Health inspection·May 20, 2025

F 0550 was at the dining area. The bag contained a yellow fluid and did not have a cover to provide privacy. Level of Harm - Minimal harm or potential for actual harm During a follow-up observation and interview on 05/19/2025 at 09:22 a.m., revealed Resident #254 was in his electric wheelchair, with the room door open. Resident #254's condom catheter bag was on the left side of the electric wheelchair, facing the door. The condom catheter drainage bag was visible through the open door and not in a privacy bag. Resident #254 stated the staff provided care every day, but without privacy bag in place since he had the condom catheter a month ago. Residents Affected - Few During an interview with RN D on 05/20/2025 at 10:45 a.m., RN D stated she was the charge nurse and condom catheters should be covered with privacy bags. RN D said she was not aware Resident #254 did not have a privacy cover over his condom catheter bag. She stated the nurses and CNAs were responsible for ensuring the privacy covers were on the bags. RN D stated the covers were important to maintain privacy and dignity. During an interview with CNA E on 05/20/2025 at 11:06 a.m., CNA E stated the nurses and CNAs were responsible for placing the privacy covers over the bags and stated she did inform the charge nurse each time about the privacy covers. CNA E stated the privacy bags were important because without such Resident's dignity were lowered and stated she empty the condom catheter bag whenever it was full. During an interview with the DON on 05/20/2025 at 01:24 p.m., the DON stated the charge nurse and CNAs were responsible for making sure catheter bags had privacy covers. The DON stated all residents should have privacy covers on the condom catheter, and it was important for the resident's dignity and their right to privacy. During an interview with the ADM on 05/20/2025 at 02:01 p.m., the ADM stated the condom catheter bags should be covered due to dignity issues, Residents would not be comfortable and could cause embarrassment. The ADM stated CNAs were responsible for placing the privacy covers. Record review of the facility's Policy titled, Resident Rights (Revised October 2022), stated in part, that a resident has right to a dignified existence; to be treated with respect, kindness, and dignity; exercise his or her rights as a resident of the facility and as a resident or citizen of the United States; the right to privacy and confidentiality. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676318 If continuation sheet Page 2 of 26 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676318 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/20/2025 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 0558 Reasonably accommodate the needs and preferences of each resident. 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 ensure the resident's had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences, except when to do so would endanger the health or safety of the resident or other residents, for 14 of 24 residents (Resident #12, Resident #31 and 12 confidential Residents), reviewed for resident rights. Residents Affected - Some The facility failed to ensure staff performed rounds every two hours on the night shift. 12 of 12 residents who attended Resident Council stated CNAs do not perform rounds every 2 hours at night. Residents stated they have not had access to water due to the lack of rounding. Residents stated they have not had assistance with adjusting the temperature of their rooms and have not had assistance with turning due to the lack of rounding. The facility failed to ensure Resident #12 and #31 were rounded by night shif staff. This failure could place residents including at risk of not receiving needed care and services in a timely manner. The findings were: Record review of Resident #12's face sheet revealed a [AGE] year-old female, who was admitted to the facility on [DATE]. Resident #12 had diagnoses which included: Pain, Cerebral palsy (a group of disorders that affect a person's ability to move and maintain balance and posture), Acute and chronic respiratory failure with hypoxia (failure of the respiratory system to adequately supply the body with oxygen, resulting to low oxygen levels in the tissues), Constipation (problem with passing stool), Muscle weakness (a decrease in the strength and ability of muscles to perform their normal functions, often resulting in a reduced ability to move the body), Overactive bladder (a sudden, strong urge to urinate), Anxiety disorder (group of mental health conditions categorized by excessive and persistent fear or worry that significantly impacts daily life), GERD [a condition where stomach acid flows back up into the esophagus (the tube connecting the stomach and mouth), causing heartburn and other symptoms]. Record Review of Resident #12's quarterly MDS dated [DATE], revealed a BIMS score of 14 which indicated the resident was cognitively able to make choices and decisions for herself. Record review of Resident #12's undated Care plan revealed resident at risk for complications related to GERD and interventions required assistance through monitoring for coughing/choking while lying down. Record review of Resident #31's face sheet revealed a [AGE] year-old female, who was admitted to the facility on [DATE]. Resident #31 had diagnoses which included: Abnormal posture, Pressure ulcer stage 2 (Partial-thickness skin loss of both the outermost and inner parts), Pruritus (itching), Acute Nasopharyngitis (common cold), Hypertension (condition where the blood pressure in the arteries is persistently elevated), Muscle weakness (a decrease in the strength and ability of muscles to perform their normal functions, often resulting in a reduced ability to move the body), Anxiety disorder (group of mental health conditions categorized by excessive and persistent fear or worry that (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676318 If continuation sheet Page 3 of 26 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676318 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/20/2025 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 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some significantly impacts daily life), GERD, Difficulty in walking, Hemiplegia and Hemiparesis (are both conditions that can result from a cerebral infarction (stroke), affecting movement and function on one side of the body). Record Review of Resident #31's quarterly MDS dated [DATE], revealed a BIMS score of 15 which indicated the resident was cognitively able to make choices and decisions for herself. Record review of Resident #31's undated Care plan revealed she has a behavior problem related to history of intentional self-harm and intervention required caregivers to provide opportunity for positive interaction, attention. Stop and talk with her as passing by. Observation and interview on 5/18/25 at 12:25p.m., Resident #31seen covered with the blanket on her bed, stated staff (CNAs) do not round at night every 2 hours. They did not come back upon request. Resident #31 requested, One thing I can say is, you need to come here at night unannounced. Resident #31 stated the DON was notified. Observation and interview on 5/18/25 at 01:23p.m., Resident #12 seen on her electric wheelchair, stated