #19 and #102) reviewed so smoking, in that: Residents Affected - Few The facility failed to follow the Smoking/Tobacco Policy to ensure Residents #19 and #102 remained safe while smoking. These failures could place residents at risk of injury or death due to improper or unsafe smoking. The findings included: 1. Record review of Resident #19's admission Record, dated 01/26/24, reflected a [AGE] year-old resident admitted [DATE] with diagnosis to include dementia (a group of symptoms affecting memory, thinking, and social abilities), age related physical debility (physical weakness), major depressive disorder, anxiety (a group of conditions characterized by two brain functions such as memory loss and judgement, and intense, excessive, and persistent worry), and post-traumatic stress disorder (a mental health condition that develops following a traumatic event characterized by intrusive thoughts about the incident, recurrent distress/anxiety, flash back and avoidance of similar situations). Record review of Resident #19's MDS Quarterly Assessment, dated 11/16/23, reflected a BIMS score of 11 out of 15, which indicated moderate cognitive impairment. Record Review of Resident #19's care plan reflected [Resident #19] is a cigarette and E-cigarette smoker. with an intervention of Instruct resident about the facility policy on smoking: locations, times, safety concerns., initiated 10/21/22. 2. Record review of Resident #102's admission Record, dated 01/25/24, reflected a [AGE] year-old resident recently re-admitted [DATE] with diagnosis to include quadriplegia, post-traumatic stress disorder (a mental health condition that develops following a traumatic event characterized by intrusive thoughts about the incident, recurrent distress/anxiety, flash back and avoidance of similar situations), age related physical debility (physical weakness), lack of coordination, anxiety (a group of conditions characterized by two brain functions such as memory loss and judgement, and intense, excessive, and persistent worry), and major depressive disorder. Record review of Resident #102's MDS Quarterly Assessment, dated 12/08/23, reflected a BIMS score of 7 out of 15, which indicated severe cognitive impairment. Record Review of Resident #102's care plan reflected [Resident #102] is a cigarette and E-cigarette smoker. with an intervention of Instruct resident about the facility policy on smoking: locations, times, safety concerns., initiated 08/19/21. During an interview on 01/25/24 at 03:46 PM, the Administrator stated that smoking assessments for residents should be done upon admission, annually, and with change in conditions. He revealed smoking assessments are important for resident safety because a resident could drop their cigarette and burn themselves. He was not aware of any burns by cigarettes. The Administrator further revealed that smoking assessments could be found as NURSING-Smoking Safety Screen assessment. If they were not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675956 If continuation sheet Page 25 of 26 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 01/27/2024 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 0926 located here, then the resident did not have one. Level of Harm - Minimal harm or potential for actual harm Record Review for the NURSING-Smoking Safety Screen assessment revealed the last assessment for Resident #19 was 10/20/22 and the last assessment for Resident #102 was 06/05/22. Residents Affected - Few Record Review of the facility's policy Smoking/Tobacco Policy, rev 09/14, reflected Smoking/Tobacco Evaluation, Plan of Care and Summary to be completed upon admission, quarterly, annual, and for change of condition assessments. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675956 If continuation sheet Page 26 of 26