Health inspection·April 12, 2024

F 0583 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few them up. The MA stated that she was just in a hurry. The MA stated that there was not an emergency, but she was running behind. The MA stated that she had been trained in HIPAA and does know this was a violation. The MA stated that the training that she had received was through quarterly computer education and weekly in-services. The MA stated that the negative potential outcome of exposing a resident's information was that it could fall in the wrong hands and their information could possibly be mishandled or misused. Interview with the DON on 04/11/2024 at 2:37 PM., The DON stated that she expects staff to follow policy and procedure. The DON stated that HIPAA was the law and staff should follow the law. The DON stated that the staff had been trained quarterly in HIPAA through computer. The DON stated that the negative potential outcome was that anyone could get the resident's information and misuse it. The DON stated that the employee knew better and should have protected the resident's information. The DON stated that staff member could have put the information in her cart and locked it up. Interview with the Administrator on 04/12/2024 at 1:50 PM., The Administrator stated that his expectations were that staff should always protect the resident's information. The Administrator stated that the facility does provide training for HIPAA quarterly and through in-services every other week. The Administrator stated that the DON was responsible for training. The Administrator stated that the negative potential outcome of exposing a resident's information is that anyone could steal their information. Record Review of facility provided policy, Labeled, Protected Health Information (PHI) Management and Protection, date Revised on April 2014, stated: Policy Statement: Protected Health Information (PHI) shall not be used or disclosed except as permitted by current federal and state laws. Policy Interpretation and Implementation: 1. It is the responsibility of all personnel who have access to resident and facility information to ensure that such information is managed and protected to prevent unauthorized release or disclosure. Record Review of HIPAA Privacy Laws listed on the Texas Health and Human Services, dated 04/11/2024, online website, at: http://www.hhs.texas.gov/regulations/legal-information/hipaa-privacy-laws, date not listed. Stated: Privacy Rule: The HIPAA privacy rule establishes national standards protecting medical records and other personal health information. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676318 If continuation sheet Page 2 of 29 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 676318 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windmill Village Rehabilitation & Care Center 507 Martin Luther King Blvd Lubbock, TX 79403 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 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. Based on observations, interviews and record review, the facility failed to make residents and residents' family members aware of the grievances process and allow them to exercise their right to file a grievance leading to the facility not addressing the grievances of residents. According to the facilities' grievance policy the facility failed to make prompt effortsto resolve grievances for 5 of 26residents. The facility failed to provide residents and family members follow up communication and resolutions to filed grievances. The facility failed to file and resolve a grievance for Resident #80 regarding missing laundry. The facility failure could place the residents at risk of unresolved grievances and decreased quality of life. Findings include: During the survey process for the infection control task, it was determined that the laundry services staff members were not allowing residents enough time to locate lost clothing. Laundry was only holding lost clothing for 7-10 days and then placing the items in the hallway for anyone to reclaim. Observation of laundry services on 04/11/2024 at 8:05 AM., revealed a rack in the laundry facility with lost clothing items. Observation of the rack that was also outside the laundry services with items that were give away clothing. It was said by the laundry staff member and laundry supervisor that the rack outside was strictly for give away clothing. Interview with Resident #80 during resident sample selection for survey process on 04/09/24 at 11:30 AM. Resident #80 stated that she is missing 2 brand new bras, 2 gowns, and a t-shirt with ice cube on it. Resident # 80 stated that she had notified the Administrator and was told that he would look into it and see what he could find and let her know but no one had let her know anything. Resident # 80 stated that had been three or four months ago. Interview with the laundry Staff member on 04/11/2024 at 8:05 AM., the laundry staff member stated that when there were lost clothing it was placed on the back rack and labeled for the date that it became missing. The laundry staff member stated that when the clothing has been held in the laundry room for the 7 to 10 days then it was placed on a rack in the hallway for anyone who wants the clothing. The laundry staff member stated that they do not attempt to take the clothing around to the residents. The laundry staff member stated that for the residents that were not able to get to the laundry, she The laundry staff member stated that the only negative potential outcome that she can name was if the resident was not able to get more clothing and ran out of clothes. Interview with the laundry Supervisor on 04/11/2024 at 8:32 AM., the laundry Supervisor stated that lost or missing clothing was only held in the laundry room on the rack for 7 to 10 days and then was placed in the hallway for anyone to grab what they want out of it. The laundry Supervisor stated that they do not take the clothes around to the residents because they do not have the time to do that. The laundry Supervisor stated that if the resident realizes that they were missing clothing they were welcome to come and check as long as it was within the 7 to 10 days and if it was outside of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676318 If continuation sheet Page 3 of 29 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 676318 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windmill Village Rehabilitation & Care Center 507 Martin Luther King Blvd Lubbock, TX 79403 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 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some the timeframe then hopefully the items will still be on the rack outside of the laundry room. The laundry Supervisor stated that she felt that was enough time for a resident to know if they had lost clothing or not. Interview with the Administrator on 04/12/2024 at 11:55 PM., the Administrator stated that he does know that the resident's do need more time to locate their lost laundry or items. The Administrator stated that he did not know that this was how the laundry was being handled but he will get with the Laundry Supervisor to come up with a better plan for the residents to have more time to retrieve their clothing. The Administrator stated that the negative potential outcome of not being able to get lost laundry back to the resident possession was that they may be left with nothing to wear, and it cost the residents money on a fixed income, and they may not be able to afford it. Record review of the Resident Council Meeting on 4/10/24 at 10:00am revealed Residents in the group meeting did not know how to file a grievance, Residents did not know where to acquire a grievance form, who to turn the form into, and what happens once a grievance was filed. 12 Residents attended the meeting, none of the Residents who attended the meeting were new Admits. Interview on 4/11/24 at 2:45 PM, the Activity Director confirmed she had never discussed Grievances in Resident Council as she too does not know the Grievance procedure. The AD stated she was hired for her position in September 2023, the AD stated she was not trained for the AD position, the AD stated she was shown her office and told she needed to develop an Activities Calendar. The AD stated she was a licensed AD, however, she has no experience with the AD position and she was not trained. The AD stated she has not been told the Grievance procedure and she did not know there was a Grievance policy she could request to review. The AD stated she does not know what complaints reported in Resident Council warrant the AD filing a Grievance. The AD stated she has not documented resident complaints on the Resident Council notes as she did not know what to include on Resident Council notes. The AD stated she did not understand, nor had she been trained on the importance of a Grievance or that a Grievance needed to be followed up on by the facility. Interview and record review on 4/11/24 at 4:19PM, Confidential family member stated she has complained to the DON about her concerns regarding her mother's weight loss, diet, and quality of care; she has never been informed of the grievance procedure, told the DON would file a grievance for her, and she has not been offered a grievance form to complete. The Family member stated she has never received follow up communication to any of her concerns. The Family member stated she has never been informed of a resolution or asked if she agrees to the resolution. The Family member stated she feels there was a lack of communication with the DON and the ADM; the