she do not get needed assistance at night. Resident #12 stated it takes time for them to come take me over to my bed, it happens every night and the night shift staff (CNAs) did not round every 2 hours and been going on for couple of months especially Monday's and weekends. She stated the matter was discussed at Resident council meeting before she rolled out of the room on her electric wheelchair. Interview on 5/20/25 at 10:45a.m., RN D stated not rounding every 2 hours would lead to terrible outcomes for residents, especially those in bed all the time. RN D stated she had complaints from the residents, that CNAs did not perform rounds every 2 hours at night, and she monitors staff, if she had to. Interview on 5/20/25 at 11:46a.m., CNA E stated most of the residents needed incontinent care and rounds should be performed every 2 hours to prevent sores, skin tears and infections. CNA E stated that at night, the staff do fall asleep. She said, we had in-services/meetings, but nothing changed. Interviews during Resident Council on, 05/19/2025 at 11:00am, revealed 12 confidential residents, stated the CNAs did not round every 2 hours at night. The Residents stated the lack of rounds being performed every 2 hours made them feel ignored, not a priority, and their needs were not being met. The Residents stated they informed the DON of the issue with rounding on the night shift when she attended Resident Council on 12/23/2024; however, the night CNAs continued to disregard rounding every 2 hours. The Residents stated the DON informed them during the council meeting she would complete an in-service with the night CNAs regarding the importance of rounding every 2 hours. In an interview on 5/20/2025 at 11:40am, the DON stated CNAs should be performing rounds at a minimum of every 2 hours. The DON stated rounds should be completed a minimum of every 2 hours during all shifts. The DON stated rounds were performed every 2 hours to ensure consistency and appropriate care for every Resident. The DON stated the potential negative outcome for rounds not being completed every 2 hours was residents not having their needs met and lack of care. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676318 If continuation sheet Page 4 of 26 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676318 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/20/2025 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 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some In an interview on 5/20/2025 at 11:00am, the Activities Director stated CNAs not rounding every two hours was discussed in Resident Council every month for the past 6 months. The AD stated the Residents stated the evening/night nurses did not perform rounds every 2 hours; the CNAs were difficult to find at night and were often on their cell phones at the nurses' station or in the hallways speaking loudly and using inappropriate language while talking on their cell phones. The AD stated she had written and submitted grievances in regards to the absence of rounding at night and had included the complaint on her Resident Council notes. The AD stated she had also mentioned the complaint several times in morning staff meetings. In an interview on 5/20/2025 at 1:14pm, the ADM stated CNAs should perform rounds every 2 hours on all shifts. The ADM stated rounds were completed to ensure ADLs and to provide incontinent care. The ADM stated rounds every 2 hours were also completed to prevent skin breakdowns and ensure ADLs were met. The ADM stated the potential negative outcome for rounds not being completed every 2 hours was skin breakdown, emergencies, and falls. Record review of the facility's undated policy for ADL indicated Certified Nurse Aides (CNAs) must attend to the needs of all residents and provide the care that residents need at all times. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676318 If continuation sheet Page 5 of 26 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676318 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/20/2025 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 0565 Honor the resident's right to organize and participate in resident/family groups in the facility. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to provide a private meeting space for residents' monthly council meetings for 12 of 24 confidential residents who were reviewed for resident council. Residents Affected - Some The facility failed to provide a private space for resident council meetings. This failure could place residents at risk of not being able to voice concerns due to a lack of privacy. Findings include: Observation of dining room on 5/19/25 at 11:00AM revealed multiple staff in and out of the dining room, multiple residents in and out of the dining room who were not attending Resident Council, and several side conversations in the dining room due to Residents visiting family members in the dining room. Interview on 5/20/24 at 10:30AM, the Activities Director stated Resident Council was held in the dining room for the entirety of her employment with the facility, 18months. The AD stated it was not a private space; her sign posted during resident council asked staff not to enter the dining room was not respected. The AD stated there were no doors to close for the dining room. She stated there was no barriers to add doors to the dining room. The AD stated the potential negative outcome for no privacy for Resident Council was Residents may not speak freely in Resident Council due to staff overhearing their conversations. Interview on 5/20/25 at 11:00AM with 12 alert and orientated residents who attended resident council stated resident council met in the dining room. They stated staff came in and out with no privacy, and they filtered what they said due to staff presence. Residents stated the AD placed a large sign at the entrance to the dining room asking staff not to enter the dining room due to resident council being held; however, staff did not respect the sign. Interview on 5/20/25 at 1:40AM the Administrator stated that she was aware the facility did not have a private area for Resident Council to meet. She stated resident council was held in the dining room and they posted signs asking staff not to enter the dining room; however, the staff did not respect the sign. She stated she had not thought of privacy screens or meeting in the courtyard. She stated with weather permitting she would like to have meetings outside but had not thought of it. She stated the potential negative outcome of not having a private setting for Resident Council was the Residents may not feel comfortable sharing their needs, thoughts, feelings, and complaints. Record review of Resident Council Minutes dated 11/17/24 revealed Resident Council was held in the dining room with 5 residents present. Record review of Resident Council Minutes dated 12/23/24 revealed Resident Council was held in the dining room with 6 residents present. Record review of Resident Council Minutes dated 1/23/25 revealed Resident Council was held in the dining room with 6 residents present. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676318 If continuation sheet Page 6 of 26 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676318 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/20/2025 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 0565 Level of Harm - Minimal harm or potential for actual harm Record review of Resident Council Minutes dated 2/18/25 revealed Resident Council was held in the dining room with 6 residents present. Record review of Resident Council Minutes dated 3/27/25 revealed Resident Council was held in the dining room with 6 residents present. Residents Affected - Some Record review of Resident Council Minutes dated 4/24/25 revealed Resident Council was held in the dining room with 6 residents present. Record Review of the facility's Resident Council Policy Revised April 2017, revealed the following: Policy Statement The facility supports residents' rights to organize and participate in the Resident Council. Policy Interpretation and Implementation 1. The purpose of the Resident Council is to provide a forum for: a. Residents, families, and resident representatives to have input in the operation of the facility. b. Discussion of concerns and suggestions for improvement. c. Consensus building and communication between residents and facility staff; and d. Disseminating information and gathering feedback from interested residents. 2. All residents are eligible to participate in the Resident Council. The facility staff encourages residents who are willing to participate. 3. The council is encouraged to elect a President or Chair to act as a liaison and facilitate communication between the council and a designated staff person who has been approved by the Council. Staff, visitors, or other guests may attend Resident Council meetings if invited by the respective resident group. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676318 If continuation sheet Page 7 of 26 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676318 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/20/2025 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 0565 4. Level of Harm - Minimal harm or potential for actual harm Council meetings are scheduled monthly or more frequently if requested by residents. The date, time and location of the meetings are noted in the Activities calendar. Residents Affected - Some 5. A Resident Council Response Form will be utilized to track issues and their resolution. The facility department related to any issues will be responsible for addressing the item(s) of concern. 6. The Quality Assurance and Performance Improvement (QAPI) Committee will review information and feedback from the Resident Council as part of their quality review. Issues documented on council response forms may be referred to the QAPI Committee, if applicable (i.e., the issue is of serious nature or if there is a pattern, etc.). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676318 If continuation sheet Page 8 of 26 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676318 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/20/2025 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 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Minimal harm or potential for actual harm Based on interviews and record review, the facility failed to ensure the resident had a right to personal privacy and confidentiality of his or her personal and medical records which included accommodations, medical treatment, written and telephone communications, personal care, visits, and meetings of family and resident groups for 12 of 12 confidential residents. Residents Affected - Some The facility failed to ensure staff were not on their personal cell phones while providing care, which included peri-care to residents. This failure could place residents at risk of not having their personal privacy maintained during medical treatment. Findings include: Interview with 12 confidential residents stated the use of cell phones by CNAs while performing care made them feel ignored, not a priority, embarrassed, concerned the CNA could make a mistake due to distraction by the cell phone conversation, and, most of all, their privacy was violated. Interview with 12 confidential residents stated the use of cell phones by CNAs occurred on every shift; however, primarily occurred during the night shift. Interviewed with 12 confidental residents stated when they confronted CNAs about the cell phone usage while care was being performed the CNAs ignored them, the CNAs stated it was their right to utilize their cell phone, and CNAs informed the residents the use of the cell phone during care was none of the Residents' business. Interviewed with 12 confidental residents stated they did not know the names of the CNAs who utilized their cell phones while performing care. The residents stated cell phone usage of the CNAs while performing care happened in the facility so often, they would say every CNA in the facility utilized their cell phone while performing care. During an interview on 5/20/25 at 11:40am with the DON, she stated staff should provide privacy any time they were performing resident care. She stated cell phones should only be used in the break room and outside of the facility. The DON stated cell phones should never be used in resident rooms, in the hallways of the facility, or at the nurses' stations. The DON stated she and her ADON oversaw training staff on cell phone usage in the facility. The DON stated there was continuous education provided to staff concerning cell phone usage via team meetings and in-service trainings. She stated the DON and ADON monitored staff by observing and addressing grievances and complaints regarding cell phone usage while performing care. She stated there was no reason privacy for residents should not be provided. She stated the potential negative outcome was resident dignity, HIPPA violations, and disrespect for residents. She stated not providing privacy could also have a psychological effect like embarrassment for the resident. During an interview on 05/20/25 at 1:14pm, the ADM stated residents should be provided privacy during resident care. She stated all staff were trained on privacy, dignity, and cell phone usage during orientation and through continuous education by the DON and the ADON. She stated staff were monitored by making rounds and correcting any issues found, and by addressing complaints and grievances concerning cell phone usage by staff while performing resident care. She stated cell phones should (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676318 If continuation sheet Page 9 of 26 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676318 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/20/2025 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 0583 Level of Harm - Minimal harm or potential for actual harm never be used in resident rooms, hallways, or nurses' stations. She stated the potential negative outcome could be mess ups, not paying attention to residents' needs, and dignity. Record review of the undated facility policy titled Confidentiality of Information and Personal Privacy revealed the following: Residents Affected - Some Policy Statement - Our facility will protect and safeguard resident confidentiality and personal privacy. Policy Interpretation and Implementation 2. The facility will strive to protect the resident's privacy regarding his or her: a. accommodations; b. medical treatment; c. written and telephone communications; d. personal care; e. visits; and f. family and resident group