Health inspection·September 7, 2025

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some MA P stated she learned in training as long as the resident name was on the cup that it was fine to keep and hold on to. During an interview on 9/06/2025 at 4:22 p.m., LVN C stated MA P had informed her Resident #14 had refused medication. She stated she did not know MA P held the meds mixed in pudding in the cart. She stated she should have had MA P and herself wasted (disposed) the medications together because of the risk for medication error with pre-dispensed medications. 2. Record review of Resident #1's face sheet dated 9/03/2025 revealed a [AGE] year-old female admitted on [DATE] and readmitted on [DATE] with diagnoses which included: epilepsy, hypotension (low blood pressure), cardiomyopathy (disease of the heart muscle) and schizophrenia (serious mental health condition that affects how people think feel and behave). Record review of Resident #1's quarterly MDS dated [DATE] revealed a BIMS score of 3, which indicated a severe cognitive impairment with behaviors that included rejection of care less than daily. Resident #1's functional status was listed partial assistance showering/bathing and supervision for oral care and eating. Record review of Resident #1's care plan dated 7/15/2025 revealed she was on hospice care with interventions to observe for pain and administer pain medications as ordered by a physician. Record review of Resident #1's BIMS evaluation dated 9/02/2025 revealed a score of 15 which indicated the resident was cognitively intact. Record review of Resident #1's physician order summary for August 2025 revealed the following medication order: Hydrocodone-acetaminophen oral tablet 10/325 mg, give 0.5 tablet by mouth every 8 hours as needed for pain with a start date 8/29/2025. Record review of Resident #1's Narcotic Administration Record for hydrocodone-acetaminophen 10/325 mg revealed LVN A signed out one dosage (0.5 mg) of the narcotic on 8/29/2025 at 8 p.m. Record review of Resident #1's August 2025 MAR revealed hydrocodone-acetaminophen 10/325 mg tablet, give 0.5 tablet every 8 hours as needed was not documented as administered. Record review of Resident #1's hospital records dated 8/31/2025 revealed the resident was admitted to the hospital due to inadvertent administration of another patient's medication while at her nursing facility. The hospital MD called the nursing facility and confirmed medications which included eight medications and a question mark for hydrocodone. Nursing facility staff stated this (hydrocodone) may not have been administered as it was a later dose for this patient. Urine drug screen noted positive for opioids, TCA's (tricyclic antidepressants) and benzos (benzodiazepines). During an interview on 9/03/2025 at 1:45 p.m., Resident #1 stated on Friday 8/29/2025 she was approached by an unknown staff member and given medications two times in a short period of time. She stated she was not sure what she was given as she trusted the staff and just took the medications. During an interview on 9/04/2025 at 1:30 p.m., LVN A stated she signed Resident #1's hydrocodone out on the narcotic record. She stated she does not believe she administered the hydrocodone to the resident. She stated pulled the hydrocodone and intended to give it when she made a medication error with Resident #1. She stated she was more worried about caring for Resident #1 than she was about documentation or the disposal of medication. She stated she threw the hydrocodone in the sharps container but did not have another staff member witness the wasting of the medication as required for a narcotic or correct any documentation. She stated she was trained to have another nurse witness the waste (disposal) with her and then document the medication waste with double signatures. During an interview on 9/04/2025 at 1:39 p.m. the DON stated she had reviewed the narcotic record for Resident #1's hydrocodone which indicated the medication was documented as removed at 8:00 pm on 8/29/2025. The DON stated she does not believe the hydrocodone was given to Resident #1 and the time did not match when it was actually pulled. She stated LVN A documented on the narcotic record when the time it was supposed to be given rather than the time it was given. The DON stated she had reviewed with LVN A. The DON stated LVN A should document the medication at the actual time the medication was given. During an interview on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455724 If continuation sheet Page 2 of 14 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 455724 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/07/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbor View Nursing & Rehabilitation 1213 Water St Kerrville, TX 78028 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete 9/07/2025 at 3:01 p.m., the DON stated medications should be wasted and discarded if not administered to avoid confusion. Record review of a facility policy, titled Medication Administration last revised 5/07/2025 revealed: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice.3. Identify resident 10. Ensure that the six rights of medication administration are followed. a. Right resident b. Right drug c. Right dosage d. Right route e. Right time f. Right documentation. 11. Review MAR to identify medication to be administered. 12. Compare medication source (bubble pack, vial, etc.) with MAR to verify resident name, medication name, form dose, route and time. 14. Remove medication from source.15. Administer medication as ordered in accordance with manufacturer specifications 19. Observe resident consumption of medication. Event ID: Facility ID: 455724 If continuation sheet Page 3 of 14 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 455724 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/07/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbor View Nursing & Rehabilitation 1213 Water St Kerrville, TX 78028 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 0760 Ensure that residents are free from significant medication errors. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure resident were free of significant medication errors for 1 of 7 (Resident #1) reviewed for pharmacy services. The facility failed to ensure Resident #1 was free of significant medication errors and received medication as prescribed by a physician on 8/29/2025. LVN A administered Resident #2's medications to Resident #1. This resulted in administration of two schedule IV-controlled substances: non prescribed medications: Temazepam 22.5 mg, Phenobarbital 129.6 mg, levothyroxine 75 mcg, Tamsulosin 0.4 mg, Levetiracetam 1250 mg, Oxcarbazepine 300 mg, Mirtazapine 7.5 mg, Risperdal 1 mg and prescribed Quetiapine (Seroquel) 800 mg which was a dose 32 times greater than prescribed for Resident #1. This medication error resulted in a change of condition, hospitalization and ICU stay for hypothermia, hypotension, and metabolic encephalopathy. The resident returned to the facility on 8/31/2025. This failure resulted in the identification of an Immediate Jeopardy (IJ) on 9/04/2025 at 6:00 p.m. The IJ template was provided to the facility on 9/04/2025 at 6:07 p.m. While the IJ was removed on 9/07/2025 the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with a potential for more than minimal harm that is not immediate jeopardy because the facility needed to monitor the implementation of the plan of removal. This failure could place residents at risk for medication errors and could result in side effects, a decline in health, hospitalization and/or death. The findings included: Record review of Resident #1's face sheet dated 9/03/2025 revealed a [AGE] year-old female admitted on [DATE] and readmitted on [DATE] with diagnoses which included: epilepsy, hypotension (low blood pressure), cardiomyopathy (disease of the heart muscle) and schizophrenia (serious mental health condition that affects how people think feel and behave). Record review of Resident #1's quarterly MDS dated [DATE] revealed a BIMS score of 3, which indicated a severe cognitive impairment with behaviors that included rejection of care less than daily. Resident #1's functional status was listed partial assistance showering/bathing and supervision for oral care and eating. Record review of Resident #1's BIMS evaluation dated 9/02/2025 revealed a score of 15 which indicated the resident was cognitively intact. Record review of Resident #1's progress notes dated 8/29/2025 at 7:50 p.m. as a late entry revealed the DON documented: Medication given to wrong Resident. She documented normal vital signs, alert and oriented with no change to mentation (Mental activity or the process of thinking). Hospice RN notified with new orders to hold all medications for the rest of the evening and for the next morning. Monitor for 72 hours for any complications or reactions. Record review of Resident #1's progress notes dated 8/29/2025 at 8:35 p.m. documented as a late entry revealed: Medication Error with blood pressure 70/40 (low), HR 72 (normal), oxygen saturation 98% on room air. A temperature was not documented. Level of consciousness: not arousable. Resident not responsive to voice or touch, called 911, hospice and DON. Record review of an incident report for Resident #1 dated 8/29/2025 written by the DON revealed: Resident was accidently given the wrong medication during med-pass. Nurse (LVN A) mistakenly administered the wrong medication, I thought I handed her the right pill cup then I turned around and saw her medication on the med cart. Immediate action taken immediately assessed Resident #1 for complications and none noted, called DON and she stated to call hospice and RP. RN from hospice stated to monitor resident. Vital signs BP 110/72 (normal), HR 74 (normal) respirations 16 (normal) oxygen saturation 98% on room air (normal) with no injuries noted post incident. The documentation indicated Resident #1 was oriented to person, place, time and situation (normal cognition). Record review of Resident #1's Hospice notes dated 8/30/2025 revealed on Friday 8/29/2025 at 7:59 p.m. LVN A reported a medication error. Hospice physician notified.hold meds except carbidopa/levodopa and monitor Q1hr (every hour). Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455724 If continuation sheet Page 4 of 14 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 455724 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/07/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbor View Nursing & Rehabilitation 1213 Water St Kerrville, TX 78028 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 0760 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Send to ED if vital signs change or sedation occurs. 9:03 p.m. LVN A reported EMS activated, secondary to hypotension. (low blood pressure). Record review of Resident #1's physician order summary for August 2025 revealed the following medication orders:Carbidopa-Levodopa 25/100 mg give 3 tablets four times a day related to neuroleptic induced parkinsonism with a start date of 6/17/2025.Divalproex (Depakote) sodium oral tablet delayed relates 500 mg, give 2 tablets by mouth two times a day for seizures with a start date of 8/15/2025Entacapone oral tablet 200 mg, give one tablet by mouth four times a day for Parkinson's disease with a start date of 5/08/2025.Lacosamide oral tablet 50 mg, give tablet by mouth two times a day with a start date of 6/17/2025.Quetiapine fumarate oral tablet 25 mg, give 1 tablet by mouth at bedtime for depression.Hydrocodone-acetaminophen oral tablet 10/325 mg, give 0.5 tablet by mouth every 8 hours as needed for pain with a start date 8/29/2025. Record review of Resident #1's Medication Audit, dated 9/03/2025 revealed LVN A documented the following medications were administered on 8/29/2025 at 7:35 p.m. (medications ordered for Resident #1):Lacosamide 50 mg-2 tablets (used to treat seizures)Carbidopa-Levodopa 25/100 mg-3 tablets (Parkinson's)Entacapone 200 mg-1 tablet (Parkinson's)Divalproex (Depakote) 500 mg-2 tablets (seizures)Quetiapine (Seroquel) 25 mg-1 tablet (antipsychotic used to treat schizophrenia) Record review of Resident #1's Narcotic Administration Record for hydrocodone-acetaminophen 10/325 mg revealed LVN A signed out one dosage (0.5 mg) of the narcotic on 8/29/2025 at 8 p.m. Record review of Resident #1's August 2025 MAR revealed hydrocodone-acetaminophen 10/325 mg tablet, give 0.5 tablet every 8 hours as needed was not documented as administered. Record review of Resident #2's face sheet dated 9/05/2025 revealed a [AGE] year-old male admitted on [DATE] with diagnoses which included: hypothyroidism, schizophrenia, and epilepsy. Record review of Resident #2's quarterly MDS dated [DATE] revealed a BIMS score of 13 which indicated he was cognitively intact with no documented behaviors. He required was independent or required supervision for