family member does feel heard when she shares concerns and when she was told she will receive follow up communication, the follow up communication does not happen. The Family member stated to her knowledge there are no grievance forms available for residents or family members to voice grievances or concerns independently. The Confidential family member stated she has never seen the grievance form and never received a copy of a completed grievance form once the grievance has been resolved. Per the grievance form and the grievance policy the Resident named in the grievance form was required to receive a copy of the resolved grievance form or the Resident's Representative was required to receive a copy of the resolved grievance form. Surveyor reviewed the grievances for April 2024, a grievance was written in regard to the confidential family members complaints on 4/1/2024. The form was completed by the ADON, the grievance stated the confidential family member heard a nurse in the secure unit being rude and hateful to residents, the report also stated the family members' resident was sent with her on Easter Sunday with a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676318 If continuation sheet Page 4 of 29 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 676318 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windmill Village Rehabilitation & Care Center 507 Martin Luther King Blvd Lubbock, TX 79403 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 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some soiled brief and no briefs were sent with the resident for the outing. The findings of the investigation stated the nurse was not rude and the resident was sent with the family member with a clean brief when she left the facility. The plan to resolve the complaint on the grievance form was blank, results of action taken was blank on the grievance form, the entire Resolution portion of the grievance form was blank, and there was no documentation of follow up with the family member filing the grievance, no documentation of the family member being given a copy of the grievance, and no signature from the family member filing the grievance. 04/11/2024 at 9:15am Surveyor attempted to complete a telephone interview with a confidential family member named in an incomplete grievance report. Surveyor left vm for family member. 04/12/2024 at 9:45am Surveyor made a second attempt to complete a telephone interview with the confidential family member, left voicemail. The complaint voiced by the family member was documented on a grievance by the SW concerning rude nursing staff and call lights not being answered in a timely manner. The grievance form was not complete: the Documentation of Investigation portion was blank, the Resolution section was blank, there was no documentation of follow up with the family member filing the grievance, no documentation of the family member being given a copy of the grievance, and no signature from the family member filing the grievance. 04/11/2024 at 9:15am Surveyor attempted to complete a telephone interview with a confidential family member named in an incomplete grievance report. Surveyor left vm for family member. 04/12/2024 at 9:45am Surveyor made a second attempt to complete a telephone interview with the confidential family member, left voicemail. Interview and record review on 04/18/2024 at 11:05am Surveyor received a return phone call from the confidential family member, the family member stated the SW completed the grievance form, the family member stated she voiced a complaint regarding her mother's glasses missing. The Confidential family member stated the SW told her the facility would replace the glasses if they were not found. The Family member stated she never received any follow communication regarding the glasses. The family member stated she followed with the ADM and was told if we find the glasses, we will let you know, there was no offer to replace the glasses. The family member stated she never received a phone call regarding any information regarding the investigation completed for the glasses, the solution for the missing glasses, she never received a copy of the grievance, and she never signed or was given the opportunity to review the grievance. The family member informed Surveyor the Resident passed away and she returned to the facility to gather her mother's belongings, her mother's wheelchair was missing, she spoke to the ADM about the wheelchair and was told if we find it, we will let you know. The family member stated the ADM did not offer to complete a grievance or provide her with a grievance to complete. The family member stated she has never had any returned any communication regarding her mother's wheelchair. Surveyor reviewed the grievance: The Documentation of Investigation was blank, the Resolution section of the grievance is blank, there was no indication the family member received a copy of the grievance, no documentation of the results of the grievance being communicated to the family member, and the grievance was not signed by the family member. Interview and record review 04/12/2024 at 1:35pm Interviewed Confidential Resident in regard to a grievance filed on her behalf by the SW on 4/4/2024. Resident stated she was aware of the grievance; she stated nursing staff were rude to her and she reported the incident to the SW. Resident stated the grievance process has never been explained to her; she stated the SW came into her room with the form and documented her complaint. Resident stated she did not know what happened once a grievance (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676318 If continuation sheet Page 5 of 29 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 676318 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windmill Village Rehabilitation & Care Center 507 Martin Luther King Blvd Lubbock, TX 79403 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 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some was filed. Resident stated the resolution she was offered was she can move to a new room or she will be provided with a referral to a different facility. Resident stated the only resolution she was ever offered was she can have a referral to another facility. Resident stated the staff who were rude to her continued to provide care to her and some of them were still rude. Resident stated following the resolution to the grievance she felt like the facility does not care about providing quality care to her and she felt like the facility was constantly trying to force her out of the facility for every complaint as she was always told she can leave if she does not like the way she was treated by staff. The Resident stated she was provided with a copy of the grievance, and she did not sign the grievance. Surveyor reviewed the grievance, the Findings section of the grievance was blank, the Expected results of actions taken section was blank, and the entire Post-Investigation Follow Up section was blank. The grievance was not signed by the Resident and the grievance did not indicate the Resident was provided a copy of the grievance. Attempted to complete a telephone interview with the SW on 04/11/2024 at 3:47PM, Surveyor left voicemail. 04/12/2024 at 1:15pm Surveyor attempted to complete a telephone interview with SW, left voicemail. Surveyor did not receive a return phone call from the SW. Interview with the Administrator 4/12/2024 at 3:06pm, the ADM stated the SW maintains possession of the grievance form, they were not accessible unless a resident asks the SW for the form. The SW reviews all grievances and decides what respective department the grievance should be assigned to The ADM stated authors of the grievance were informed of the outcome, which include any resolution taken, the resolutions were also documented on the grievance form. The ADM stated the potential negative outcome for the grievance policy not being followed was a negative outcome for resident care. Record review of the Monthly grievance logs revealed the following: January - 1 grievance logged on monthly grievance log. The grievance report was not followed up with residents or resident council. The grievance did not indicate the Resident or Residents Representative received a copy of the grievance and the grievance was not signed by the complainant. February - 3 grievances logged on monthly grievance log. The grievance reports were not completed, the Documentation of Investigation and the Post-Investigation Follow Up was blank and no follow up documentation to residents available. The grievance did not indicate the Resident or Residents Representative received a copy of the grievance and the grievance was not signed by the complainant. March - 1 grievance logged on monthly grievance log. The grievance reports were not completed, the Documentation of Investigation and the Post-Investigation Follow Up was blank and no follow up documentation to residents available. The grievance did not indicate the Resident or Residents Representative received a copy of the grievance and the grievance was not signed by the complainant. April - 2 grievance logged on monthly grievance log. The grievance reports were not completed, the Documentation of Investigation and the Post-Investigation Follow Up was blank and no follow up documentation to residents available. The grievance did not indicate the Resident or Residents Representative received a copy of the grievance and the grievance was not signed by the complainant. Record Review of the Resident Council Minutes from January 2024-March 2024 listed the names of the Residents who attended the meeting, the remainder of the sections for the council minutes were (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676318 If continuation sheet Page 6 of 29 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 676318 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windmill Village Rehabilitation & Care Center 507 Martin Luther King Blvd Lubbock, TX 79403 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 0585 blank. The minutes indicated the ADM was invited and attended the January 2024 meeting; the minutes did not document what was discussed in the meeting. Level of Harm - Minimal harm or potential for actual harm Record Review of Resident Grievances/Complaints- Staff Responsibility Policy Residents Affected - Some Policy: Staff members are encouraged to guide residents about where and how to file a grievance and/or complaints when the resident believes that his/her rights have been violated. Policy Interpretation and Implementation: 1. Should staff member overhear or be the recipient of a complaint voiced by a resident, a resident's representative concerning the resident's medical care, treatment, food, clothing, or behavior of other residents; the staff member is encouraged to guide the resident or resident representative as to how to file a written complaint with the facility. 