meetings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676318 If continuation sheet Page 10 of 26 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676318 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/20/2025 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 observation, interview, and record review, the facility failed to provide information to resident's and their representatives on their rights related to filing grievances or concerns for 12 of 24 confidential residents. The facility failed to ensure 12 of 24 confidential residents were provided, through postings in prominent locations; the Grievance Procedure, were provided access to the Grievance form, were provided information regarding who the facility grievance officer was, their contact information, and how to file an anonymous grievance. This failure could place the residents at risk of unresolved grievances and decreased quality of life. Findings include: Interviews during Resident Council on, 05/19/2025 at 11:00am, 12 confidential residents, stated they did not know they could file a Grievance anonymously and they had not observed a posting of the Grievance procedure in prominent locations. Residents attending Resident Council stated there was no system for submitting a Grievance anonymously. The 12 residents in attendance had all been Residents of the facility for 6 plus months. Observed prominent postings on 5/19/2025 at 1:45pm; Grievance forms were available on the wall outside of the Social Worker's office, there were no instructions included for completing the Grievance form; there was no system indicated for submitting a Grievance anonymously. Interview with the ADM on 5/20/2025 at 1:14pm; the ADM stated the SW was the Grievance Officer for the facility. The ADM stated the SW was responsible for the review of Grievances and assign them to department heads. The ADM stated there was no system for submitting a Grievance form anonymously. Grievance forms are available for the Residents outside the SW's office, the Grievance forms were submitted to the SW by the Resident or their family member. The ADM stated the facility should resolve grievances as soon as possible once they were submitted. The ADM stated the procedure for submission of a Grievance was the SW assigned the grievance to the appropriate department, that department addressed the grievance, resolved the grievance, and explained the resolution to the complainant. The resolution was documented on the original Grievance form. The ADM stated completed Grievances were kept in a notebook. The ADM stated she monitored the Grievance process for success by following up with the staff member assigned to resolve the Grievance, the ADM stated she would also meet with the complainant to ensure they were satisfied with the resolution. The ADM stated she was responsible for ensuring staff were trained on the Grievance process. The ADM stated the potential negative outcome for Resident's not having a system to file Grievances anonymously was the Resident may not file a Grievance and the issue will not be resolved. Record Review of the Grievance Policy revised January 2017. Policy Statement Residents, family, and resident representatives have the right to voice or file grievances without discrimination or reprisal in any form, and without fear of discrimination or reprisal. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676318 If continuation sheet Page 11 of 26 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676318 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/20/2025 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 You are requested to follow the procedures outlined below when filing grievance or complaint: Level of Harm - Minimal harm or potential for actual harm 1. Obtain a Resident Grievance/Complaint Form from the nurses' station or from the business office. Residents Affected - Some 2. Answer all questions on the form, as applicable. Be sure that all information is accurate. 3. You may sign the form, or file anonymously. 4. Give the completed form to the Administrator or his/her designee. If the Administrator is not available, you may leave the form with the supervisor on duty, or you may submit it anonymously to the appropriate person you wish to handle the grievance or complaint. 5. Within five (5) working days of the date you filed the grievance; you will be notified of the results of the investigation. (Note: Complaints of abuse, harassment, or mistreatment will be immediately investigated, and you may request a report of the findings, recommendations, and/or corrective action taken within five (5) working days of the filing of the report.) 6. Should you disagree with the findings, recommendations, or actions taken, you may meet with the Administrator, or you may file a complaint with any of the advocacy agencies listed on the residents' bulletin board. 7. It is the policy of this facility to assist you in filing a grievance or complaint. Should you feel that our staff has not assisted you in this matter, or you feel that you are being discriminated against for taking such steps, you are encouraged to report such incidents to the Administrator at once. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676318 If continuation sheet Page 12 of 26 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676318 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/20/2025 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that its medication error rate was not 5 percent or greater. The facility had a medication error rate of 8.0% based on 2 errors out of 25 opportunities, which involved 2 of 3 residents (Resident #8 and Resident #304) reviewed for medication administration. Residents Affected - Few 1. MA A failed to properly verify and dispense Eliquis (blood thinner) according to physician's order with a start date of 12/04/24 for Resident #304, when on 05/19/25 MA A dispensed and was going to administer Resident #304 with one 2.5 MG tablet instead of two 2.5 MG tablets until surveyor intervention. 2. MA A failed to administer Vitamin A (supplement) according to physician's order dated 05/13/25 to Resident #8, when on 05/19/25 MA A was unable to administer the Vitamin A supplement to Resident #8, resulting in a missed dose. These failures could place residents at risk of incomplete therapeutic outcomes, increased negative side effects, and decline in health. Findings included: 1. Record review of Resident #304's face sheet dated 05/20/25 revealed a [AGE] year-old female with an original admission date of 05/09/19. Resident #304 had diagnoses which included: cerebral infarction (stroke), peripheral vascular disease (reduced blood flow to limbs), hypertension (high blood pressure), and atherosclerotic heart disease (damage of the major blood vessels). Record review of Resident #304's Quarterly MDS, dated [DATE], revealed a BIMS score of 11, which indicated the resident was moderately cognitively impaired. Record review of Resident #304's current physician's orders revealed an order with a start date of 12/04/24 for Eliquis Oral Tablet 2.5 MG, give 5 MG by mouth two times a day. During a medication administration observation on 05/19/25 at 9:03 AM for Resident #304, MA A dispensed one Eliquis 2.5 MG tablet into a medication cup. Observation of the medication card and order for Resident #304's medication - Eliquis 2.5 MG showed: give two tablets by mouth two times daily. MA A picked up the medication cup and entered the resident's room to administer the medication. After surveyor intervention, MA A returned to the cart, verified the order, and dispensed an additional Eliquis 2.5 MG tablet into the medication cup and administered the medication to Resident #304. During an interview on 05/19/25 at 9:09 AM, MA A stated she failed to verify and dispense the correct dose of Eliquis medication for Resident #304. She stated she failed to read the order correctly and only dispensed one tablet instead of two, which would have resulted in Resident #304 being underdosed. MA A stated she had been trained on accuracy of medication administration through in-services and skills checks conducted by nursing administration. She stated a potential negative outcome for failure to administer medications according to physician's orders would be the resident getting sick. 2. Record review of Resident #8's face sheet dated 05/20/25 revealed an [AGE] year-old female with an original admission date of 12/14/21. Resident #8 had diagnoses which included: unspecified muscle (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676318 If continuation sheet Page 13 of 26 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676318 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/20/2025 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 0759 Level of Harm - Minimal harm or potential for actual harm disorder, gastric ulcer (a break in the lining of the stomach), glaucoma (condition causing gradual loss of sight), kidney failure, and hypertension (high blood pressure). Record review of Resident #8's admission MDS, dated [DATE], revealed a BIMS score of 12, which indicated the resident was moderately cognitively impaired. Residents Affected - Few Record review of Resident #8's current physician's orders revealed an order with a start date of 05/13/25, for Vitamin A Oral Capsule 3 MG (10000UT), give 1 capsule by mouth one time a day for supplement. During a medication administration observation on 05/19/25 at AM 9:46 AM for Resident #8, MA A verified the physician's order for Vitamin A and determined the medication was not available on the medication cart. MA A stated a note in the MAR indicated the medication was on order. MA A checked the medication room and determined the medication was not available in the facility. MA A was unable to administer the medication to Resident #8, resulting in a missed dose. During an interview on 05/19/25 at 9:53 AM, MA A stated she was not able to administer Resident #8's Vitamin A medication according to physician's orders due to the medication not being available in the facility. She stated the medication had been ordered, according to the notation in the MAR. She stated she did not know why the medication was unavailable and her protocol was to let the DON know so the medication could be obtained. MA A stated a potential negative outcome for failure to administer medications according to physician's orders would be the resident getting sick. During an interview on 05/20/25 at 10:27 AM, the ADM stated medications should be given according to physician's orders. She stated the DON was responsible to assure staff were trained on accuracy of medication administration and the timely acquisition of medications. She stated the system to monitor for proper medication administration was periodic skills checks conducted by nursing administration and medication pass observations conducted by the Pharmacy Consultant. The ADM stated her expectation of staff was to follow the five rights of medication administration. She stated a potential negative outcome for failure to administer medication according to physician's orders would be the resident missing a dose of medication. During an interview on 05/20/25 at 10:46 AM, the DON stated she was made aware that there were medication errors made during medication pass observation. She stated staff were in-serviced on verification of physician's orders and timely ordering of medications. The DON stated staff were monitored for accuracy of medication administration through competency checks and periodic medication pass observations conducted by nursing administration. She stated a potential negative outcome for failure to administer medications according to physician's orders would be complications or harm to a resident's health. Record review of the facility's policy titled, Administering Oral Medications, Revised October 2010, revealed: Purpose The purpose of this procedure is to provide guidelines for the safe administration of oral medications. . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676318 If continuation sheet Page 14 of 26 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676318 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/20/2025 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 0759 Steps in the Procedure Level of Harm - Minimal harm or potential for actual harm . 3. Place the MAR within easy viewing distance. Residents Affected - Few . 6. Check the label on the mediation and confirm the medication name and dose with the MAR. . 8. Check the medication dose. Re-check to confirm the proper dose. 9. Prepare the correct dose of medication. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676318 If continuation sheet Page 15 of 26 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676318 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/20/2025 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 - Some 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 for 3 of 4 medication carts (medication cart for hall 200, medication cart for hall 100, and nurse's medication cart for hall 200), reviewed for medication storage. The facility failed on 05/19/25 to maintain proper medication storage after the following was found: 1. The medication cart for 200 hall contained 10.5 loose pills. 2. The medication cart for 100 hall contained 3 loose pills. 3. The nurse's medication cart for hall 200 contained 10 loose pills. This failure could place residents at risk of not receiving prescribed medications as ordered and place the facility at risk of drug diversions. The findings included: 1. On 05/19/25 at 9:03 AM an observation of the medication cart for 200 hall was conducted with MA A. Ten and one-half loose pills were found in the drawers of the medication cart. MA A placed the pills in a dispensing cup and took the cup to the DON for medication identification. The DON identified the medications as followed: -Rosuvastatin 10 mg - used to lower cholesterol (one pill) -Mirtazapine 15 mg - used to treat depression (one pill) -Lasix 20 mg - used to treat swelling (one pill) -Omeprazole 20 mg - used to treat indigestion (one pill) -Pantoprazole 40 mg - used to treat heartburn (one pill) -Sertraline hydrochloride 50 mg - used to treat depression (one pill) -Keppra 500 mg - used to treat seizures (one pill) -Methocarbamol 500 mg - used to treat muscle spasms (one pill) -Eliquis 2.5 mg - used to prevent blood clots (one pill) -Atorvastatin 10 mg - used to lower cholesterol (one pill) -Lasix - strength unknown - used to treat swelling (1/2 pill) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676318 If continuation sheet Page 16 of 26 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676318 