Health inspection·August 9, 2024

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some and doffed dirty gloves. CNA A donned clean gloves and placed a clean brief on Resident #1. CNA A failed to utilize hand hygiene between glove changes. During an interview with CNA A on 8/9/2024 at 12:59AM, she stated she had been trained on hand hygiene between glove changes and hand hygiene and her last training was sometime this year. CNA A stated the infection preventionist was the DON. CNA A stated the potential negative outcomes of not utilizing hand hygiene is spreading germs from residents to caregivers or to other residents. CNA A stated she was nervous and realized afterwards that she had missed some steps. Resident #2 Record review of Resident #2's undated face sheet revealed a [AGE] year-old female originally admitted on [DATE]. Resident #2 had a medical history of cerebral palsy (weakness in or problems with using the muscles), dysphagia (trouble swallowing), neuromuscular dysfunction of bladder (the nerves and muscles don't work together very well) and multiple sclerosis (chronic disease of the central nervous system). Record review of Resident #2's quarterly MDS assessment dated [DATE], Section C- Cognitive patterns revealed Resident #2 had a BIMS score of 15 which indicated Resident #1 was cognitively intact. Section H- Bladder and bowel revealed Resident #2 was always incontinent of bladder. Record review of Resident #2's care plan dated 5/04/24 revealed The resident has bladder incontinence. Check Resident #2 as required for incontinence. Wash, rinse, and dry perineum. Change clothing PRN after incontinence episodes. During an observation on 8/9/2024 at 12:04 AM CNA B washed her hands with soap and water and donned clean gloves. CNA B unfastened Resident #2's brief and cleaned the residents front with a wet wipe. CNA B doffed dirty gloves and donned clean gloves. CNA B wiped Resident #2s front again with a wet wipe and doffed dirty gloves. CNA B donned clean gloves and assisted Resident #2 onto her left side. CNA B cleaned Resident #2's buttock with a wet wipe and removed the dirty brief. CNA B grabbed a clean brief with contaminated gloves and placed the brief onto Resident #2. CNA B doffed dirty gloves and removed the dirty trash bag. CNA B washed her hands with soap and water. CNA B failed to utilize hand hygiene between glove changes and failed to change gloves before grabbing the clean brief. During an interview with CNA B on 8/9/2024 at 12:20AM she stated she had no training on hand hygiene or infection control. CNA B stated they had an in-service on hand hygiene but did not know when. CNA B stated she did not know who the Infection Preventionist was. CNA B stated a potential negative outcome of not utilizing proper hand hygiene between glove changes could be passing on germs. CNA B stated she knew she had messed up during the incontinence care. Resident #3 Record review of Resident #3's undated face sheet revealed a [AGE] year-old male originally admitted on [DATE]. Resident #3 had a medical history of neuroleptic induced parkinsonism (Parkinsonism a term used to describe the collection of signs and movement symptoms caused by antipsychotic medication), type 2 diabetes, and psychotic disorder with delusions (false beliefs that are not based on reality). Record review of Resident #3's quarterly MDS assessment dated [DATE], Section C- Cognitive patterns (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676318 If continuation sheet Page 2 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676318 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/09/2024 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 revealed Resident #3 had a BIMS score of 03 which indicated Resident #3 had severe cognitive deficit. Section H- Bladder and bowel revealed Resident #3 was always incontinent of bowel and bladder. Record review of Resident #3's care plan dated 5/10/24 revealed Resident #3 bladder incontinence. Check Resident #3 as required for incontinence. Wash, rinse, and dry perineum. Change clothing PRN after incontinence episodes. During an observation on 8/9/2024 at 11:05 AM, CNA C washed her hands with soap and water and donned clean gloves. CNA C unfastened Resident #3's brief and cleaned resident with wet wipes. Resident #3 turned to his left side and CNA C clean his buttocks with wet wipes. CNA C removed Resident #3's brief and placed a clean brief on the resident. CNA C doffed dirty gloves and washed her hands with soap and water. CNA C failed to change gloves throughout the incontinence care. CNA C failed to utilize hand hygiene during the incontinence care. During an interview with CNA C on 8/9/2024 at 11:30AM, she stated the IP is the ADM. CNA C stated she has been trained on hand hygiene and her last training was a couple months ago. CNA C stated hand hygiene should occur before and after care and in between care. She stated hand hygiene should occur between glove changes, or if you take off your gloves. CNA C stated the potential negative outcome of not utilizing hand hygiene between glove changes could be spreading infection and the residents getting sick from that infection. CNA C stated she was nervous to do incontinence care. She stated they had told her to come do care and did not feel like she had time to prepare. She stated she had been trained as a CNA in the hospital and not a nursing facility and she feels it is different. During an interview with DON on 8/9/2024 at 12:25PM, she stated the IP is the ADON. She stated the IP is responsible for hand hygiene and infection prevention training. She stated training is done monthly on a random selection basis. She stated 15 employees are picked a month and they are observed on hand hygiene and how to don and doff PPE. The DON stated night shift staff is also included in these training. She stated the potential negative outcomes of not utilizing hand hygiene is spreading diseases to residents and to staff members. She stated staff should be washing their hands when going into a room, coming out of a room, and between glove changes or if their gloves are soiled. She stated staff can use soap and water or ABHS. The DON stated she was not aware they were not utilizing hand hygiene between glove changes. During an interview with the ADM on 8/9/2024 at 12:41 PM, he stated the IP is the DON and the ADON, but they all have the training. He stated training on hand hygiene is done quarterly and the last training was last month. The ADM stated they have a schedule, and they observe and do the check offs with staff on hand hygiene. He stated the DON or ADON will come in on night shift and do competencies with them as well. He stated the potential negative outcome of not utilizing hand hygiene between glove changes could be infection. The ADM stated hand hygiene should occur before, during and after care and anytime gloves are removed. The ADM stated he was not aware of staff not utilizing hand hygiene between glove changes. During an interview with the ADON on 8/9/2024 at 12:55 PM she stated she was the IP. She stated she had done training on hand hygiene, and it is done monthly. She stated the new hire staff are trained separately before they begin to work with residents. The ADON stated during the checkoff she monitors how staff washes their hands, how they dry their hands and if they are using enough soap and water. She stated she does the same for the night shift staff and comes in and observes their hand hygiene technique. She stated the potential negative outcomes of not utilizing hand hygiene between glove changes could be spreading infection and transferring it to other residents or their own family. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676318 If continuation sheet Page 3 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676318 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/09/2024 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 She stated hand hygiene should occur before, after and during incontinence care. She stated staff should be changing gloves and using ABHS or washing their hands with soap and water between glove changes. The ADON stated she was not aware of staff not utilizing hand hygiene between glove changes. She stated they would be doing an in-service that will address handwashing and glove changes. Record review of facility policy titled, Infection Prevention and Control Program, last revised August 2016 revealed: 1. The infection prevention and control program is a facility-wide effort involving all disciplines and individuals and is an integral part of the quality assurance and performance improvement program. 2. The elements of the infection prevention and control program consist of coordination/oversight, policies/procedures, surveillance, data analysis, antibiotic stewardship, outbreak management, prevention of infection, and employee health and safety. Record review of facility policy titled Handwashing/Hand Hygiene, last revised on December 2023 revealed: Policy Statement This facility considers hand hygiene the primary means to prevent the spread of infections . 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: . . j. After contact with blood or bodily fluids. .h. Before moving from a contaminated body site to a clean body site during resident care; .m. After removing gloves. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676318 If continuation sheet Page 4 of 4