Health inspection·June 22, 2023

F 0656 Record review of Resident #10's care plan on 6/22/2023 revealed no care plan for breathing treatments. Level of Harm - Minimal harm or potential for actual harm During an interview and record review of Resident #68's care plan on 6/22/2023 at 4:40 PM with the Director of Nursing (DON) she said there should be a care plan for nebulizer treatments. The DON said the MDS department does the care plans, and the DON did not know why a care plan was not developed. Residents Affected - Few During an interview and record review of Resident #68's care plan on 6/22/2023 at 4:50 PM the MDS coordinator (care plan specialist) #1 and #2 said it looked like the care plan for breathing treatments slipped through the cracks. They both said there should be a care plan for breathing treatments. MDS coordinator (care plan specialist) #1 and #2 said they reviewed orders in the morning meeting and communicate with the assistant director of nurses on a daily basis. Care plans are reviewed by nurses and CNAs and used as a guide for resident care. A resident with a doctor's order for as-needed breathing treatments or Oxygen should be assessed for that need on a regular basis. Failure to do so could result in acute respiratory failure and can be life-threatening. During an interview and record review of Resident #10's care plan on 6/22/2023 at 6:00 PM with the Director of Nursing (DON) she said there should be a care plan for nebulizer treatments. The DON said the MDS department does the care plans, and the DON did not know why a care plan was not developed The facility's Care Plans policy dated 10/24/2022 indicated the following: 1 The comprehensive care plan will describe, at a minimum, the following: The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. 2 The comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676206 If continuation sheet Page 2 of 8 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 676206 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Arbor View 218 Baltic Edinburg, TX 78539 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure review and revision of comprehensive care plans for 1 resident (Resident #72) of 13 residents reviewed for comprehensive care plan revisions in that: The facility failed to review and revise Resident #72's comprehensive person-centered care plan to address the initiation of Haldol Decanoate, an antipsychotic medication. This deficient practice could affect residents and place them at risk of not receiving appropriate interventions to meet their current needs. The findings were: Review of Resident #72's admission record, dated 06/22/2023, revealed he was a [AGE] year old male, admitted to the facility on [DATE], with diagnoses of type 2 diabetes mellitus, heart failure, myocardial infarction (heart attack), hypertension (high blood pressure), dementia with mood disturbance, peripheral vascular disease (narrowed blood vessels reduce blood flow to the limbs). Review of Resident #72's quarterly MDS assessment dated [DATE], revealed Resident #72 had a BIMS of 10 which indicated his cognition was moderately impaired. Resident #72 had adequate hearing and staff could understand him and he usually was able to understand. Resident #72 required extensive assistance with two-person assist for bed mobility, extensive assistance with one person physical assist for transfers, locomotion when not in wheelchair, dressing, eating, toileting, and personal hygiene. Resident #72 was occasionally incontinent of bladder and always continent of bowels. Review of Progress Notes for Resident #72 revealed, on 02/14/23 at 11:44 a.m. Nurse Note: Note Text: heard yelling out loud noted resident aggressive using foul language towards other resident very upset attempting to hit other resident redirected resident but continue very upset stating nobody is going to tell him what to do and got aggressive towards staff. NP was notified and orders given. Review of Resident #72's comprehensive person-centered care plan revised date of 02/09/23 revealed Focus .has a behavior problem (verbally abusive, aggressive, foul language with other residents), r/t (related to) dementia with mood disturbance. Interventions/Tasks Administer medications as ordered . (No medication listed. No antipsychotic medication listed on care plan) Review of 04/18/23 Psychiatric Nursing Home Progress Note written by NP revealed Pt is w/c bound: he has a cane he sometimes uses to 'move' out of the way. He says he is a good person but they the sick ones make him angry. Medication adjustment by NP: Increase Keppra 750mg PO BID; Stop Keppra 500mg PO BID; Restart Lexapro 20mg PO daily - depression/anxiety. Call if condition worsens. Review of Progress Notes for Resident #72 revealed, on 04/18/23 at 02:26 p.m. Nurse Note: Note Text: SN (Skilled Nurse) removed cane from Pt's room as Pt threatened another resident to hit him with it. SN spoke to Pt's [family member], (name), via phone call. Family member will pick up cane from Administrator's office. Pt's [family member] verbalized understanding. (DON) made aware. Review of Progress Notes for Resident #72 revealed, on 04/18/23 at 03:43 p.m. Nurse Note: Note Text: (ANP D) for psych into facility to evaluate resident. New orders given d/c Keppra 500mg PO BID, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676206 If continuation sheet Page 3 of 8 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 676206 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Arbor View 218 Baltic Edinburg, TX 78539 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Start Keppra 750mg PO BID for Labile Moods, Lexapro 20mg PO QD for Depression/Anxiety. New orders received and carried out. Review of 05/24/23 Psychiatric Nursing Home Progress Note