ADL care. Record Review of Resident #2's Medication Audit, dated 9/03/2025 revealed LVN A documented the following medications were administered on 8/29/2025 at 7:34 p.m. (medications intended for Resident #2, but administered to Resident #1 as medication error): 1. Levothyroxine 75 mcg-1 tablet (used to treat hypothyroidism)2. Phenobarbital 64.8 mg- 2 tablets (a barbiturate, Class IV controlled substance, used for seizures)3. Tamsulosin 0.4 mg-1 capsule (used for incontinence)4. Levetiracetam 1250 mg-2 tablet (used for seizures)5. Oxcarbazepine 300 mg-1 tablet (used for seizures and/or bi-polar disorder)6. Temazepam 22.5 mg-1 tablet (a benzodiazepine, Class IV controlled substance used for insomnia)7. Mirtazapine 7.5 mg (used for anxiety/depression)8. Risperdal 1 mg-1 tablet (schizophrenia)9. Quetiapine (Seroquel) 400 mg- 2 tablets (antipsychotics used to treat schizophrenia) Record review of a handwritten statement dated 8/29/2025, signed by LVN A revealed:7:25 p.m.-realized meds given to (Resident #1) were meds for (Resident #2).7:30 p.m.-called DON. Was instructed to call the resident's physician and RP.7:40 p.m.-hospice was called, talked to RN. Was instructed to monitor resident and wait for RN to call back with orders.7:50 p.m. RN from hospice called back with orders from hospice physician. Orders were to hold all medications, monitor for 72 hours, hold morning medications. If any adverse reactions occur call 911.8:00 p.m.-Checked on Resident #1. Resident woke up easily, talked to this nurse, went back to sleep. Vitals taken BP 110/72 (normal), HR 74 (normal), oxygen saturation 98% on room air (normal).8:35 p.m.- Checked on resident again. Resident was difficult to wake. Not responsive to voice or touch. Manual BP 70/40 (low), HR 72 (normal) oxygen 97% on room air (normal).8:50 p.m.- Called 911, notified DON, notified RN hospice9:00 p.m.-Paramedics arrived at 9:00 p.m., left at 9:10 p.m. Record review of Resident #1's hospital records dated 8/31/2025 revealed the resident was admitted to the hospital due to inadvertent administration of another patient's medication while at her nursing facility. The records reflected, This (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455724 If continuation sheet Page 5 of 14 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 455724 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/07/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbor View Nursing & Rehabilitation 1213 Water St Kerrville, TX 78028 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 0760 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few resulted in acute encephalopathy, hypothermia. She received several doses of Narcan (medication used to reverse opioid overdose) which did not seem to change the patient's clinical course significantly. The hospital MD called the nursing facility and confirmed medications (given) as follows: Quetiapine 800 mg (a dosage 32 times greater than ordered by Resident #1's physician), Levetiracetam 1250 mg, Mirtazapine 7.5 mg, Oxcarbazepine 300 mg, Phenobarbital 129.6 mg, Risperdal 1 mg, Temazepam 22.5 mg, Levothyroxine (no dose specified), and questions mark hydrocodone. Nursing facility staff stated this (hydrocodone) may not have been administered as it was a later dose for this patient. Urine drug screen noted positive for opioids, TCA's (tricyclic antidepressants) and benzos (benzodiazepines). The patient was later noted to be obtunded and hypothermic .transfer to ICU. She was very lethargic but followed commands in all extremities. She would attempt to open eyes but could not open them fully. After arriving in the ICU, the patient's mental status worsened .she was given an additional dose of Narcan with no significant response. She was noted to be hypotensive and required norepinephrine. [NAME] was put in place given her hypothermia. Assessment/Plan: accidental overdose, EEG on 8/30-moderate encephalopathy-supportive care, discussed with poison control, hypotension: likely additive effect of sedating medications, hypothermia, secondary to thermal dysregulation given multiple neuroleptic medications and acute encephalopathy. Record review of form 3613-A Provider Investigative Report dated 9/04/2025 [BH6] revealed the facility self-reported a medication error when charge nurse LVN A self-reported she gave the wrong medication to Resident #1. The report indicated the medication error occurred on 8/29/2025 at 7:10 p.m. and Resident later became lethargic and was hypotensive (low blood pressure) and was sent to the hospital for evaluation on 8/29/2025 at 9:12 p.m. The report indicated Resident #1 was given several doses or Narcan at the hospital and was monitored for hypotension and metabolic encephalopathy. The report indicated it was an isolated incident, LVN A received counseling, a written warning, and additional training. The findings were confirmed. During an observation and interview on 9/03/2025 at 1:57 p.m., Resident #1 was observed moving around her room. She was awake and alert. She was able to correctly identify the correct time and year, had knowledge of the current president, knew her location and was able to recall what she had for lunch. Resident #1 stated on Friday (8/29/2025), she could not remember what time, she was near the 200-hallway nurse's station. She stated she remembered someone giving her medicine and then a short time later they gave her some more. She stated she remember someone saying her name and then it was lights out and she did not remember anything else until she woke up in the hospital. She stated when she woke up in the hospital, the hospital staff told her, her blood pressure was dangerously low, and her temperature was very low. She stated they also told her she had received someone else's medication that was really strong, in addition to her own medication. Resident #1 stated staff was now pouring out her medication and identifying each pill. She stated she was taking the medication and had not refused any. She described the person who gave her medication as female but was unable to recall her name and could not remember if she had seen the staff since the incident. She stated she was not able to describe any of the medication given to her. She stated she did not pay much attention. She stated the same person had approached her twice with the medication and she trusted them and just took it. She stated taking medication was just part of the routine, even when it was