Health inspection·June 27, 2025

F 0609 depressive type. Level of Harm - Minimal harm or potential for actual harm 2. Record review of Resident #2's face sheet dated 06/27/25, reflected a [AGE] year-old male original admission date of 03/06/2021 with diagnoses of unspecified dementia (a general term for a decline in mental ability severe enough to interfere with daily life), unspecified severity, with other behavioral disturbance (exhibits symptoms of dementia where the severity is not specified and also experiences behavioral disturbances beyond agitation and atherosclerotic heart disease of native coronary artery without angina pectoris (the coronary arteries (blood vessels supplying the heart) are narrowed due to atherosclerosis (plaque buildup) but the patient does not experience chest pain). Residents Affected - Few Record review of Resident #2's MDS , dated 05/27/25, reflected a BIMS score of 7, which indicated severe cognitive impairment. Record review of Resident #2's care plan, revised dated 12/10/21, reflected Resident #2 was physically aggressive with staff at times related to dementia. Record review of Resident #1's nursing progress notes by RN A, dated 06/23/2025, reflected staff notified RN A that Resident #1 had a physical altercation with Resident #2 in the smoking area, Resident #2 punched Resident #1 in the face and Resident #1 threw coffee on Resident #2 (coffee was cold). Resident #1 stated, I requested him to move from the way, the other resident got agitated and punched in my face which made me upset that's why I threw coffee on him. Action taken - staff immediately separated the two residents and ensured their safety and residents assessed for immediate medical or psychological needs, skin evaluation completed, bruise noted to below left eye and left cheek and scratch to left arm. Pain assessment done, PRN Tylenol administered, assessed coffee cup, coffee noted cold., neuro checks initiated and were in progress, administrator, NP made aware, called POA to notify, unable to reach and left a message, resident is own RP, observed closely for any change in behaviors, response: Resident #1 alert and responded verbally, she was resting in bed with no s/s of distress/discomfort noted at this time. Record review of nursing progress notes, by LVN A, dated 06/23/25, reflected Resident #2 was assessed from head to toe three different times, no burn noted during assessment. Resident #2 did not sustain any burn in any area of his body, and he denied any pain or discomfort, will continue monitoring . Observation on 06/27/25 at 12:27 PM of Resident #1 revealed swollen a crescent shaped bruise approximately 1 inch wide and 1.5 inches in length approximately .5 inches below Resident #1's left eye and 5 red indentions scattered in a line approximately 4 inches long about 6 inches below the residents left elbow and about 4 inches above the wrist. Interview on 06/27/25 at 12:27 PM with Resident #1 revealed, she remembered the incident and said she was mad when it happened and was mad now and her face still hurt but her arm no longer hurt. Interview on 06/27/25 at 5:10 PM with Resident #2 revealed he remembered the incident with Resident #1, but he was no longer upset with Resident #1, and everything was good . Interview on 06/27/25 at 1:41 PM with RN A revealed she did not witness the altercation between Resident #1 and Resident #2. She assessed Resident #1 after the AD/BOM and HRC reported the incident to her. Her understanding was Resident #1 poured coffee on Resident #2, and Resident #2 punched Resident #1 in the face, but the coffee poured on Resident #2 was not hot. RN A said at the time of her (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 06/27/2025 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few assessment or Resident #1, Resident #1 had a bruise below the left eye and a scratch to her left arm. She said she would consider the bruise to Resident #1's face, an injury because it was in the area of the brain . She said she considered the altercation a resident-to-resident altercation and a form of abuse. She said she was trained in ANE, and the administrator was the abuse and neglect coordinator, and all incidents of abuse and neglect should be reported to the administrator. RN A said she did not find any changes to Resident #1's mental status or vital signs when she conducted her assessment and Resident #1 was at her normal baseline. RN A said she called the NP, and the NP told her to monitor Resident #1 and report if Resident #1 had any change of condition, and Resident #1 did not have a change in condition. Interview on 06/27/25 at 2:04 PM with LVN B revealed she assessed Resident #2 after his altercation with Resident #1. She said she did not witness the altercation between the two residents, but it was reported to her by the AD/BOM who told LVN B Resident #1 poured coffee on Resident #2. LVN B assessed him for burns. She said she assessed him three separate times by the end of her shift and found no injury. She said she was trained in ANE when she was hired at the facility. She said because the residents engaged in a physical altercation, it was abuse and the incident was reported to the administrator directly after it occurred. She felt Resident #1 received minor injury in the altercation and because there was injury to her face, they started neuro checks, because the neuro checks would reveal if there was a major injury. Interview on 06/27/25 at 2:14 PM with the AD/BOM revealed she heard yelling from her office and went outside. She said a resident was yelling at Resident #2 because he was mad Resident #2 hit Resident #1. The AD/BOM said she separated both residents and asked what happened. They reported to her they were lined up waiting to smoke and Resident #2 was standing in front of Resident #1. Resident #1 wanted to get in front of Resident #2. Resident #1 asked to get in front of Resident #2 and Resident #2 told her No so Resident #1 threw coffee on Resident #2. When Resident #1 threw the coffee at him, Resident #2 hit Resident #1. The AD/BOM said neither resident was scared, and Resident #1 wanted to get her cigarettes so she could smoke. She stated she was trained in the different types of abuse when she was hired. She stated when one resident hit another resident it was a form of abuse and staff were to report it to the Administrator regardless of the level of injury. She said residents cussing or yelling at each other was a form of abuse. She said the Administrator was the ANE coordinator and the incident was reported to the Administrator. Interview on 06/27/25 at 4:27 PM with the Administrator revealed he did not report the incident between Resident #1 and Resident #2 to the state survey agency because a lot of their cases were unique. When he spoke with Resident #1 about the incident, she said she was not in pain or hurting. Resident #1 she initiated the contact with Resident #2, and she understood he was a man who had difficulty controlling his impulses. He said he did not report the incident because it did not require first aide. He said when he spoke with Resident #1 about it, she repeatedly said she just wanted to go out and smoke her cigarettes. He said Resident #1 was not crying or upset about the incident when he spoke with her, and he did not feel like she was abused or neglected. The Administrator said the facility followed the Long-Term Care Regulation Provider Letter to guide them for reporting incidents to HHSC. Record review of the Long-Term Care Regulation Provider Letter Title Abuse, Neglect Exploitation, Misappropriation of Resident Property and Other Incidents that a Nursing Facility Must Report to the Health and Human Services Commission reflected: Type of Incident to Report (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 06/27/2025 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 0609 Abuse (with or without serious bodily injury) Level of Harm - Minimal harm or potential for actual harm When to report: Immediately, but not later than two hours after the incident occurs or is suspected Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675956 If continuation sheet Page 4 of 4