2. Staff member will inform resident or representative that he or she may file a grievance without fear or threat to any other form of reprisal. 3. Staff members will inform the resident or representative as to where to obtain a grievance form and where to locate the procedures for filing a grievance or complaint. 4. All alleged abuse, mistreatment, neglect, injuries of unknown source, and misappropriation of property will be reported to the Administrator. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676318 If continuation sheet Page 7 of 29 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 676318 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windmill Village Rehabilitation & Care Center 507 Martin Luther King Blvd Lubbock, TX 79403 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 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure preadmission screening for individuals identified with MI, DD, or ID were evaluated for services assessments 6 of 24 residents (Residents #2, #41, #71, #78, #83 and #292) reviewed for PASRR screening, in that: Residents Affected - Some Residents #2, #41, #71, #78, #83 and #292 did not have an accurate PASRR Level 1 assessments when they had a diagnosis of mental illness. These failures could place residents with an inaccurate PASRR Level 1 and no PASRR Level 2 Evaluation at risk for not receiving care and services to meet their needs. The findings included: Resident #2 Record review of Resident #2 electronic face sheet dated 04/10/2024 revealed an [AGE] year-old male admitted to the facility on [DATE]. The face sheet listed under Diagnoses Information, major depressive disorder. Record review of Resident #2's Quarterly MDS dated [DATE], revealed under section I Active Diagnoses, a diagnosis of Dementia. Additionally, under Section C Cognitive Patterns, the MDS revealed a BIMS score of 07 indicating the resident was severely cognitively impaired. Record review of Resident #2's most recent care plan, undated, revealed a focus area and diagnosis of depressive disorder, this problem started 05/31/2021. Record review of Physician progress notes for Resident #2 dated 04/10/2024 revealed under current medications, Resident #2 was prescribed Divalproex Sodium Oral Tablet Delayed Release 500mg one tablet by mouth twice a day, and Fluoxetine HCL Oral Capsule 40mg for depressive disorder. Record review of Resident #2's Preadmission Screening and Resident Review Level One (PL1) form dated 4/21/2021, revealed under section C0100 Mental Illness an answer of No, indicating the resident did not have a mental illness. Resident #41 Record review of Resident #41 electronic face sheet dated 04/10/2024 revealed an [AGE] year-old female admitted to the facility on [DATE]. The face sheet indicates under Diagnoses Information, Major Depressive Disorder, Unspecified. Record review of Resident #41's Annual MDS dated [DATE], revealed under section I Active Diagnoses, a diagnosis of depression. Additionally, under Section C Cognitive Patterns, the MDS revealed a BIMS score of 11 indicating the resident was moderately cognitively impaired. Record review of Resident #41's most recent care plan, undated, revealed a diagnosis of Major Depressive Disorder. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676318 If continuation sheet Page 8 of 29 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 676318 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windmill Village Rehabilitation & Care Center 507 Martin Luther King Blvd Lubbock, TX 79403 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 0645 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of Physician orders for Resident #41 dated 03/31/2024 revealed under Diagnoses, Resident #41 has a diagnosis of Major Depressive Disorder. Record review of Resident #41's Preadmission Screening and Resident Review Level One (PL1) form dated 03/14/2024 revealed under section C0100 Mental Illness an answer of No, indicating the resident did not have a mental illness. Resident #71: Record Review of Resident #71's face sheet dated 04/12/2024 revealed a [AGE] year-old male, originally admitted on [DATE] and readmitted on [DATE] with a primary diagnosis of epilepsy, schizoaffective disorder, difficulty swallowing, major depressive disorder, cognitive communication deficit, and anxiety disorder. Record review of Resident #71's admission MDS with a date of 02/15/2024, revealed a BIMS score of 06 which indicates Resident #71 had severe impairment. Resident #71 was listed as having delusions with inattention, disorganized thinking and altered level of consciousness. Resident #71 was triggered on the MDS for Cognitive loss/dementia and Psychotropic drug use. Resident #71 had listed on the MDS under medications that he had been taking antipsychotics and antidepressants. Record Review of Resident #71's Care Plan dated 05/1/2021 revealed Resident #71 was listed as having a psychosocial wellbeing problem with anxiety and major depression with the interventions of: assist/encourage/support resident to set realistic goals, consult with pastoral care, social services, psych services, psychologist who sees him weekly, provide opportunities for resident and family to participate in care. Record Review of Resident #71's Care Plan dated 12/27/2021 revealed Resident #71 was listed as having major depressive disorder with psychotic symptoms with interventions of: assist resident, family, caregivers to clarify strengths, positive coping skills and reinforce these, behavioral health consults as needed, referred and visits with doctor weekly, needs encouragement/assistance/support to maintain as much independence and control as possible. Strengths are that he can ask for help, express feelings, and communicates well, Monitor/record/report to doctor prn acute episode feelings or sadness, loss of pleasure and interest in activities, feelings of worthlessness or guilt, change in appetite/eating habits, change in sleep patterns, diminished ability to concentrate, change in psychomotor skills, Monitor/record/report to doctor prn mood patterns and signs and symptoms of depression, anxiety, sad mood as peer facility behavior monitoring protocols. Record Review of Resident #71's care plan dated 04/11/2024 revealed Resident #71 was listed as being PASRR Positive related to severe mental illness with interventions of: coordinate services with RP from LMHA, invite LMHA and RP to care plan meeting, provide service coordination with representative from LIDDA, report any need to evaluate for services and/or durable medical equipment to maintain, report any need to re-evaluate for additional TRR special services. During a Record Review of Resident #71 PASRR information on 4/11/2024 revealed that Resident #71 PASRR Level 2 screening showed a date of 10/05/2023 and PASRR Level 1 screening with a date of 02/07/2024, indicating that a Level 2 screening would have been provided prior to a level 1 screening. Resident #78 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676318 If continuation sheet Page 9 of 29 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 676318 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windmill Village Rehabilitation & Care Center 507 Martin Luther King Blvd Lubbock, TX 79403 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 0645 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of Resident #78's electronic face sheet dated 04/10/2024 revealed an [AGE] year-old male most recently admitted to the facility on [DATE]. The face sheet listed under diagnosis information a diagnosis of major depressive disorder, single episode, unspecified. Record review of Resident #78's Quarterly MDS dated [DATE], revealed under section I Active Diagnoses, a diagnosis of depression. Additionally, under Section C Cognitive Patterns, the MDS revealed a BIMS score of 13 indicating the resident was cognitively intact. Record review of Resident #78's most recent care plan, undated, revealed a focus area and diagnosis of major depressive disorder, this problem started 12/08/2021. Resident #78 was prescribed Mirtazapine, every shift to address this diagnosis. Record review of Physician progress notes for Resident #78 dated 03/31/2024 revealed under current medications, Resident #78 was prescribed Mirtazapine, monitor