given twice. She stated they might give her a water pill one time and then something else at a later time. Resident #1 stated since she had returned to the facility, she felt fine and was back to herself with no lingering effects. During an interview on 9/03/2025 at 5:41 p.m., LVN A stated on 8/29/2025 at 7:25 p.m. she gave Resident #1, Resident #2's medication in error. She stated she was standing with the med cart near Resident #1's doorway speaking with the resident. She stated she remembered preparing and passing (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455724 If continuation sheet Page 6 of 14 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 455724 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/07/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbor View Nursing & Rehabilitation 1213 Water St Kerrville, TX 78028 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 0760 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few meds to another resident and then preparing meds for both Resident #1 and Resident #2 at the same time on top of the medication cart [BH7] and she got the two medication cups confused. She stated she was trying to give medications to two residents at the same time, got distracted and made a mistake. She stated Resident #2 had approached her asking for his medication. LVN A stated immediately after Resident #1 had consumed the pills, she turned around, saw the other medication cup with contained two Depakote pills that belonged to Resident #1 and realized her error. LVN A stated she did not give Resident #1 her pills. She stated she had pulled Resident #1's normal evening pills, plus hydrocodone. She stated she threw all the pills in the sharps container but did not have any witnesses. She stated she was panicking and was focused on Resident #1. She stated no other staff were around. She stated she immediately called the DON who told her to call the hospice physician and notify them. She stated she called hospice and told them Resident #1 was okay and that her vitals were normal. She stated the hospice RN gave her orders from the hospice physician to monitor the resident as she saw fit anywhere from every 15 minutes to one hour, to hold the rest of her medication for that evening and if there were any adverse reactions to send her out (send to the emergency room). LVN A stated at first, she was okay but when she checked on her at 8:25 p.m., Resident #1 was lethargic. LVN A stated she tried to obtain a blood pressure and at first was unable to get one. She stated she was finally able to get a manual blood pressure reading of 70/40 (low). She stated at 8:25 p.m., Resident #1 was unresponsive. LVN A stated it looked like Resident #1 was sleeping in her bed but there was something about her eyes that did not look normal. She stated her eyes were cracked open a little and she knew they were not normal. She stated she took the rest of her vital signs which were all normal. She described her breathing as normal but breathing very deeply and a little slower. LVN A stated she performed a sternal rub, which made the resident open her eyes. She stated the resident was not communicating. LVN A stated she notified hospice and called 911. She stated she was honest on the 911 call and with EMS personnel. She told them what happened. She stated she recognized she made a mistake, and it was important for her to be honest so they would know how to appropriately treat Resident #1. LVN A stated the DON told her she was glad she had reported it immediately. She stated she was written up and was told they needed to go over what happened. She stated she received an in-service on the medication 5 rights (of administration). She stated ADON O shadowed her on her next shift watching her perform medication pass to ensure she was doing everything correctly. LVN A stated she administered Levothyroxine 25 mg, Seroquel 800 mg, Keppra 1250 mg, Risperdal 50 mg, mirtazapine 7.5 mg, phenobarbital 65 mg, temazepam 22.5 mg, Buspar 20 mg and tamsulosin 7.25 mg. She stated those are the medications she remembers giving. LVN A stated she couldn't remember for sure if she gave hydrocodone but thinks she probably did not. She stated she thinks it was part of the wasted medications because she does not remember giving it to Resident #1. LVN A stated the whole situation scared her and she had been very concerned about Resident #1's outcome and wellbeing. She stated she kept in contact with the hospital post incident until she knew she was recovering. LVN A stated she was trained to administer medications to the right person, right dose, right time, right medication with the right documentation. She stated she was trained to pull one patient's med, take it to the resident, watch them take it, throw away the cup before moving on to the next patient. She stated it did not happen like that because she made a mistake. She stated she had no excuses for it. LVN stated she was fairly new to the facility. She had completed nurse competencies upon hire in June 2025? which included a medication pass which she passed. She stated it was not an intentional act, and she was not trying to harm Resident #1. She stated she was not okay until she learned Resident #1 was okay. LVN A stated it was important to give the right medication to the right resident so they could live. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455724 If continuation sheet Page 7 of 14 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 455724 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/07/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbor View Nursing & Rehabilitation 1213 Water St Kerrville, TX 78028 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 0760 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few During an interview on 9/04/2025 at 12:46 p.m., Resident #1's RP stated she was informed by an unknown person at an unknown time that Resident #1 was given too many medications. She stated she was given a list of the medications that should not have been given verbally. The RP stated Resident #1 ended up in the hospital in ICU, mostly because she could not stay warm and because of the medications. The RP stated when Resident #1 woke up in ICU she was her regular self which was about 12 hours later. The RP stated Resident #1 just had to sleep and let the medications work out of her system. She stated Resident #1 was back at the facility doing her normal activities and