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/20/2025 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 2. On 05/19/25 at 9:46 AM an observation of the medication cart for 100 hall was conducted with MA A. Three loose pills were found in the drawers of the medication cart. MA A placed the pills in a dispensing cup and took the cup to the DON for medication identification. The DON identified the medications as followed: Residents Affected - Some -Metoprolol 25 mg - used to treat high blood pressure (one pill) -Zofran 4 mg - used to prevent nausea and vomiting (one pill) -Amitriptyline - strength unknown - used to treat depression (one pill) During an interview on 05/19/25 at 9:51 AM, MA A stated there should not be loose pills on the medication cart. She stated she was not sure why there were loose pills on the medication carts for halls 100 and 200. She stated it was her responsibility to check the medication carts for loose pills. MA A stated the medication carts were periodically audited for loose medications by nursing administration and the Pharmacy Consultant. She stated a potential negative outcome of loose medications on the cart would be that a resident could miss a dose of medication. 3. On 05/19/25 at 10:15 AM an observation of the nurse's medication cart for 200 hall was conducted with RN C. Ten loose pills were found in the drawers of the medication cart. RN C placed the pills in a dispensing cup and took the cup to the DON for identification. The DON identified the medications as followed: -Famotidine - strength unknown - used to treat stomach ulcers (2 pills) -Ondansetron 4 mg -used to prevent nausea and vomiting (five pills) -Levothyroxine 100 mcg - used to treat low thyroid (one pill) -Clonidine 0.1 mg - used to treat high blood pressure (one pill) -Benzonatate 200 mg - used to treat cough (one pill) During an interview on 05/20/25 at 10:15 AM, RN C stated there should not be loose pills on the medication cart. She stated she did not know why there were loose medications on the cart. She stated the medication cards were very tight in the drawers and the pills sometimes get knocked loose from the blister packs. RN C stated it was the responsibility of the charge nurse to check the cart for loose medications. She stated the carts were audited periodically for proper medication storage by the Pharmacy Consultant and by nursing administration. RN C stated a potential negative outcome for loose pills on the medication cart would be the resident missing a dose of medication or the medication not being able to be reordered from the pharmacy. During an interview on 05/20/25 at 10:27 AM, the ADM stated she was not aware that there were loose medications on the medication carts for halls 100 and 200. She stated it was the responsibility of the charge nurse and medication aid to assure medications were properly stored on the medication carts. The ADM stated proper storage of medications on the carts was monitored through periodic cart audits conducted by nursing administration and the Pharmacy Consultant. She stated her expectation of staff for proper medication storage was to follow policy and routinely check carts for loose medications. The ADM stated a potential negative outcome for loose medications on the cart would be a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676318 If continuation sheet Page 17 of 26 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676318 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/20/2025 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 resident missing a medication. Level of Harm - Minimal harm or potential for actual harm During an interview on 05/20/25 at 10:46 AM, the DON stated there should not be loose medications on the medication carts. She stated the charge nurse or medication aid assigned to the cart was responsible to assure medications were stored properly. She stated staff were trained on proper medication storage and the medication carts were monitored through spot checks conducted by nursing administration. The DON stated the Pharmacy Consultant conducted cart audits approximately monthly to check for proper storage of medications. She stated a potential negative outcome for loose pills on the medication cart would be missed doses of medication for residents. Residents Affected - Some Record review of the facility's policy titled, Storage of Medications, Revised April 2019, revealed: Policy Statement The facility stores all drugs and biologicals in a safe, secure, and orderly manner. Policy Interpretation and Implementation . 2. Drugs and biologicals are stored in the packaging, containers or other dispensing systems in which they are received. 3. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676318 If continuation sheet Page 18 of 26 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676318 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/20/2025 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 0790 Provide routine and 24-hour emergency dental care for each resident. 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 assist residents in obtaining routine and 24-hour emergency dental care for 1 of 24 residents (Resident #8) reviewed for dental services. Residents Affected - Few The facility did not assist Resident #8, who had missing teeth, with a dental service consult. This failure could place residents at risk of oral complications, dental pain, and diminished quality of life. Findings included: Record review of Resident #8's face sheet showed a [AGE] year-old woman, who was admitted on [DATE]. Diagnoses included: Cerebral infarction (referred to as a stroke, means the death of brain muscle due to a reduced blood supply), Chronic obstructive pulmonary disease (a progressive lung disease that makes it hard to breathe), Constipation (problem with passing stool), Muscle weakness (a decrease in the strength and ability of muscles to perform their normal functions, often resulting in a reduced ability to move the body), Heart Failure (condition in which the heart does not pump blood as well as it should), Diabetes Mellitus (long term condition where body has trouble controlling blood sugar and using it for energy), Cognitive communication deficit (difficulty with any aspect of communication that is affected by disruption of intellectual processes like attention, memory). Record Review of Resident #8's quarterly MDS dated [DATE], revealed a BIMS score of 09 slightly cognitively impaired. Record review of Resident #8's Care plan showed resident has an ADL self-care performance deficit and personal hygiene requires No assistance. The care plan also reflected the resident had behaviors which included non-compliance with Lasix medication that treats fluid retention caused by Heart failure. Record Review of Resident #8's Oral Care showed she had tooth extractions without replacement since 02/13/2023. Interview and Observation on 5/18/25 at 01:23 p.m. with Resident #8 stated I asked them to fix my teeth though no pains, resident placed her hand over her mouth showing portions of tooth extraction with no replacement. Resident #8 raised her seven fingers which implied 7 months, when asked how long she has been waiting for approval for dental follow up. Observation of Resident #8's upper and lower gums had no artificial teeth (denture) on them. Interview on 5/19/25 at 11:31 a.m. with SW stated they were waiting for resident #8 dental approval from Cooperate or the ADM (No document seen/reviewed or provided). SW stated not sure how long the time process was for resident #8 to get the approval for her dentures. Interview on 5/20/25 at 10:45 a.m. with RN D stated she would immediately let the SW, Physician or NP (Nurse Practitioner) know if there were any dental issues. RN D stated delay in Resident #8 dental services would affect her dignity and lower her level of socialization. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676318 If continuation sheet Page 19 of 26 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676318 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/20/2025 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 0790 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 5/20/25 at 11:46 a.m. with CNA E stated if a resident had dental problems, she would let her nurse know and she had not done any dental care on Resident #8. Interview on 5/20/25 at 1:24 p.m. with DON stated the social worker made the dental appointments. Usually, if resident had painful teeth or something with their mouth, they would contact the Physician or NP immediately. Interview on 5/20/25 at 02:01 p.m. with ADM stated only records found was Resident #8's extractions and no other information regarding the referrals to the surgeon and the progress of her dental services till date. ADM stated facility had quarterly visit by the dentist. Then, a letter for dental approval was sent off to Resident #8' for the in-house dental services and she was not sure of the date the letter was sent. Record Review of facility policy Dental Services revised December 2016, under Policy stated, Routine and emergency dental services are available to meet the resident's oral health services in accordance with the resident's assessment and plan of care. Record Review of facility policy Routine Dental Care revised April 2007, under Policy stated, Each resident will receive routine dental care. Record Review of facility policy Quality of Life - Dignity revised October 2022, stated Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676318 If continuation sheet Page 20 of 26 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676318 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/20/2025 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 - Some 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, in that: The facility failed on 05/18/2025 to seal and date food stored in refrigerator. The facility failed on 05/18/2025 to ensure kitchen equipment was clean. These failures could place residents at risk for food contamination and foodborne illness. The findings included: The following observations were made on 05/18/2025 at beginning 9:45 AM during initial tour of the kitchen: Observation of the following stored in dry storage room: 4 dessert cake pans with cake on rolling cart not covered. Large container of cornmeal with lid open. Observation of the following stored in the refrigerator: Bag of green beans with no date. Bag of corn with no date. Bag of spaghetti with meat sauce no date. Metal bowl of cooked beans with no date. Metal bowl of tartar sauce cups with no date. Observation of the Ice machine in dining room with cream color buildup in drip pan and on top beside ice spout. Observation of the Steam table with food residue on top and splatters on glass barrier. During a follow up visit and observation on 05/18/2025 at 2:00 PM was a Bowl of cheese slices not covered stored in the refrigerator. During an interview on 05/20/25 at 9:10 AM the DM, who stated all items in the fridge and in the storage, room are to be labelled with date and sealed. She stated the dietary aides are responsible to monitor the fridge and dry storage rooms and she follows up daily. She stated anyone who puts food in the fridge for storage was responsible for dating and making sure it was sealed. The DM stated all staff have been trained and safe serve certificates are all current for the kitchen staff. DM (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676318 If continuation sheet Page 21 of 26 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676318 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/20/2025 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 - Some stated the potential negative outcome could be bacteria in food and be harmful to resident. She stated it was maintenance responsibility to clean the ice machine in the dining room. DM stated the kitchen staff do not clean the ice machine. During an interview on 05/20/25 at 10:56 AM with ADM, she stated DM and staff were responsible for dating items in fridge and dry storage room and making sure all items are sealed. All staff have been trained on food storage in the refrigerator and dry storage . The facility policy was to have all items sealed and dated. She stated the possible negative outcome could be serving expired food to residents. During an interview on 05/20/25 at 12:00 PM with maintenance supervisor who stated he was not sure who cleans the outside of the ice machine. He stated he cleans the inside of the machine (filter and compressor) every 3 months. He stated, I guess everything is my responsibility. He stated he had not been trained on cleaning the outside of the machine. He stated it should be cleaned daily. During an interview on 05/20/25 at 12:10 PM with the ADM, she stated she was not sure who was responsible for cleaning the outside of ice machine. She stated she has reached out to corporate for clarification. During an interview on 05/20/25 at 12:33 PM with the maintenance supervisor, he stated I spoke with my supervisor at corporate and he stated the kitchen was responsible for daily cleaning of the outside of ice machine. Record review of the facility's policy, titled Food Receiving and Storage revised date 2014, reflected the following: Policy Statement- Foods shall be received and stored in a manner that complies with safe food handling practices. Policy Interpretation and Implementation . 7. All foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date) . Record review of the facility's policy, titled Sanitization revised date 2014, reflected the following: Policy Statement - The food service area shall be maintained in a clean and sanitary manner. Policy Interpretation and Implementation . 12. Ice machines and ice storage containers will be drained, cleaned, and sanitized per manufacturer's instructions and facility policy . Record review of the FDA Food Code 2022 reflected the federally established standards. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676318 If continuation sheet Page 22 of 26 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676318 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/20/2025 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 maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 24 residents (Resident #73, #97 and #304) reviewed for infection control. Residents Affected - Some 1. The facility failed on 05/18/25 to implement and maintain Enhanced Barrier Precautions physicians ordered on 04/16/25 when LVN B failed to wear proper PPE when providing wound care for Resident #97. 