for codes every shift related to Major depressive disorder. Record review of Resident #78's Preadmission Screening and Resident Review Level One (PL1) form dated 08/26/2022 revealed under section C0100 Mental Illness an answer of No, indicating the resident did not have a mental illness. Resident #83 Record review of Resident #83 electronic face sheet dated 04/10/2024 revealed an [AGE] year-old male admitted to the facility recently on 02/20/2024. The face sheet indicates under Dementia, Mood Disturbance, Anxiety, Unspecified. Record review of Resident #83's Annual MDS dated [DATE], revealed under section I Active Diagnoses, a diagnosis of depression. Additionally, under Section C Cognitive Patterns, the MDS revealed a BIMS score of 09 indicating the resident was moderately cognitively impaired. Record review of Resident #83's most recent care plan, undated, revealed a diagnosis of Major Depressive Disorder. Record review of Physician progress notes for Resident #83 dated 04/10/2024 revealed under current medications, Resident #83 was prescribed Depakote Oral Tablet Delayed Release 125mg, one tablet by mouth twice a day and Celexa Oral Tablet 20mg, one tablet by mouth once a day for depressive disorder. Record review of Resident #83's Preadmission Screening and Resident Review Level One (PL1) form dated 02/16/2024 revealed under section C0100 Mental Illness an answer of No, indicating the resident did not have a mental illness. Resident #292 Record review of Resident #292 electronic face dated 04/10/2024 sheet revealed an [AGE] year-old female admitted to the facility on [DATE]. The face sheet indicates under Diagnoses Information, Dementia, Mood Disturbance, Anxiety, Unspecified. Record review of Resident #292's MDS dated [DATE], revealed section I Active Diagnoses, not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676318 If continuation sheet Page 10 of 29 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 676318 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windmill Village Rehabilitation & Care Center 507 Martin Luther King Blvd Lubbock, TX 79403 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 0645 available. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #292 most recent baseline plan, undated, revealed no care areas for Anxiety and Dementia, Unspecified. Residents Affected - Some Record review of Physician orders for Resident #292 dated 04/12/2024 revealed under current medications, Resident #292 was prescribed Donepezil HCL Oral Tablet 10mg, one tablet by mouth once a day and Celexa Oral Tablet 20mg, for dementia. Record review of Resident #292's Preadmission Screening and Resident Review Level One (PL1) form dated 03/27/2024 revealed under section C0100 Mental Illness an answer of No, indicating the resident did not have a mental illness. During an interview conducted on 04/11/24 at 9:44am with the MDS Nurse, she verified Residents #2, #41, #71, #78, #83 and #292 had a diagnosis of mental illness. The MDS Nurse verified Residents #2, #41, #71, #78, #83 and #292 did not have PASRR 2 Evaluations as their PASRR 1s were negative. The MDS Nurse stated the purpose of the PASRR 1 was to identify Residents who required additional services which the facility cannot offer. She said if the PASRR 1 was positive then it gets put into an online system and they reach out to the necessary people to ensure a PASRR 2 Evaluation was done. She said she was responsible for entering the PASRR 1 into the system, the MDS nurse was also responsible for ensuring PASRR 1s were accurate by comparing them to medical records. The MDS Nurse stated the potential harm if a resident with a diagnosis of a mental illness had a negative PASRR 1, and no subsequent level PASRR 2 evaluation was the residents could potentially go without services. During an interview with the ADM on 04/11/24 at 9:33am, he verified Residents #2, #41, #71, #78, #83 and #292 had diagnosis of mental illnesses. The ADM confirmed Residents #2, #41, #71, #78, #83 and #292 did not have PASRR 2 Evaluation as their PASRR 1s were negative. The ADM stated it was the MDS nurses' responsibility to ensure every resident admitted to the facility had an accurate PASRR 1. The ADM also stated it was the MDS nurses' responsibility to ensure PASRR 1s were completed accurately by comparing them to the residents' medical records. The ADM stated positive PASRR 1 should be referred to the local mental health authority for completion of a PASRR 2 Evaluation. The ADM stated the potential harm to a resident without an accurate PASRR 1 and a subsequent PASRR 2 Evaluation was the residents will not receive the services they need. Record review of the Preadmission Screening and Resident Review (PASRR) Policy Revised March 15, 2023, read: The facility policy for PASARR states all applicants admitted to a Medicaid-certified nursing facility are evaluated for mental health prior to admissions and offered the most appropriate setting for their needs. If the PASARR level one screening indicated the individual may have an Intellectual Disability or a Mental Illness diagnosis the facility will confer with local mental health providers to complete a PASARR level two screening. Following the completion of the level two screening a care plan will be developed by the facility to meet the needs of a resident with an Intellectual Disability or a Mental Illness diagnosis. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676318 If continuation sheet Page 11 of 29 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 676318 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windmill Village Rehabilitation & Care Center 507 Martin Luther King Blvd Lubbock, TX 79403 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive care plan to meet the highest practicable physical, mental, and psychosocial well-being for 3 of 24 residents (Residents #18, #38, and #78) reviewed for care plans. The facility failed to develop a care plan for Residents #18's current advanced directives. The facility failed to implement a care plan for Resident #38 for nutrition. The facility failed to implement a care plan for Resident #78 for falls. These failures could place residents at risk of not receiving the care required to meet their individualized needs. Findings include: Resident #18 Record review of the admission record for Resident #18, dated 04/09/24 revealed an [AGE] year-old female who was admitted to the facility on [DATE] with the following diagnoses: Parkinson's disease (brain disorder), Alzheimer's disease (memory disorder), and essential hypertension (high blood pressure). Record review of Resident #18's comprehensive MDS assessment dated [DATE] revealed that Resident #18 was understood and had a BIMS score of 05 indicating that the resident's cognition was severely impaired. Record review of the order summary report for Resident #18, undated, revealed there were orders for Code Status: Do Not Resuscitate (DNR) with a start date of 02/08/24. Record review of the current care plan for Resident #18, undated, revealed there was no care areas for advanced directives. Resident #38 Record review of Resident #38's face sheet, undated, revealed an [AGE] year-old-female was admitted to the facility on [DATE] with diagnoses to include dementia, depression, cognitive communication disorder, and anxiety disorder, and vitamin deficiency. Record review of Resident #38's Comprehensive Minimum Data Set, dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 3, which indicated the resident was severely cognitively impaired. Section I Active Diagnosis Summary: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676318 If continuation sheet Page 12 of 29 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 676318 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windmill Village Rehabilitation & Care Center 507 Martin Luther King Blvd Lubbock, TX 79403 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 0656 Malnutrition or at risk of Malnutrition Level of Harm - Minimal harm or potential for actual harm Dementia Anxiety Residents Affected - Few Depression Record review of Resident #38's care plan undated revealed a focus area care planned for including ADL self-care performance deficit, Dementia, and Limited Mobility. Interventions included eating: The resident requires EXTENSIVE assistance to eat. Additional focus area included for Resident #38: has a potential nutritional problem r/t therapeutic and mechanically altered diet and risk for malnutrition. DIET: regular diet, mechanical soft, thin consistency, may have peanut butter and jelly sandwich and mashed potatoes at each meal. Goal: Resident 38 will maintain adequate nutritional status as evidenced by maintaining weight within 5% of 135 pounds, no signs or symptoms of malnutrition, and consuming at least 50% of at least 2 meals daily. Interventions included: Invite the resident to activities that promote additional intake. May serve peanut butter and jelly sandwich and mashed potatoes for each meal. May have breakfast items for each meal. Monitor/document/report signs and symptoms of dysphagia: pocketing, choking, coughing, drooling, holding food in mouth, several attempts at swallowing, refusing to eat, appears concerned during meals. Monitor/record/report to the doctor of signs and symptoms of malnutrition: emaciation (Cachexia), muscle wasting, significant weight loss: 3lbs in 1 week, >5% in 1 month, >7.5% in 3 months, >10% in 6 months. Resident #38 is to have peanut butter and jelly sandwiches twice daily. Provide, serve diet as ordered. Monitor intake and record every meal. Resident #78 Record review of Resident #78's face sheet, undated, revealed an [AGE] year-old-male was admitted to the facility on [DATE] with diagnoses to include major depressive disorder, muscle weakness, difficulty in walking, and lack of coordination. Record review of Resident #78's Comprehensive Minimum Data Set, dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 13, which indicated the resident was cognitively intact. Section V Care Area Assessment (CAA) Summary: CAA Results: 11. Falls Section J Health conditions revealed no history of falls. Record review of Resident #78's care plan undated revealed a focus area care plan for falls with or without injuries, Goals: Resident #78 will be free of falls through the review date, Interventions: Place floor mat next to [Resident #78] bed on floor. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676318 If continuation sheet Page 13 of 29 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 676318 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windmill Village Rehabilitation & Care Center 507 Martin Luther King Blvd Lubbock, TX 79403 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview and observation on 04/09/24 at 12:15pm, Resident #38 did not eat any of her lunch, her hands were in her lap the entire meal period, no staff encouraged Resident #38 to eat. Surveyor asked confidential CNA if Resident #38 will be offered an alternative meal, CNA informed Surveyor Resident #38 was supposed to have breakfast food for every meal, a peanut and butter sandwich for every meal, and mashed potatoes for every meal, CNA presented Surveyor with Resident #38's meal ticket which stated Resident #38 was to have a peanut butter and jelly sandwich and mashed potatoes with every meal, Resident #38 was not provided with any of these food items at lunch. CNA stated Resident #38 was not provided with a peanut butter and jelly sandwich and mashed potatoes at breakfast. During an interview on 04/09/24 at 1:23pm, the DON stated the care plan was recently updated adding the peanut butter and jelly sandwich, breakfast food, and mashed potatoes; she stated she would speak to the dietary manager to ensure the lack of these food items being provided to Resident #38 was corrected. Surveyor informed the DON Resident #38 was not being offered extensive assistance with eating as her care planned indicated, the DON stated she would in-service her nursing staff to ensure Resident #38 is provided with meal assistance. The DON stated the potential negative outcome for Resident 38's care plan not being followed was Resident #38 could experience malnutrition and extensive weight loss. Observation on 04/09/24 at 4:45 PM revealed Resident #38 was not provided a peanut butter and jelly sandwich or mashed potatoes for dinner. Resident #38 was not provided assistance during the dinner meal, Resident #38 was not encouraged or prompted to eat. Resident #38 ate approximately 10% of her meal. Observation on 04/10/24 at 12:05pm revealed Resident #38 was not eating the noon meal, Resident #38's hands were in the lap, and Resident #38 was not offered assistance during the meal. Resident #38 was not provided with breakfast food for lunch, Resident #38 was not provided with a peanut butter and jelly sandwich, or mashed potatoes. During an interview and observation on 04/10/2024 at 12:51pm, Resident #78 and family member stated that, there's not been any floor mat since the past one year, the floor mat was only used the time Resident #78 was admitted and no floor mat was observed on the floor. During an interview and observation on 04/11/2024 at 9:33am, Resident #78 stated that his family member will not be coming to visit him today. No floor mat was observed on the floor. Observation on 04/11/24 at 12:12pm revealed was not provided breakfast food for lunch, she was provided with a peanut butter and jelly sandwich, she was not provided with mashed potatoes. Resident #38 ate ½ of her peanut butter and jelly sandwich for her noon meal. Resident #38 was not provided with assistance during her noon meal. Observation on 04/11/24 4:51pm revealed Resident #38 was not provided with breakfast food for dinner, Resident #38 was not provided a peanut butter and jelly sandwich, and Resident #38 was not offered mashed potatoes. Resident #38 was offered a tater tot by staff twice during this observation, she ate both tater tots. The two tater tots Resident #38 offered were the only food items Resident #38 ate during the dinner meal. During an interview on 04/12/24 at 9:16 AM, the DON stated nursing management and the MDS nurse were responsible for ensuring the care plan has all care areas required. The DON stated it was unknown why Resident #18 was missing a care area for advanced directives. The DON stated she has been (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676318 If continuation sheet Page 14 of 29 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 676318 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windmill Village Rehabilitation & Care Center 507 Martin Luther King Blvd Lubbock, TX 79403 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few trained on care plans but has not been trained with the current company that took over on March 1, 2024. The DON stated it was unknown exactly what the potential negative outcome to the resident would be due to her nursing staff looking in other places for code status. During an interview on 04/12/24 at 9:27 AM, the MDS nurse stated it was unknown why Resident #18 was missing a care plan for advanced directives. The MDS nurse stated as the RN, she was responsible for ensuring advanced directives were in the care plan. The MD nurse stated it was unknown the last time the care plans were audited for advanced directives. The MDS nurse stated the potential negative outcome to the resident was she could possibly get coded with chest compressions, which were not her wishes. During an interview on 04/12/24 at 11:55 AM, the ADM stated the DON and the MDS nurse worked together for the care plans. The ADM stated he did not know why Resident #18 was missing a care plan for advanced directives. The ADM stated the DON and the MDS nurse had been trained on care plans, it was unknown exactly when, but it had been done since the beginning of March with the change of company. The ADM stated it was important for staff to know advanced directives for residents and it was visible in other places in their chart, so he was unsure what the potential negative outcome would be to the residents. During an interview on 04/12/24 at 11:57am, the DON stated that the floor mat should not have been discontinued and care plan was a plan that provides all nursing staff with a plan of care for each resident. She said the potential negative outcome of not implementing care plans was that the resident could receive subpar treatment, and confusion could be caused among staff. She said it could potentially cause poor care for the resident. She said she was unaware that any residents were missing care plans. She said she had not received any reports about issues with care plans. She said the care plan should start with the CAAs from Section V. She and her nursing administration alongside the MDS Coordinator care planned for both acute problems and for the CAAs. She said she expected all care plans to be accurate. When asked where the nurses get information on care plans, she stated that, they asses that information on POC. During an interview on 04/12/24 at 12:07pm, the ADM stated that the potential negative outcome of not implementing care plans was that residents could receive inappropriate care. He said the purpose of the care plan was to ensure all needs of the residents were being met. He said all staff used the care plan. He said he was unaware that any residents were missing any care plans. He said the system to monitor care plans was the MDS Coordinator. He said he had not been trained regarding the completion of the care plan. He said he expected care plans to be completed accurately and meet the needs of the resident. He said the MDS coordinator was responsible for completing care plans. Record review of the facility policy titled, Care Plans, Comprehensive Person-Centered, with a revised date of December 2016, reflected the following: Policy statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation: .8. The comprehensive, person-centered care plan will: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676318 If continuation sheet Page 15 of 29 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 676318 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windmill Village Rehabilitation & Care Center 507 Martin Luther King Blvd Lubbock, TX 79403 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 0656 Level of Harm - Minimal harm or potential for actual harm .b. Describe services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; .j. Reflect the resident's expressed wishes regarding care and treatment goals Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676318 If continuation sheet Page 16 of 29 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 676318 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windmill Village Rehabilitation & Care Center 507 Martin Luther King Blvd Lubbock, TX 79403 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were stored properly in the cart for 1 of 4 medication carts (hall 200) in that: 1. MA was in the middle of medication pass when she realized she was missing a medication, she placed the already dispensed medications in an open medication cup and then placed them in her unlocked medication cart and