doing fine. The RP stated Resident #1 had not expressed any issues or concerns about staff. The RP stated she thought there should be better safeguards at the facility and believes there to be some sort of reprimand going on. She described Resident #1's as picking and choosing what she wanted to remember. She stated she could typically remember things that had occurred within the past two weeks but not necessarily things of the past with accuracy. During an interview on 9/04/2025 at 12:47 p.m., the hospice case manager stated the hospice RN was not available for interview. She stated the RN had documented notes in the hospice record. During an interview on 9/04/2025 at 1:23 p.m., the hospice physician stated he did receive notification from the hospice RN of the medication error. He stated the hospice RN sent him a list of medications that Resident #1 had received. He stated he gave orders to watch vitals and watch for sedation. He stated approximately 40 minutes later Resident #1 was sent to the ER. He stated it was important to avoid medication errors because it could cause side effects and the scheduled III and scheduled IV medications and other medications, such as non-prescribed medications could cause complications. He stated hydrocodone was not on his list of medications given, however probarbital, Risperdal, mirtazapine, oxcarbazepine, and levothyroxine were that he could remember. He stated the facility monitored her vital signs and sent her to out when she had a change. The hospice physician stated Resident #1's hospital stay was directly related to the medication error. During an interview on 9/04/2025 at 1:39 p.m., the DON stated LVN A absolutely did not follow the facilities policy for medication administration. She stated the facility policy indicated they were supposed to only pull one person's medication at a time. The DON stated if LVN A had done that, we would not be having a conversation. She further stated LVN A did not follow the five rights of medication administration which included the right patient, right time, right medication, right dosage and right documentation. The DON stated on 8/29/2025 at 7:31 p.m., she received a call from LVN A. She stated LVN A stated she gave Resident #2's medication to Resident #1 on accident. The DON stated she told LVN A to call hospice and the RP and she asked if Resident #1 was okay. The DON stated LVN A said yes. She stated LVN A called back and told me hospice gave orders to monitor Resident #1. The DON stated she told LVN A, Resident #1 needed monitoring for 72 hours, she told her she needed to write a statement and notify her of any changes. The DON said LVN A was freaking out, but med errors occur all the time. She stated she spoke with LVN A several times. The DON said at 9:16 p.m., LVN A notified her that Resident #1 was experiencing hypotension (low blood pressure) and was hard to rouse. The DON said she told LVN A she needed to send her house, even though she was on hospice she needed to go to the hospital. The DON said Resident #1 received Narcan and was treated in ICU for metabolic encephalopathy. She stated the facility self-reported the incident because of the serious injury. She stated she notified the Administrator, and he agreed. The DON stated she participated in the investigation. She found that LVN A had two medication cups on the top of the med cart, and she went and grabbed the wrong cut. The DON stated LVN A realized it right away and called her. The DON stated there were a million different reasons med errors occur. She stated there are lots of distractions, nurses try to multitask while doing med pass. The DON stated she told LVN A she had a lot of integrity for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455724 If continuation sheet Page 8 of 14 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 455724 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/07/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbor View Nursing & Rehabilitation 1213 Water St Kerrville, TX 78028 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 0760 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few admitting it. The DON stated she had no concerns about the way the change of condition was handled. She stated Resident #1 was monitored and sent out pretty quickly when a change of condition was noted. The DON stated the facility did not have a SW that was working, they had just hired one who was still training. She stated she had spoken to Resident #1 in the hallway and asked how she was doing. She said Resident #1 indicated she was glad to be back. She stated she did not ask her any specific questions just a general how you are doing. She stated to her knowledge Resident #1 had not expressed a desire to speak to anyone about the incident. The DON stated the next day, ADON O in-serviced LVN A on the five rights of safe administration and watched her do med pass. The DON stated LVN A was current on her competencies and there had been no concerns with the med pass observation. The DON denied any other complaints about medication administration or complaints or grievances about LVN A. The DON stated LVN A was written up, she was provided more education. She was instructed to write out a timeline which she did. The DON stated she helped LVN A put the notes in the computer. She stated she reviewed LVN A's notes to make sure it was accurate. The DON stated to avoid reoccurrence they were providing in-service education to all staff who administer meds. She stated they had not completed the training at the time of the interview. She stated their goal was to watch a med pass with all staff who perform medications which had not been completed. She stated today (9/04/2025, after surveyor entrance on 9/03/2025), they completed a med cart review. The DON stated she had provided 1:1 counseling to LVN A and would have her sign the write up today. She stated the medication error was an isolated event. The DON stated she ensures residents are free from harm by ensuring the facility policies are being followed and ensuring staff was competent. She stated she was available to staff at all times, even at night and had an open-door policy. She stated it was important for Resident's to receive the right medications to treat chronic illness and because it was detrimental if medications were not dispensed properly. During an interview on 9/04/2025 at 5:30 p.m., the Administrator stated he became aware of the