2. The facility failed on 05/19/25 to ensure proper medication administration infection control procedures were used when MA A failed to sanitize her hands before or after medication administration for Resident #73 and #304. These failures could place residents at risk for the spread of infection and cross contamination. Findings included: 1. Record review of Resident #97's face sheet dated 05/18/25 revealed a [AGE] year-old female with an admission date of 04/14/25. Resident #97 had diagnoses which included: pancreatitis (inflammation of the pancreas), dysphagia (difficulty swallowing), cognitive communication deficit (difficulty with communication), and cerebral infarction (stroke). Record review of Resident #97's admission MDS, dated [DATE], revealed a BIMS score of 14, which indicated the resident was mildly cognitively impaired. Record review of Resident #97's current physician's orders revealed an order with a start date of 04/16/25 for Nursing Intervention: Implement and maintain Enhanced Barrier Precautions when performing high contact care activities every shift. Further review revealed an order with a start date of 04/24/25 for daily wound care to the right lower leg and an order with a start date of 05/07/25 for daily wound care to left lower leg. During an observation of wound care on 05/18/25 at 11:35 AM for Resident #97, LVN B gathered supplies and entered the resident's room. Resident #97 was on Enhanced Barrier Precautions, per signage on the outside of the door. A PPE cart was observed at the entrance to Resident #97's room. LVN B washed her hands, applied gloves, and performed wound care on the right and left lower leg wounds, according to physician's orders. Following the procedure, LVN B removed her gloves, sanitized her hands and exited the room. LVN B failed to put on required PPE (gown) prior to performing wound care for Resident #97. During an interview on 05/18/25 at 11:40 AM, LVN B stated she did not put on a gown prior to performing wound care for Resident #97 because she did not remember the gown until she had already started the wound care procedure and it was too late at that point. She stated a gown should always be worn when performing wound care on a resident who was on EBP. LVN B stated she was trained on EBP through in-services conducted by the DON. She stated a potential negative outcome for failure to wear proper PPE during wound care for a resident on EBP would be wound infections from outside germs. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676318 If continuation sheet Page 23 of 26 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676318 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/20/2025 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 2. During an observation of medication pass on 05/19/25 at 9:36 AM, MA A prepared medications for Resident #73 and administered her medications. MA A did not sanitize her hands before or after medication administration. During an observation of medication pass on 05/19/25 at 9:46 AM, MA A prepared medications for Resident #304 and administered her medications. MA A did not sanitize her hands before or after medication administration. During an interview on 05/19/25 at 10:08 AM, MA A stated she did not sanitize her hands before or after administering medications to Resident #73 and Resident #304 because she changed to a different medication cart and forgot to set her sanitizer out on top of the cart. She stated hand hygiene should always be performed before and after handling and administering medications. MA A stated she was trained on hand hygiene during medication pass through in-services conducted by the ADON and through monthly medication administration skills checks. She stated a potential negative outcome for failure to sanitize hands before and after medication administration was spreading germs. During interview on 05/20/25 at 10:27 AM, the ADM stated nursing administration was responsible for training staff on proper hand hygiene and Enhanced Barrier Precautions. She stated her expectation of staff regarding hand hygiene and EBP was that they always follow policy for hand sanitizing during medication administration and always wear proper PPE when performing direct care on a resident on EBP. The ADM stated a potential negative outcome of failure to properly sanitize hands during medication administration and observe the rules of EBP would be the spread of infection. During an interview on 05/20/25 at 10:46 AM, the DON stated she and the ADON's were responsible for training staff on proper hand hygiene during medication administration and Enhanced Barrier Precautions. The DON stated proper PPE during wound care should include a gown and gloves. She stated hand hygiene should be performed before and after medication administration for each resident. The DON stated staff are trained on hand hygiene and EBP through competencies and in-services conducted monthly and as needed. She stated the facility planned to incorporate computer-based training for staff in the next month. The DON stated a potential negative outcome of failure to properly sanitize hands and observe the rules of EBP would be the spread of infection. Record review of the facility's polity titled, Implementation of Standard Transmission-Based Precautions, Dated March 2024, revealed: Policy Statement Infection control measures are implemented in attempts to prevent the spread of communicable diseases. . Policy Implementation . 3. Enhanced Barrier Precautions (EBP) - Expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDRO to staff hands and clothing. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676318 If continuation sheet Page 24 of 26 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676318 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/20/2025 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 I. Examples of Enhanced-Based Precaution residents: Residents Affected - Some -Wounds - includes chronic wounds, but are not limited to pressure ulcers, diabetic ulcers, unhealed surgical wounds and venous stasis ulcers; II. Enhanced-Based Precautions are indicated during: -Wound care; any skin opening requiring dressing. Record review of the facility's policy titled, Administering Oral Medications, Revised October 2010, revealed: Purpose The purpose of this procedure is to provide guidelines for the safe administration of oral medications. . Steps in the Procedure 1. Wash your hands . 21. Remain with the resident until all medications have been taken. . 23. Perform hand antisepsis. Record review of the facility's policy titled, Handwashing/Hand Hygiene, Revised December 2023, revealed: Policy Statement This facility considers hand hygiene the primary means to prevent the spread of infections. Policy Interpretation and Implementation . 2. All personnel shall follow the hand washing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676318 If continuation sheet Page 25 of 26 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676318 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/20/2025 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 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: Level of Harm - Minimal harm or potential for actual harm . Residents Affected - Some b. Before and after direct contact with residents; c. Before preparing or handling medications; FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676318 If continuation sheet Page 26 of 26