written by NP revealed Pt is very demanding; Episodes of physical and verbal aggression; other residents do not wish to sit with him; male roommate asked to be moved. Pt wants no tv, no a/c, no lights, at times refuses meds. Medication by NP: Increase Gabapentin 300 mg PO TID for neuropathy; Haldol Decanoate 50mg IM monthly for unsp psychosis/aggression; Please keep me posted Review of Physician Order dated 05/24/23 reflected Haldol Decanoate Intramuscular Solution 50mg/mL (Haloperidol Decanoate) Inject 1 mL intramuscularly one time a day starting on the 25th and ending on the 25th every month for psychosis. Ordered by NP C. Review of Resident #72's Medication Administration Record for May 2023 revealed Resident #72 received Haldol Decanoate Intramuscular Solution 50mg/mL on 05/25/23 per physician orders. Review of Progress Notes for Resident #72 revealed, on 06/01/23 at 05:21 p.m. Nurse Note: Note Text: RESIDENT BECAME AGGRESSIVE AND STARTED YELLING AND CURSING AT FAMILY MEMBER AND PATIENT IN DINING ROOM FOR SITTING AT HIS TABLE. RESIDENT WAS REORIENTED, AND RECEIVED TEACHING REGARDING INAPPROPIATE BEHAVIOR AND THAT HE CANT BE YELLING AT PEOPLE AND MUCH LESS PUT HIS HANDS ON SOMEONE ELSE, RESIDENT STATED THAT HE IS CALM UNTIL SOMEONE MAKES HIM MAD, AND THAT HE DOES NOT CARE IF HE GETS KICKED OUT OF FACILITY, HE WILL HIT SOMEONE IF HE HAS TOO. RESIDENT REMAINED CALM FOR REMAINDER OF DINNER. In an interview on 06/22/23 at 01:57 p.m., DON stated ANP D, the psych NP, ordered Haldol for Resident #72's verbal yelling and cussing. DON stated NP C rounds three times a week and noticed his verbal behaviors and referred Resident #72 to (ANP D). DON stated ANP D gave diagnosis of psychosis on 05/24/23. DON stated if a resident received an antipsychotic it should be care planned. DON stated Resident #72's antipsychotic is not care planned. Attempted telephone interview on 06/22/23 at 04:04 p.m., with ANP D. No answer. Voicemail left. In an interview on 06/22/23 at 04:55 p.m., MDS A and MDS B stated they are the ones who review the orders. MDS A stated during the morning meetings, they are told when there are things to add to a resident's care plan. MDS A stated the nurses communicate with ADON about new orders that come in. MDS B stated they miss some items because there are a lot of orders that come in. MDS B stated in the morning meeting MDS is given the orders that were placed the day before. MDS A stated antipsychotics are care planned. MDS A stated there is no excuse for not putting the orders on care plan and they should have caught it. Record review of facility's Care Plan Revisions Upon Status Change Policy, dated 10/24/22, revealed: Policy: The purpose of this procedure is to provide a consistent process for reviewing and revising the care plan for those residents experiencing a status change. Policy Explanation and Compliance Guidelines: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676206 If continuation sheet Page 4 of 8 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 676206 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Arbor View 218 Baltic Edinburg, TX 78539 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 0657 1. Level of Harm - Minimal harm or potential for actual harm The comprehensive care plan will be reviewed, and revised as necessary, when a resident experiences a status change. Residents Affected - Few 2. Procedure for reviewing and revising the care plan when a resident experiences a status change: c. The team meeting discussion will be documented in the nursing progress notes. d. The care plan will be updated with the new or modified interventions. Record review of facility's Psychoactive Medication Management Policy, not dated, revealed: Upon noting an order for psychoactive medication on admission or initiation of therapy: 5. Care plan the targeted behavior and for why the resident is receiving the medication Forms and Timing of Completion: 5. Care Plan - upon initiation of medication5. Care Plan - upon initiation of medication FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676206 If continuation sheet Page 5 of 8 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 676206 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Arbor View 218 Baltic Edinburg, TX 78539 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record for 1 (Resident #72) of 13 residents whose records were reviewed for pharmacy services. The facility failed to ensure Resident #72 was not prescribed Haldol Decanoate (an antipsychotic) without appropriate diagnosis for its use. This deficient practice could place residents without a diagnosis for taking psychotropic medications at risk for receiving unnecessary medications. The findings were: Review of Resident #72's admission record, dated 06/22/2023, revealed he was a [AGE] year old male, admitted to the facility on [DATE], with diagnoses of type 2 diabetes mellitus, heart failure, myocardial infarction (heart attack), hypertension (high blood pressure), dementia with mood disturbance, peripheral vascular disease (narrowed blood vessels reduce blood flow to the limbs). Review of Resident #72's quarterly MDS assessment dated [DATE], revealed Resident #72 had a BIMS of 10 which indicated his cognition was moderately impaired. Resident #72 had adequate hearing and staff could understand him and he usually was able to understand. Resident #72 required extensive assistance with two-person assist for bed mobility, extensive assistance with one person physical assist for transfers, locomotion when not in wheelchair, dressing, eating, toileting, and personal hygiene. Resident #72 was occasionally incontinent of bladder and always continent of bowels. Review of Resident #72's comprehensive person-centered care plan revised