then proceeded to the supply room to find the other medication. This failure could place residents at risk of not receiving prescribed medications as ordered and drug diversions. The findings include: Observation of medication pass with MA on 04/11/2024 at 7:30 AM revealed MA was in the middle of medication pass with Surveyor for Resident #25, when she realized she was missing a medication (protonix), she placed the already dispensed medications (probiotic 1 capsule, aspirin 81 mg 1 tablet, atorvastatin 20 mg 1 tablet, amlodipine 5 mg 1 tablet, clopidogrel 75 mg 1 tablet, lisinopril 40 mg 1 tablet) in an open medication cup and then placed them in her unlocked medication cart and then proceeded to the supply room to find the other medication. MA looked for the missing protonix medication and returned back to the unlocked medication cart for a few minutes. Interview with MA on 04/11/2024 at 7:42 AM., MA stated that she should have made sure to have all medications before beginning medication administration and she should not have placed the open medications in the medication cart. MA stated that she had been trained in medication administration through school. MA stated that the facility had provided in-services before for medication administration. MA stated that the negative potential outcome of storing medications in the unlocked cart in an open medication cup was that she could possibly administer to the wrong resident. Interview with the DON on 04/11/2024 at 2:37 pm., the DON stated that she expects the staff to not store open medications in the cart and expects them to lock the carts. The DON stated that training was provided through in-services monthly. The DON stated that the negative potential outcome was that the medication could have been given to the wrong resident or a resident could have opened the cart and taken it. DON stated that she oversees the training for staff. Interview with the Administrator on 04/12/2024 at 1:50 pm., the Administrator stated that he expects staff to follow policy for proper storing of medications. The Administrator stated that the facility does provide training annually through in-services. The Administrator stated that the negative potential outcome of not properly storing medications was that the wrong medication could be given to the wrong resident. Record Review of the facility provided policy, labeled, Storage of Medications, date Revised April 2019, revealed: Policy Statement: The facility stores all drugs and biologicals in a safe, secure, and orderly manner. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676318 If continuation sheet Page 17 of 29 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 676318 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windmill Village Rehabilitation & Care Center 507 Martin Luther King Blvd Lubbock, TX 79403 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 0761 Policy Interpretation and Implementation: Level of Harm - Minimal harm or potential for actual harm 2. Drugs and biologicals are stored in the packaging, containers or other dispensing systems in which they are received. Only the issuing pharmacy is authorized to otr4ansfer medications between containers. Residents Affected - Few 3. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. 6. Hazardous drugs shall be clearly marked as such and shall be stored separately from other medications. 8. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes), containing drugs and biologicals are locked when not in use. 9. Unlocked medication carts are not left unattended. 10. Residents medications are stored separately from each other to prevent the possibility of mixing medications between residents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676318 If continuation sheet Page 18 of 29 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 676318 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windmill Village Rehabilitation & Care Center 507 Martin Luther King Blvd Lubbock, TX 79403 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 0770 Provide timely, quality laboratory services/tests to meet the needs of residents. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to provide or obtain laboratory services only when ordered by a physician for 1 of 24 residents (Resident #62) reviewed for labs in that: Residents Affected - Some The facility failed to obtain Keppra level labs for Resident #62 as ordered by the physician. This failure could put residents who may have lab work ordered at risk of not having their medical needs met. Findings include: Record review of the admission record for Resident #62, dated 04/09/24, revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses to include cerebral infarction (stroke), acute respiratory failure (lung problems), dysphagia (swallowing difficulties) and other seizures (sudden, uncontrolled burst of electrical activity in the brain). Record review of the comprehensive MDS for Resident #62, dated 11/10/23, reflected Resident #62 was understood and had a BIMS score of 07, which indicated his cognition was moderately impaired. The MDS further revealed Resident #62 had an active diagnosis of seizure disorder or epilepsy. Record review of the current physician orders for Resident #62, undated, revealed an order for, Obtain Keppra level one time a day every 3 months with a start date of 05/12/23. Record review of lab results in the electronic medical record from 05/01/23 to 04/11/24 for Resident #62 revealed there was no documentation of a Keppra Level being drawn and collected. During an interview on 04/11/24 at 9:31 AM, LVN A stated was able to see the order for Keppra levels every 3 months from May of 2023 and she was unable to locate any Keppra level labs for Resident #62. LVN A stated she went back to when the lab was ordered for Resident #62 and was unable to locate any Keppra level labs. LVN A stated the charge nurses, and the DON were responsible for ensuring resident's receive lab services as ordered by the physician. LVN A stated she did not know why Resident #62 did not have any Keppra level labs in his chart, but she would call the lab to see if they had any copies of Keppra levels for Resident #62. LVN A stated the potential negative outcomes to the residents were they may not have enough of the medicine or too much of the medicine and they could have seizures. During an interview on 04/11/24 at 12:39 PM, LVN A stated she called the lab and no copies of Keppra levels were found for Resident #62 from May 2023 to April 2024. During an interview on 04/12/24 at 9:16 AM, the DON stated the Keppra level labs that were ordered for Resident #62 were missed. The DON stated it was unknown why the Keppra levels were missed for Resident #62. The DON stated Resident #62 could have refused the lab draws but she was unable to locate any documentation of Resident #62 refusing lab services. The DON stated Resident #62 could have shut down, it was unknown exactly what happened and why the Keppra levels were not done. The DON stated the nursing administration was responsible for ensuring lab services were being performed as ordered. The DON stated the potential negative outcomes to the resident were he could have a seizure if [Keppra] levels were not therapeutic, the resident could be hospitalized due to status epilepticus, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676318 If continuation sheet Page 19 of 29 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 676318 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windmill Village Rehabilitation & Care Center 507 Martin Luther King Blvd Lubbock, TX 79403 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 0770 and there was an unknown range of medicine in the resident's system. Level of Harm - Minimal harm or potential for actual harm During an interview on 04/12/24 at 11:55 AM, the ADM stated the DON typically reviewed all labs to ensure they were getting done. The ADM stated the charge nurse should also check that labs were being done. The ADM stated he did not know why Resident #62's Keppra level labs were not done. The ADM stated he was not a nurse, so he could not tell what negative impact that would have had on the resident. The ADM stated if it [Keppra level] was for a purpose, it was important. Residents Affected - Some Record review of the facility policy titled, Lab and Diagnostic Test Results - Clinical Protocol, with a revised date of November 2018 reflected the following: Assessment and Recognition 1. The physician will identify and order diagnostic and lab testing based on the resident's diagnostic and monitoring needs. 2. The staff will process test requisitions and arrange for tests. 