Inspection·July 11, 2024

F 0641 10/18/2023 05:50 Level of Harm - Minimal harm or potential for actual harm NURSING - Nurse Note Residents Affected - Few Note Text: pt stated trying get up and went forward from wheelchair and hit bottom lip on floor causing a cut, also chip noted to top tooth with silver cap with assistance of other nurse and staff assessed and picked up pt to bed, notified husband and dr, neuro checks initiated. Record review of facility's incident log not dated revealed that on 10/18/2023 Resident #2 had an unwitnessed fall. No other falls noted. Interview on 07/11/24 at 9:48 AM MDS Nurse A, stated that the MDS department completes resident MDS assessments quarterly and as needed for significant changes, they assist with care plans, and talk to insurances. She said that other staff also assist with completing MDS assessments. She said that falls are typically completed by the MDS department, placed in PCC, and then added to the care plan. She said that they don't always update MDS as a Significant Change when there is a fall. She said that if it was not a significant injury, they do not complete a Significant Change MDS. She said that a significant injury would include injuries such as fracture, injury to head, or injury when a resident must be sent out for care because treatment cannot be completed at the facility. She said that they look at the RAI to see what should or should not be considered a major injury. She said that the RAI was located on PCC. She said that the RAI, section J was captured during the date the quarterly was completed and done within the last 180 days if already claimed in a significant change MDS. She said that for Resident #2 the quarterly MDS was completed on 10/16/23 before the fall. The MDS coordinator said that the discharge was done on 11/20/23 and that it was not coded correctly. She said that the fall should have been captured on the Discharge MDS. She said that she would not consider it a significant change MDS due to no major injury, so the fall would have been captured on Discharge MDS. She said that if the fall was not captured on the MDS, they can modify. She said that they have 2 years to fix. She said that they usually do quarterly audits which are completed by Regional corporate nurses. She said that they provide them with the information needed and they amend it. She said that there would not be any negative outcome. She said if it was care planned there should be no negative outcomes to the resident. She said that all the information gathered through care plan and MDS assessment would come from the resident assessments. Interview on 07/11/24 at 11:10 am DON stated that she has been working at the facility as a nurse for 12 years. She said that the MDS assessment was usually completed if there was a significant injury, such as a fracture or wound. She said that she would consider the injuries sustained during Resident #2's fall as a significant change that would warrant a significant change MDS or at least be coded on the Discharge MDS. She said an adverse effect of not completing an MDS assessment would be no updated care plans to communicate with other staff. She said that she was not sure if the care plans are completed first or the MDS. 2. Record review of Resident #3's Face Sheet revealed Resident #3 was admitted on [DATE] and was [AGE] years old. Resident #3 had diagnoses Type 2 Diabetes Mellitus, Legal Blindness, Epilepsy, Anemia, Emotional Lability, Muscle Wasting and Atrophy, other lack of coordination. Record review of Resident #3's comprehensive care plan reflected: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676206 If continuation sheet Page 2 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676206 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/11/2024 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 0641 The resident has had an actual fall on 04/04/2024- with raised area to left side of head and skin tear to left hand and skin tear to the left upper arm. Initiated: 04/05/2024. Level of Harm - Minimal harm or potential for actual harm Revision on: 04/05/24. Residents Affected - Few Record review of Resident #3's annual MDS dated [DATE] revealed: A score of 3 (severely impaired) for Brief Interview of [NAME] Status. Required substantial/maximal assistance from seat to stand. No falls since previous quarterly MDS assessment. Record review of facility's incident log not dated revealed that on 04/04/2024 at 2:15 PM Resident #3 had an unwitnessed fall. Record review of Resident #3's Change of Condition Communication Form dated 04/04/2024 revealed: Signs/Symptoms Details: Raised area to left side to the head, skin tear to left forearm, skin tear to right middle finger. SN was doing hall walking round and heard the resident yelling for help saying she hurt herself I closed my cart, and went into resident room and found resident face up on the left side of the bed. Upon assessment SN noticed raised skin to the left side of the head discoloration to right left eye and skin tear 3 inches in length to the left forearm, resident told family member she was reaching for her pillow that had fallen and didn't ask for assistance check started family was notified and NP was notified. An observation on 07/09/2024 at 1:17 PM, revealed Resident #3 was in her bed laying down, well dressed, and groomed. Resident #3 said did not remember any recent falls, that she cannot see and does not know. Interview on 07/11/2024 at 2:50 PM, with MDS Nurse A, who completed Resident #3 MDS assessment. MDS Nurse stated that if a fall with injury such as head injury or something that requires immediate intervention or being sent to ER , was sustained, a significant change MDS would be created but if fall without major injury it would be coded on the following MDS. She stated that the fall on 4/4/24 for Resident #3 should have been coded on MDS dated [DATE] but was not. She said not coding Resident#3's fall could reflect an inaccurate assessment but no negative outcome for Resident #3 as the fall was care planned and Resident #3 received proper care and services needed. In an interview on 05/29/24 at 3:54 PM, DON said the fall for Resident #3 needed to be coded in MDS and care planned to communicate to other staff the needs that Resident #3 required. Record review of CMS's RAI Version 3.0 Manual dated 10/2023, that Administrator provided, reflected (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676206 If continuation sheet Page 3 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676206 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/11/2024 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 0641 section: Level of Harm - Minimal harm or potential for actual harm J1800: Any falls since admission/entry or reentry or Prior to Assessment. Coding instructions: Residents Affected - Few Code 1, yes if the resident has fallen since the last assessment. Continue to number of falls since admission/entry or reentry or prior to assessment. J1900: Any falls since admission/entry or reentry or Prior to Assessment. Coding instructions: Code 1, yes if the resident had one non-injurious fall since admission/entry or reentry or prior assessment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676206 If continuation sheet Page 4 of 4