date of 02/09/23 revealed Focus .has a behavior problem (verbally abusive, aggressive, foul language with other residents), r/t (related to) dementia with mood disturbance. Interventions/Tasks Administer medications as ordered . Review of 05/24/23 Psychiatric Nursing Home Progress Note written by NP revealed Pt is very demanding; Episodes of physical and verbal aggression; other residents do not wish to sit with him; male roommate asked to be moved. Pt wants no tv, no a/c, no lights, at times refuses meds. Medication by NP: Increase Gabapentin 300 mg PO TID for neuropathy; Haldol Decanoate 50mg IM monthly for unsp psychosis/aggression; Please keep me posted Review of Physician Order dated 05/24/23 Haldol Decanoate Intramuscular Solution 50mg/mL (Haloperidol Decanoate) Inject 1 mL intramuscularly one time a day starting on the 25th and ending on the 25th every month for psychosis. Ordered by NP C. Haldol order with Black Box Warning: Warning: Increased mortality in elderly patients with dementia-related psychosis. Elderly patients with dementia-related psychosis treated with antipsychotic are at an increased risk of death . Haloperidol is not approved for the treatment of dementia- related psychosis. Resident #72 did not have a diagnosis of psychosis and Resident #72 was a [AGE] year old male who had a diagnosis of dementia. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676206 If continuation sheet Page 6 of 8 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 676206 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Arbor View 218 Baltic Edinburg, TX 78539 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident #72's Medication Administration Record for May 2023 revealed Resident #72 received Haldol Decanoate Intramuscular Solution 50mg/mL on 05/25/23 per physician orders. In an interview on 06/22/23 at 01:57 p.m., DON stated ANP D, the psych NP, ordered Haldol for Resident #72's verbal yelling and cussing. DON stated NP C rounds three times a week and noticed his verbal behaviors and referred Resident #72 to (ANP D). DON stated diagnosis of psychosis is not on the diagnosis list on PCC (Point Click Care) for Resident #72. DON also stated residents with the diagnosis of Alzheimer's or Dementia it was not recommended they be on an antipsychotic, but if the doctor or psych NP orders it, they (residents) can get it. Attempted telephone interview on 06/22/23 at 04:04 p.m., with ANP D. No answer. Voicemail left. Record review of facility's Psychoactive Medication Management Policy, not dated, revealed: Upon noting an order for psychoactive medication on admission or initiation of therapy: 1. Complete the Psychoactive Medication Evaluation at the initiation of psychoactive medication therapy; Forms and Timing of Completion: 1. The Psychoactive Medication Evaluation completed on admission, readmission, quarterly, and annually and with the initiation of the psychoactive medication; . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676206 If continuation sheet Page 7 of 8 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 676206 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Arbor View 218 Baltic Edinburg, TX 78539 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 0921 Level of Harm - Minimal harm or potential for actual harm Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observation, interview and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 1 of 1 kitchen reviewed in that; Residents Affected - Few Water was observed on the floor of the walk in refrigerator. This failure could place staff at risk of injury while preparing meals for residents. Findings included: Initial kitchen tour, observations and interview with Dietary Manager on 6/20/23 at 9:46 am revealed water on the floor inside the walk in refrigerator. Water was also found at the entrance of the walk in dry storage room located next to the walk in refrigerator. The Dietary Manager said the floor gets wet when the weather is hot outside. She said it does not happen often and it just started happening again recently. She said she put in a work order and told the Maintenance manager and he was working on it and they will be remodeling and replacing both the walk in refrigerator and freezer. The Dietary Manager said she knew having the floor wet in the refrigerator is a potential for accident with staff and reminds them to walk with caution when they see water on the floor. She also said that she requires all her staff to wear non-slip footwear to prevent falls. In an interview on 6/22/23 at 3:51 pm the Maintenance Director said when the problem with the water in the refrigerator happens, he receives a request for work order. He checks the air conditioning units outside and if he is able to fix it, he will do so, if not he calls in the air conditioning company they contract with so they can work on it. He said he received a verbal order on 6/21/23 to work on the water issue in the refrigerator. The Maintenance Director said this does not happen often and happens only in the summer when the weather is hot. In an interview on 6/22/23 at 4:11 pm the Administrator said they were working on the issue of the water on the floor in the walk in refrigerator and will be replacing the inside paneling in the walk in refrigerator and freezer and the air conditioning compressor which is most likely causing the condensation inside. Record review of the facility's General Kitchen Safety Guidelines dated October 2018 states; Policy: The facility will follow basic safety guidelines in order to reduce the risk of accidents and ensure the safety of employees. Procedure: 1. Clean all floor spills immediately to prevent falls. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676206 If continuation sheet Page 8 of 8