medication error by phone call from the DON. He stated he was not a clinical person, so a lot of the investigation of the incident fell on the DON, although he provided oversite. The Administrator stated he could not specify if there was serious harm, but he knows Resident #1 was being watched for something very serious. The Administrator stated the facility ensured the incident was isolated, that everyone else was fine. He stated LVN A was distraught and knew what she had done wrong. He stated he was surprised to learn Resident #1 had to be sent to the hospital. The Administrator stated he had not spoken to Resident #1 since she had returned to the hospital but did inquire to staff who reported she was not having any difficulties. He stated he did self-report the incident as required. He stated LVN A was new to the facility, they had not had any complaints from residents or families. He stated although medication errors are fairly common for nurses, he could not remember the last time the facility had a medication error. The Administrator stated he communicated with residents during rounding and ensured residents were free from harm by being involved in clinical stand-up meetings. He stated he reviews facility incidents in the evenings for the next business day. The Administrator stated safety was important. He stated LVN A made the mistake and the facility was responsible. When asked if she followed facility policy for medication administration, he stated he did not know the details of how the medication error occurred. He stated the DON, who was clinical could answer the question better. The Administrator stated the facility had not held an AD HOC QAPI meeting to discuss the incident. He stated he had a conversation with the Medical Director. The Administrator stated the Medical Director gave directions to the facility, but he was going to decline to answer on what the direction was because he was not qualified to speak on it. The Administrator stated he was confirming on the investigative report the medication error by LVN A (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455724 If continuation sheet Page 9 of 14 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 455724 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/07/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbor View Nursing & Rehabilitation 1213 Water St Kerrville, TX 78028 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 0760 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few and stated there was no intent to harm. Record review of a facility Medication Administration Policy In-Service dated 8/22/2025-8/25/2025 (prior to medication error) which covered the facility policy, following physician orders precisely, including parameters, notifying the physician promptly for any variance or concerns revealed: LVN A had signed the in-service record as completed. Record review of LVN A's Nursing Orientation and Competency Checklist dated 7/11/2025 revealed she had successfully completed a med-pass video, med pass with supervision by preceptor (a teacher or instructor) and medication pass skills check off. Record review of a facility policy, titled Medication Administration last revised 5/07/2025 revealed: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice.3. Identify resident 10. Ensure that the six rights of medication administration are followed. a. Right resident b. Right drug c. Right dosage d. Right route e. Right time f. Right documentation. 11. Review MAR to identify medication to be administered. 12. Compare medication source (bubble pack, vial, etc.) with MAR to verify resident name, medication name, form dose, route and time. 14. Remove medication from source.15. Administer medication as ordered in accordance with manufacturer specifications 19. Observe resident consumption of medication. Record review of a facility policy, titled Medication Errors last revised 05/07/2025 revealed: It is the policy of this facility to provide protection for the health, welfare, and rights of each resident by ensuring residents receive care and services safely in an environment free of significant medication errors. Definitions: Significant medication error means one which causes the resident discomfort or jeopardized his/her health and safety. Policy Explanation and Compliance Guidelines: 1. The facility shall ensure medications will be administered as follows: a. according to physician orders c. In accordance with accepted standards and principles which apply to professionals providing services 6. To prevent medication errors and ensure safe medication administration, nurses should verify the following information: a. Right medication, dose, route, and time of administration b. Right resident and right documentation. The Administrator was notified of an IJ on 09/04/2025 at 6:00 p.m. and was given a copy of the IJ Template and a Plan of Removal (POR) was requested. The Plan of Removal was accepted on 09/05/2025 at 5:39 p.m. and included the following: Correction for the Resident Affected Immediate clinical response (COMPLETED 8/29/25): Resident assessed; EMS/transfer to ED for hypotension. Drug name/strength/route/quantity/time and vitals documented in EMR and incident record. Notifications (COMPLETED 8/29/25): Attending provider, responsible party, DON/Administrator, and Hospice were notified and documented. Protection on return: Enhanced monitoring per medical director (e.g., every shift x 72 hours, focused assessments as indicated, provider follow-up, and care plan update with specific risk reduction interventions. Resident #1 spoke with Social Services Director on 9/4 and Director of Nursing and with a licensed Social Worker, with Hospice. Resident #1 offered counseling services. She refused psych services and is going to see the Chaplain through Hospice. Identification of Other Residents Potentially Affected Cart sweep & product control completed by DON/ADON: All carts involved on unit secured; any loose/pre-popped pills destroyed per facility guidelines and documented on a medication cart sweep log. Lookback review: Full set of vitals ordered q -shift for all residents residing on the 200 hall x3days beginning 9/4/25. Facility wide spot-checks completed: Unannounced inspection of all med carts/rooms for pre-popping, unlabeled cups/bags; findings logged and corrected immediately. Safe Surveys conducted by the SS Director on 9/5 for residents on 200 hall regarding comfort with staff