3. The laboratory, diagnostic radiology provider, or other testing source will report test results to the facility FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676318 If continuation sheet Page 20 of 29 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 676318 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windmill Village Rehabilitation & Care Center 507 Martin Luther King Blvd Lubbock, TX 79403 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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to provide food that was palatable, and at a safe, and appetizing temperature for 3 of 3 food forms (Regular, Mechanical Soft, and Pureed) for 1 of 1 meal reviewed for palatability. Residents Affected - Some 1) The facility failed to provide food that was palatable for 3 of 3 food forms served (Regular, Mechanical Soft, and Pureed) at 1 of 1 meal observed (04/10/24 lunch). These failures could place residents at risk of decreased food intake, hunger, and unwanted weight loss. The findings included: During confidential individual interviews 4 of 11 residents voiced concerns related to food palatability. One resident stated The food is not good. I do not like it. Another resident stated, The food is disgusting. I do not like it. I mainly eat the snacks they give. One other resident stated, The food is very salty. Another resident stated, The food is hard to eat because it is so salty. Record review of the Resident Council Minutes dated 10/26/23 revealed resident comments related to the food served in the facility. It was documented, cold food at dinners - The following interviews and observations were made during a kitchen tour on 04/10/24 that began at 10:37 AM and concluded at 12:34 PM: On 04/10/24 at 10:37 AM the Dietary Manager was informed of a request for a test tray for the noon meal. On 04/10/24 at 12:21 PM the test trays arrived at the conference room and sampling began at 12:24 PM with the following results: Alternate meal plate - Regular Texture Spaghetti and meatballs, lukewarm Mixed vegetables, overcooked/very soft/mushy and bland/poor flavor. Regular Meal - Regular Texture Swiss Steak with brown gravy, meat was tough, hard to cut through. Mashed potatoes, tasted like instant mashed potatoes and lukewarm. Green beans, overcooked/very soft/mushy. Regular Meal - Mechanical Soft Texture (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676318 If continuation sheet Page 21 of 29 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 676318 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windmill Village Rehabilitation & Care Center 507 Martin Luther King Blvd Lubbock, TX 79403 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 0804 Swiss Steak with brown gravy, meat was tough, hard to chew. Level of Harm - Minimal harm or potential for actual harm Mashed potatoes, tasted like instant mashed potatoes. Green beans, overcooked/very soft/mushy. Residents Affected - Some Regular Meal - Puree Texture Green beans, poor taste that was not like green beans. Chicken Salad Sandwich - Regular Texture Very strong vinegar taste, poor taste Interview on 04/10/24 at 2:49 PM, the Dietary Manager stated she tasted all the food that was made in the kitchen, even the sandwiches. The Dietary Manager stated she did not know why some of the residents were complaining of how the food tasted. The Dietary Manager stated she was responsible for ensuring the food tastes good for the residents. The Dietary Manager stated she was last trained on food palatability in March of 2023 at a seminar. The Dietary Manager stated the potential negative outcome to the residents was they could lose weight if they did not want to eat. Interview on 04/10/24 at 3:50 PM, the ADM stated the facility did not have a policy related to food palatability specifically. Interview on 04/12/24 at 11:55 AM, the ADM stated he tastes the food there several times a week due to getting a tray and eating at the facility. The ADM stated he has not had any problems with the taste of the food from what he has eaten. The ADM stated none of the residents had complained to him about the taste of the food and he would go around and ask residents in the dining room with no complaints. The ADM stated the Dietary Manager was responsible for ensuring the food tasted good and was trained recently, unknown exactly when. The ADM stated the potential negative outcome to the residents was weight loss. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676318 If continuation sheet Page 22 of 29 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 676318 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windmill Village Rehabilitation & Care Center 507 Martin Luther King Blvd Lubbock, TX 79403 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for dietary services. 1) The facility failed to protect foods from potential contamination. 2) The facility failed to ensure foods were not expired. These failures could place residents at risk for food contamination and foodborne illness. The findings included: - The following observation was made during a kitchen tour on 04/09/24 that began at 10:00 AM and concluded at 10:35 AM: -An opened bag of potato chips on the counter, open date 04/08/24. -An opened bag od bologna in the fridge, open date 04/05/24. -an opened gallon jug of milk in the fridge, best by 04/19/24. -an opened bag of shredded cheddar cheese in the fridge; open date 04/07/24. -an opened container of boiled eggs, best by 04/08/24. -2 stacks of small bowls stored right side up in the dish washing room. Interview on 04/10/24 at 2:49 PM, the Dietary Manager stated all the dietary staff were responsible for ensuring food items were secure and not expired. The Dietary Manager stated she did not know how the items were missed. The Dietary Manager stated she was responsible for ensuring food items were secure and not expired. The Dietary Manager stated the staff believed the opened food items were closed all the way and they were not. The Dietary Manager stated she trains staff regularly via in-services and she would be able to provide copies. The Dietary Manager stated the potential negative outcomes to the residents were the food may not taste as good or the residents could be given expired food items. Interview on 04/10/24 at 3:37 PM, the Dietary Manager stated she was unable to access her previous in-services regarding food storage and food palatability due to technological issues. Interview on 04/12/24 at 11:55 AM, the ADM stated he expects dietary staff to make sure food containers were sealed and not expired. The ADM stated the Dietary Manager was responsible for making sure foods were properly sealed and not expired. The ADM stated he did not know why these items were missed in the kitchen. The ADM stated the potential negative outcomes to the residents were expired food was bad food and unsealed food would not stay fresh. Record review of the facility policy and procedure titled, Food Storage, dated 2021, reflected the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676318 If continuation sheet Page 23 of 29 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 676318 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windmill Village Rehabilitation & Care Center 507 Martin Luther King Blvd Lubbock, TX 79403 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 following: Level of Harm - Minimal harm or potential for actual harm Policy: Sufficient storage facilities will be provided to keep foods safe, wholesome, and appetizing. Food will be stored in an area that is clean, dry and free from contaminants. Food will be stored, at appropriate temperatures and by methods designed to prevent contamination or cross contamination Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676318 If continuation sheet Page 24 of 29 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 676318 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windmill Village Rehabilitation & Care Center 507 Martin Luther King Blvd Lubbock, TX 79403 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 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to establish and maintain an infection prevention and control program, designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 3 of 6 Residents observed for infection control for practices (Resident #3, #17, and #19) in that: Residents Affected - Some 1. CNA A failed to wash hands prior to gathering perineal care supplies for Resident #3, CNA A failed to use proper hand washing during perineal care for Resident #3 while going from dirty to clean. CNA A failed to use correct hand washing practices after providing perineal care for Resident #3. 2. RN failed to use proper hand washing practices after providing wound care for Resident #17. 3. CNA B failed to use proper hand washing practices before and after providing perineal care for Resident #19. These failures could place residents at risk for infection through cross contamination of pathogens. The findings included: Resident #3: Record Review of Resident #3 face sheet, date retrieved on 04/11/2024, revealed an [AGE] year-old female, admitted on [DATE] with a primary diagnosis of atrial fibrillation, shortness of breath, muscle wasting, type 2 diabetes, deficiency in vitamins, hyperlipidemia, high blood pressure, acid reflux, constipation, and calculus of kidney pain, Record review of Resident #3's Annual MDS with a date of 10/23/2024, revealed a BIMS score of 12 which indicated resident was moderately impaired. During an observation of perineal care with the CNA C on 4/11/2024 at 1:06 PM., CNA C failed to wash her hands prior to gathering supplies. CNA washed her hands after incontinent care. CNA put on clean gloves to provide peri care, removed Resident #3's pants after explaining to Resident #3 the procedure she would be providing. CNA C removed dirty gloves and discarded. CNA C did not perform hand hygiene. CNA C put on clean gloves. CNA C removed Resident #3's brief. CNA C used the one swipe per wipe method to clean Resident #3, cleaning right to left and then center groin. CNA turned Resident #3 to the left side to clean the back side. CNA C removed dirty gloves and discarded. CNA C put on pair of clean gloves. CNA C did not perform hand hygiene before placing on clean gloves. CNA C used the one wipe per swipe method to clean the back side of Resident #3, starting from the right side, then left side, then center buttocks. CNA C removed dirty gloves and discarded. CNA C put on clean gloves and then placed Resident #3's pants back on. CNA C removed