Health inspection·March 6, 2025

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Observation and interview on 03/04/2025 at 10:36 a.m. revealed Resident #19 lying in bed. He said the staff do not check on him very often, and do not answer call lights promptly. Observation revealed the call light activator (pressure-type) switch was placed on the over bed table, out of the resident's reach. The Surveyor activated the call light at that time (10:36 a.m.). Observation on 03/04/2025 at 10:43 a.m. revealed RN L enter Resident #19's room. RN L exited the room at 10:47 a.m. The call light remained on. Observation on 03/04/2025 at 11:02 a.m. revealed CNA K entered the day room area across from Resident #19's room. The call light in the hallway was on and visible. CNA K put lotion or hand sanitizer on his hands, got a drink of water, and left the area, walking past Resident #19's room. Observation and interview on 03/04/2025 at 11:08 a.m. revealed Resident #19 was in the same position. He said RN L adjusted the television and left. He said he told RN L that he needed to be cleaned up. Resident #19 said He told me he would get someone and he just left. Observation on 03/04/2025 at 11:11 a.m. revealed RN L walk to the day room area across from Resident #19's room and looked into the room. Resident #19's call light was still on and visible. RN L left the area. Observation on 03/04/2025 at 11:15 a.m. revealed a female staff entered Resident #19's room. She exited the room. Observation at that time revealed the call light was off. Observation on 03/04/2025 at 11:30 a.m. revealed the Maintenance Director entered Resident #19's room. The Surveyor was in the day room and heard the resident say something but could not hear clearly enough to understand. The Maintenance Director said I'll get somebody and left the room. Observation on 03/04/2025 at 11:38 a.m. revealed LVN T entered Resident #19's room briefly and exited. Observation on 03/04/25 at 11:42 a.m. revealed CNA K enter the day room across from Resident #19's room, drank some water, and left the area. Observation on 03/04/2025 at 11:44 a.m. revealed the Speech Therapist enter Resident #19's room. Observation on 03/04/2025 at 11:48 a.m. revealed LVN T propelled Resident #19's roommate into the room. In an interview on 03/04/2025 at 12:00 p.m. LVN T said the first time she checked on Resident #19 (11:38 a.m.) she was seeing if he needed to be repositioned. She said the second time she went in (11:48 a.m.) Resident #19 said he would wait until the Speech Therapist left. Observation and interview on 03/04/2025 at 12:02 p.m. revealed RN L was at the nurses' station. RN (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676371 If continuation sheet Page 2 of 5 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 676371 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Quail Valley Post-Acute Healthcare 3640 Hampton Dr Missouri City, TX 77459 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few L said when he went in to Resident #19's room the resident said he needed the television fixed. RN L said Resident #19 also said he needed to be changed. RN L said he went to tell the CNA . Observation at that time revealed RN L approached CNA F in the hallway. The Surveyor could not hear what RN L said to CNA F, but CNA F responded, I'll change him this afternoon. At that time the Surveyor asked RN L what a reasonable time frame was for a resident to be changed after he requested it. RN L said Reasonable is thirty minutes. Maximum one hour. He said he had told CNA K earlier. In an interview on 03/04/2025 at 12:06 p.m., CNA F said she had checked on Resident #19 when she started her shift at 6:00 a.m. She said she asked him if he needed to be changed then, and he said not before breakfast. She said she had just gone back into the room, but the Speech Therapist was in there. She said RN L had not told her earlier that Resident #19 needed care. She said CNA K just told her. Observation on 03/04/2025 at 12:10 p.m. revealed RN L and CNA F enter Resident #19's room. In an interview on 03/04/2025 at 12:31 p.m., Resident #19 said he had been cleaned up. Observation revealed the call light activator switch was on the over bed table, out of reach. In an interview on 03/04/2025 at 12:33 p.m., CNA K said RN L had told him to tell CNA F that Resident #19 needed to be changed. He said he told CNA F sometime after 11 [11:00 a.m.]