administering medicationsSystemic Changes to Prevent Recurrence Education & competency (to be COMPLETED by 9/4/25 or prior to next scheduled shift) by DON/Designee. Mandatory in-service for all licensed nurses/medication aides on pre-popping prohibition, two identifier (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455724 If continuation sheet Page 10 of 14 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 455724 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/07/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbor View Nursing & Rehabilitation 1213 Water St Kerrville, TX 78028 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 0760 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete verification, error reporting, and cart security; return demonstration med pass competency for every nurse. Targeted coaching & corrective action: Involved nurse was removed from independent med pass and was trained, re-educated, and monitored/supervised by the ADON until she demonstrated competency in the Six Riof Medication Pass. Pharmacy partnership: Consultant Pharmacist to conduct focused storage/handling rounds monthly x 3 months. Monitoring to Ensure Ongoing Compliance (QAPI) Med pass observations will be completed by DON/Designee 3x weekly x3 weeks, weekly x 3 weeks, then monthly x 3 months at random throughout the facility or until substantial compliance is achieved. Results/Discrepancies reported to QAPI ADHOC QAPI held on 9/5/25. The surveyor verification of the Plan of Removal on 09/07/2025 was as follows: Record review of Resident #1's progress note dated 8/29/2025 at 7:25 p.m. (documented as a late entry) by LVN A stated a medication error occurred. The DON and Hospice RN were notified of the error. Vital signs were documented all within normal limits. LVN A documented at 7:35 pm she noted Resident #1 was lethargic with low blood pressure of 70/40. Hospice notified who advised to send to the hospital. Record review of a facility incident report dated 8/29/2025 at 7:25 p.m. stated Resident #1 was accidently given the wrong medication during med-pass by handing the resident the wrong medication cup. Assessment and notifications documented. -During an interview on 9/07/2025 at 11:56 a.m., stated LVN A made the original notifications to hospice, DON and the RP and were documented in Resident #1's progress notes on 8/29/2025. -Record review of Resident #1's progress notes dated 8/31/2025 revealed the resident received an assessment, monitoring for falls and instructions not to get up unassisted to prevent falls after re-admission from the hospital. (8/32/2025) Resident #1's provider was notified of her return from hospi Event ID: Facility ID: 455724 If continuation sheet Page 11 of 14 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 455724 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/07/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbor View Nursing & Rehabilitation 1213 Water St Kerrville, TX 78028 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain medical records that were complete and accurately documented in accordance with accepted professional standards and practices for 1 (Resident #1) of 7 residents reviewed for medical records 1. The facility failed to ensure LVN A documented Resident #1s medication error, medications given, assessment, vitals, change of condition, contact with MD and RP, follow up orders, or transfer to the hospital by EMS on 8/29/2025. 2. The facility failed to upload Resident #1's hospital records from the 8/29/2025 hospital stay into the permanent medical record. 3. The facility failed to ensure LVN A documentation of medication administration accurately reflected any medications given on 8/29/2025. These failures placed residents at risk for delayed or inaccurate medical information which could result in a lack of continuity of care. The findings included:Record review of Resident #1's face sheet dated 9/03/2025 revealed a [AGE] year-old female admitted on [DATE] and readmitted on [DATE] with diagnoses which included: epilepsy, hypotension (low blood pressure), cardiomyopathy (disease of the heart muscle) and schizophrenia (serious mental health condition that affects how people think feel and behave). Record review of a handwritten statement (not part of the medical record) dated 8/29/2025, signed by LVN A revealed:7:25 p.m.-realized meds given to (Resident #1) were meds for (Resident #2).7:30 p.m.-called DON. Was instructed to call the resident's physician and RP.7:40 p.m.-hospice was called, talked to RN. Was instructed to monitor resident and wait for RN to call back with orders.7:50 p.m. RN from hospice called back with orders from hospice physician. Orders were to hold all medications, monitor for 72 hours, hold morning medications. If any adverse reactions occur call 911.8:00 p.m.-Checked on Resident #1. Resident woke up easily, talked to this nurse, went back to sleep. Vitals taken BP 110/72 (normal), HR 74 (normal), oxygen saturation 98% on room air (normal).8:35 p.m.- Checked on resident again. Resident was difficult to wake. Not responsive to voice or touch. Manual BP 70/40 (low), HR 72 (normal) oxygen 97% on room air (normal).8:50 p.m.- Called 911, notified DON, notified RN hospice9:00 p.m.-Paramedics arrived at 9:00 p.m., left at 9:10 p.m. Record review of Resident #1's permanent medical record revealed no entries were made by LVN A for events on 8/29/2025 about the resident's medication error, which medications she gave to Resident #1, her assessment, follow up assessments, vitals, change of condition, contact with hospice MD and RP or follow up orders, or transfer to the hospital by EMS as viewed on 9/03/2025. A late entry was made by the DON on 9/03/2025. Record review of Resident #1's progress notes revealed on 8/31/2025 Resident #1 returned to the facility from a local hospital. Record review of Resident #1's medical record revealed the hospital records for 8/29/2025 had not been uploaded into the electronic record when viewed on 9/03/2025 and again on 9/04/2025. During an interview on 9/04/2025 at 11:11 a.m., LVN B reviewed Resident #1's medical record and stated she did not see the events of 8/29/2025 documented by LVN A. She stated there was an entry of events made on 9/03/2025 by the DON (surveyor arrived at facility on 9/03/2025). She stated she was unable to locate the hospital records for Resident #1 in the medical record. LVN B stated she had reviewed paper copies of the