dirty gloves and discarded. CNA C went to the resident bathroom sink to wash hands. CNA C washed her hands by turning on water, putting sufficient amount of soap on hands. CNA C lathered soap and washed her hands for 9 seconds and then rinsed her hands. CNA used a clean paper towel to dry both hands and then used the same paper towel that was used to dry off hands, to turn off the faucet. During an Interview with CNA C on 04/11/2024 at 1:22 PM., CNA C stated that she had been trained in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676318 If continuation sheet Page 25 of 29 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 676318 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windmill Village Rehabilitation & Care Center 507 Martin Luther King Blvd Lubbock, TX 79403 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some infection control practices through in-services approximately monthly. CNA C stated that the negative potential outcome for not using accurate infection control practices was the spread of germs. Resident #17: Record Review of Resident #17 face sheet date retrieved on 04/11/2024, revealed an [AGE] year-old male, originally admitted on [DATE] with a primary diagnoses of muscle wasting, anemia, type 2 diabetes, heart failure, high blood pressure, hyperlipidemia, end stage renal disease, chronic obstructive pulmonary disease, difficulty swallowing, gastrointestinal hemorrhage, viral herpes, anxiety, dementia, anemia, atherosclerotic heart disease, pleural effusion, respiratory failure, acid reflux, pain Record review of Resident #17's MDS with a date of 12/05/2023, revealed a BIMS score of 13 which indicated resident was moderately impaired. Observation of wound care procedure on 04/11/2024 at 9:10 AM for Resident #19 revealed RN failed to use proper infection control practices after wound care procedure. After RN completed the wound care, she proceeded in washing her hands in Resident #17's bathroom sink. RN turned on the water, placed sufficient amount of soap in her hands. RN then immediately started rubbing her hands under the water without allowing the soap to lather for the 20 recommended seconds. RN grabbed three clean paper towels and using all of the paper towels at once dried both her hands. RN used the dirty paper towels to turn off the faucet. Interview with RN on 04/11/2024 at 9:32 AM., RN stated that she had been trained in infection control practices/handwashing. RN stated that she knew that she should have let the soap lather while washing her hands. RN stated that she has had training in the form of in-services every couple of weeks. RN stated that the negative potential outcome of not providing proper infection control practices was spreading infections. Resident #19: Record Review of Resident #19's face sheet date retrieved on 04/11/2024 revealed an [AGE] year-old female admitted on [DATE] with a primary diagnoses of muscle wasting and atrophy, difficulty swallowing, diverticulitis, major depressive disorder, anemia, atelectasis, deficiency in vitamins, high blood pressure, atherosclerotic heart disease, acid reflux, urinary tract infection, and sciatica. Record review of Resident #19's MDS with a date of 09/14/2023, revealed the BIMS score was left blank and incomplete. Observations with CNA B on 04/12/2024 at 2:53 PM during perineal care for Resident # 19 revealed CNA B failed to use proper hand washing techniques prior to perineal care for Resident #19. CNA B turned on the water and put the soap in her hands and lathered on hands while rubbing hands together for 3 seconds and then rinsed. CNA B used a paper towel to dry her hands and used the same paper towel to turn off faucet. CNA B washed her hands again after providing perineal care. CNA B turned on the water and put soap in her hands and rubbed hands together for 7 seconds and then rinsed hands. CNA B used two dry clean paper towels to dry her hands and then used the same paper towel that she used to dry her hands to turn off the faucet. Interview with CNA B on 04/12/2024 at 3:12 PM CNA B stated that she should have washed her hands for longer than she did but was nervous. CNA B stated that she had been trained in infection control (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676318 If continuation sheet Page 26 of 29 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 676318 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windmill Village Rehabilitation & Care Center 507 Martin Luther King Blvd Lubbock, TX 79403 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some practices/ Hand washing by in-services and computer every week. CNA B stated that the negative potential outcome for not providing proper hand washing techniques was spreading germs and could possibly make others sick. During an interview with the DON on 4/11/2024 at 2:37 PM., the DON stated she expected staff to follow the policy and procedures accurately for infection control practices. The DON stated that she does in-services monthly for infection control practices but was willing to immediately do more in-services and competency checks for infection control practices. The DON stated that the negative potential outcome for not providing accurate infection control practices was the spread of infection and germs. During an interview with the Administrator on 4/12//2024 at 1:49 PM., the Administrator stated that he expects staff to follow policy and procedures of the facility for infection control practices. The Administrator stated that they provide in-services quarterly for training and competency checks. The Administrator stated that the DON was responsible for the training. The Administrator stated that the negative potential outcome for not practicing infection control practices was the spread of infections. Record review of the facility policy titled, Handwashing/Hand Hygiene, date Revised 12/22/2023 revealed: Policy Statement: This facility considers hand hygiene the primary means to prevent the spread of infections. Policy Interpretation and Implementation: 1. All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare associated infections. 2. All personnel shall follow the handwashing /hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. 6. Wash hands with soap (antimicrobial or non-antimicrobial) and water for the following situations: a). When hands are visibly soiled b). After contact with a resident with infectious diarrhea including, but not limited to infections caused by norovirus, salmonella, shigella, and C. difficile. 7. Use an alcohol-based hand rub containing at least 60-90% alcohol, or alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: b). Before and after direct contact with residents. c). Before preparing or handling medications d). Before preforming any non-surgical invasive procedures. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676318 If continuation sheet Page 27 of 29 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 676318 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windmill Village Rehabilitation & Care Center 507 Martin Luther King Blvd Lubbock, TX 79403 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 e). Before and after handling an invasive device (urinary catheters, IV access sites). Level of Harm - Minimal harm or potential for actual harm g). Before handling clean or soiled dressings, gauze pads, etc. h). Before moving from a contaminated body site to a clean body site during resident care. Residents Affected - Some i). After contact with a resident's intact skin. j). After contact with blood or bodily fluids. k). After handling used dressings, contaminated equipment, etc. l). After contact with objects (medical equipment) in the immediate vicinity of the resident. m). After removing gloves. 8. Hand hygiene is the final step after removing and disposing of personal protective equipment. 9. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare associated infections. Procedure: Washing hands: 1. Wet hands first with water, then apply an amount of product recommended by the manufacturer to hands. 2. Rub hands together vigorously for at least 20 seconds, covering all surfaces of the hands and fingers. 3. Rinse hands with water and dry thoroughly with a disposable towel. 4. Use towel to turn off faucet. 5. Avoid using hot water, because repeated exposure to hot water may increase the risk of dermatitis. Using Alcohol-based hand runs: 1. Apply generous amount of product to palm of hand and rub hands together. 2. Cover all surfaces of hands and fingers util hands are dry. 3. Follow manufacturer's directions for volume of product to use. Applying and Removing Gloves: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676318 If continuation sheet Page 28 of 29 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 676318 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windmill Village Rehabilitation & Care Center 507 Martin Luther King Blvd Lubbock, TX 79403 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 1. Perform hand hygiene before applying non-sterile gloves. Level of Harm - Minimal harm or potential for actual harm 2. When applying, remove one glove from the dispensing box at a time, touching only the top of the cuff. Residents Affected - Some 3. When removing gloves, pinch the glove at the wrist and peel away from the hand, turning the glove inside out. 4. Hold the removed glove in the gloved hand and remove the other glove by rolling it down the hand and folding it into the first glove. 5. Perform hand hygiene. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676318 If continuation sheet Page 29 of 29