. In an interview on 03/06/25 at 11:25 a.m., the DON said a reasonable time for a resident to be changed after activating the call light was between five to twenty minutes. The DON stated if a nurse answered a residents call light, If the resident requires two persons, get help. Or they can change the resident. If they're in the middle of med pass or something they can attempt to get a CNA. The DON said waiting from 10:36a.m. to 12:10p.m. was not reasonable. She said RN L should have told the resident he would come back or find a CNA. She said the CNA does not need to be assigned to that hall to help a resident. She said the possible negative outcomes for the resident would be a decline in the resident's comfort level, including dignity, and skin breakdown. The facility policy Call Lights: Accessibility and Timely Response (10/13/2022) read, in part, .5. Staff will ensure the call light is within reach of resident and secured, as needed .10. All staff members who see or hear an activated call light are responsible for responding. If the staff member cannot provide what the resident desires, the appropriate personnel should be notified. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676371 If continuation sheet Page 3 of 5 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 676371 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Quail Valley Post-Acute Healthcare 3640 Hampton Dr Missouri City, TX 77459 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 and to help prevent the development and transmission of communicable diseases and infections for 1 resident (Resident #19) of 7 residents reviewed for infeciton control. Residents Affected - Few -Staff provided incontinent care for the resident and did not practice hand hygiene prior to repositioning the resident and arranging the linens. The deficient practice placed the residents at risk for infection. Findings included: Record review of the admission Record for Resident #19 revealed he was [AGE] years old and was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, quadriplegia (loss of use of all four extremities), anxiety disorder, and muscle wasting and atrophy. Record review of the MDS assessment dated [DATE] revealed Resident #19 scored 10/15 on the BIMS, indicative of moderately impaired cognition. The MDS reflected the resident was dependent for hygiene. The MDS reflected the resident had a suprapubic indwelling catheter for urine and was incontinent of bowel. Record review of the Care Plan (revised 07/05/2023) for Resident #19 revealed hethe resident had bowel incontinence. One Intervention read, in part, .Check resident at frequent hours and provide incontinent care as needed. Record review of the Care Plan (revised 09/08/2022) for Resident #19 revealed the resident was at risk for skin breakdown from bowel incontinence. One Intervention read, in part, .Provide timely incontinent care . Observation and interview on 03/06/2025 revealed CNA A and CNA G provide incontinent care for Resident #19. Both staff washed their hands and donned gowns and gloves. CNA G loosened the resident's brief. CNA A used disposable wipes to wipe the right groin area. She then discarded the wipe. She repeated the sequence for the left groin. The resident was turned onto his right side. The resident had two wound dressings that were intact and appeared clean. CNA A used disposable wipes to clean a small amount of feces from the perineal area, and discarded the wipes. The staff turned Resident #19 onto his left side. CNA G removed the soiled brief and discarded it. CNA A cleaned the resident again. Both staff placed a new brief under the resident and secured it. CNA A and CNA G did not remove their gloves or practice hand hygiene before repositioning the resident. They then covered the resident with linens. CNA A then, while wearing the same gloves, moved Resident #19's motorized wheelchair. Both staff then removed their gowns and gloves. CNA A and CNA B stated they did not perform glove changes and hand hygiene, but should have. In an interview on 03/06/2025 at 4:05 p.m., the DON said when providing incontinent care, the staff should have changed gloves when going from dirty to clean. They should have practiced hand hygiene after removing the dirty brief and discarding it. She said a negative outcome would be an increased (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676371 If continuation sheet Page 4 of 5 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 676371 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Quail Valley Post-Acute Healthcare 3640 Hampton Dr Missouri City, TX 77459 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 risk of infection. Level of Harm - Minimal harm or potential for actual harm The facility policy Hand Hygiene (10/24/2022) read, in part, .1. Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676371 If continuation sheet Page 5 of 5