hospital records. She stated they were most likely in the DON's office. She stated the facility did not have a medical records person. She stated their process was to give any documents for upload to a member of management. She stated she wasn't sure who was responsible. LVN B stated they didn't have a basket or folder to put the medical records in at the nurse's station. LVN B stated they were trained to document events when they happen. She stated having accurate medical records was important for continuity of care, so they know what was going on with the patient (resident) at the time. During an interview on 9/04/2025 at 11:27 a.m., ADON N (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455724 If continuation sheet Page 12 of 14 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 455724 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/07/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbor View Nursing & Rehabilitation 1213 Water St Kerrville, TX 78028 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some stated she was not certain where Resident #1's hospital records were located and would have to look for them. During an interview on 9/04/2025 at 1:30 p.m., LVN A stated she did not document on Resident #1's medical record the medication error, assessment, vitals signs, notifications of hospice or RP, or transfer to the hospital because she was not sure what to write in the medical record. She stated she thought she was not supposed to document the error. She stated she wrote out a statement with the same information. She acknowledged by stating that her statement was not part of the medical record. She stated on 9/03/2025 (after surveyor arrival) she sat with the DON and reviewed what should be documented. She stated the DON helped write in the medical record. LVN A stated she was trained to document in the patient's (Resident's) medical record. She stated a change of condition should be document so they know what happened, so they keep good records, to document changes and so they could track improvement or decline. During an interview on 9/04/2025 at 1:39 p.m., the DON stated she had heard that medication errors should not be documented in the medical record. She stated after reviewing, she put it in Resident #1's medical record on 9/03/2025. The DON stated LVN A should have documented vitals, assessments and transfer out of the facility, as well as notification but she thought LVN A was scared. The DON stated LVN A wrote on a piece of paper verbatim what occurred. The DON stated it was important for this information to be included in the resident's medical record for a historical view of change of condition. During an interview on 9/07/2025 at 3:01 p.m., the DON stated the facility did not have a medical records person or position. She stated the ADON was responsible for uploading any records into the medical record. She stated the process for upload when coming back from a medical visitor or hospital visit was for records to be left in a box near the ADON's office. She stated the ADON would then upload withing a week to 10 days depending on what was going on at the facility. The DON stated she had not reviewed the facility policy on medical records. The DON stated notes on medical care should be documented the same shift they occurred. Record review of Resident #1's Medication Audit, dated 9/03/2025 revealed LVN A documented the following medications were administered on 8/29/2025 at 7:35 p.m. (medications ordered for Resident #1): Lacosamide 50 mg-2 tablets (used to treat seizures) Carbidopa-Levodopa 25/100 mg-3 tablets (Parkinson's) Entacapone 200 mg-1 tablet (Parkinson's) Divalproex (Depakote) 500 mg-2 tablets (seizures) Quetiapine (Seroquel) 25 mg-1 tablet (antipsychotic used to treat schizophrenia) Record review of Resident #1's August MAR revealed lacosamide, carbidopa-levodopa, entacapone, divalproex and quetiapine had been documented as administered to the resident by LVN A. During an interview on 9/03/2025 at 5:41 p.m., LVN A stated her normal activity when dispensing medications was to document administration as she pops the medication. She stated if the resident refuses medication she would come back write a note and unclick the documentation (press a button on the electronic medical record). LVN A stated on 8/29/2025 she documented administering Resident #1's evening meds. She stated she made a medication error and accidently administered Resident #2's medications to Resident #1. She stated she did not give Resident #1 the medication she had signed off as administered. LVN A stated she did not go back and correct the resident MAR to indicate the medications had not been administered because she was panicking, and documentation was the least thing on her mind. She stated the medication error occurred at 7:25 p.m., and she didn't sign off Resident #1's medications until 7:25 p.m. because she just clicked the meds. She stated they were yellow which indicated it was time to administer them, so she just clicked them off. She stated she was trained to document when the medication was pulled and not after it was given. She stated if she was honest, she had not looked at the facility policy for medication administration in a while. During an interview on 9/04/2025 at 1:39 p.m., the DON stated medications should not be documented until after the medication was given in a perfect world. The DON stated as a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455724 If continuation sheet Page 13 of 14 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 455724 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/07/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbor View Nursing & Rehabilitation 1213 Water St Kerrville, TX 78028 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete nurse, she knew it was easy to sign them off when they are popped (removed from blister pack). The DON stated she was not aware LVN A was documenting before administration at the time, but she was aware of it now and was retraining staff. Record review of a facility policy, titled Medication Administration last revised 5/07/2025 revealed: 10. Ensure that the six rights of medication administration are followed: f. Right documentation 20. Sign MAR after administered. 21. If medication is a controlled substance, sign narcotic book. 23. Correct any discrepancies and report to nurse manager. Event ID: Facility ID: 455724 If continuation sheet Page 14 of 14