Inspection·September 25, 2024

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident #11 and provided care in the morning around 9:00 a.m. She said at that time, they made sure Resident #11 had his call light within reach. She said he may have moved it away from himself. CNA K said Resident 11 does sometimes use his call light when he needs something. She said Administration and also the nurse in charge always remind them to always make sure the residents are able to reach their call lights to be able to ask for help or assistance. She said if a resident cannot reach it, he or she could fall and get hurt trying to get out of bed. During an interview on 09/25/24 at 10:55 a.m. LVN E said when she starts her shift she goes in to every residents room to introduce herself and to make sure residents are doing well and have everything within their reach including the call lights. She said Resident #11 uses his call light when he needs something. She said she always makes sure he has it within his reach and reminds him to use it. LVN E said that if a resident cannot reach the call light, then they cannot get help, they may have a fall and be at risk of getting hurt. Record review of facility's policy titled Call Lights: Accessibility and Timely Response date implemented: 10/13/22 states; Policy: The purpose of this policy is to assure the facility is adequately equipped with a call light at each residents' bedside, toilet, and bathing facility to allow residents to call for assistance. Policy Explanation and Compliance Guidelines: 1. All staff will be educated on proper use of the resident call system, including how the system works and ensuring resident access to the call light. 2. All residents will be educated on how to call for help by using the resident call system. 5. Staff will ensure the call light is within reachof resident and secured. As needed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676206 If continuation sheet Page 2 of 9 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 09/25/2024 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for the facility's only kitchen reviewed for storage, preparation and sanitation. The facility failed to ensure that food/ drink items in the reach- in freezer, refrigerator, and dry storage area were properly stored, labeled, and dated and were not expired. These failures could place residents at risk for food contamination. Findings included: During observation and interview on initial tour with Dietary Aide on 09/22/24 at 11:15 AM, Revealed two out of six milk jugs in the refrigerator were open and used and did not have an open date. The Dietary Aide stated they had probably just used it because they usually have an open date. One bags of low moisture mozzarella cheese was open to air in an unsealed bag. The Dietary Aide stated they would seal it properly. One bag of Mild Cheddar Cheese was open and not sealed. Mild cheddar cheese was wrapped with plastic wrap at the opening but not sealed from air. One of two boxes of mixed frozen vegetables were not sealed and open to air. One of two southern style biscuit and broccoli melody 1 out 1 were open to air in the freezer. The Dietary Aide stated the Dietary Manager had quit about 2 weeks ago. The facility Administrator was ordering what was needed for the kitchen. During interview with the Dietician on 09/24/24 at 10:40 AM, she stated that she was contract and visits the facility 2-3 times a month. The dietitian stated that Dietary Managers from other sister facilities have been helping in the last 2 weeks. During interview with the Administrator on 09/25/24 at 09:45 AM, she stated that she didn't know exactly when the previous dietary manager resigned, she wants to say about 2-3 weeks, but that thankfully there were 4 sister facilities in the area and the other three facility dietary managers have rotated into this facility to assist. The dietary managers will stay at the facility and sister facility will call if dietary manager is needed. She stated the dietary managers would do orders needed and she would approve. During an observation and interview with the Dietary Manager on 09/25/24 at 09:50 AM, who was from the sister facility that will start officially on 10/05/24 a follow-up walk through of refrigerator and freezer were completed. In the freezer there was 1 out 2 southern style biscuits still open to air, broccoli melody 1 out 1 no longer there and discussed of findings during initial walk through as she was not present. She stated that open foods need to be labeled with received date, open date and placed in bag or container. Surveyor discussed the finding of open milk jugs with no open date but no longer on shelf, cheese open and not sealed and she stated she was made aware of that and that was addressed. She did not know of biscuits but would address it immediately. During interview with the Dietary Manager from sister facility, on 09/25/24 at 10:54 AM, she stated that the food open to air in the freezer would get freezer burn, fresh produce could be open to air as it was fresh. She stated that if something was not dated like the cheese and milk it was to be discarded and would do in-services with staff. She stated that a negative outcome to residents would be if food in freezer or fridge was open to air more than a day and exposed to air it would affect (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676206 If continuation sheet Page 3 of 9 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 09/25/2024 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some the flavor and taste of the food. The food might absorb odors in fridge or freezer, and it should be discarded. The only negative outcome would be the flavor of food would be different. Record review of the Facility Policy for Food Storage Policy Number 03.003 revised June 2019 stated: To ensure that all food served by the facility is of good quality and safe for consumption, all food will be stored according to the state, federal and US Food Codes and HACCP guidelines. 2. Refrigerators d. Date, label and tightly sealed all refrigerated foods using clean, nonabsorbent covered containers that are approved for food storage. 3. Freezer e. Store frozen foods in moisture-proof wrap or containers that are labeled and dated. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676206 If continuation sheet Page 4 of 9 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 09/25/2024 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 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 observations, interviews, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 (Resident #101, Resident #108, and Resident #1) of 4 residents observed for Infection Control. Residents Affected - Few 1. CNA A failed to follow proper infection control while providing incontinent care to Resident #101. 2. CNA B failed to follow proper infection control while providing incontinent care to Resident #108. 3. The facility failed to prevent Resident#1's urinary catheter tubing (bag) from touching the floor. These failures could place the residents at risk of cross-contamination and development of infections. Findings included: 1. Review of Resident #101's Face Sheet, dated 09/25/2024, reflected that the resident was a [AGE] year-old male originally admitted on [DATE]. Resident #101 was diagnosed with benign prostatic hyperplasia without lower urinary tract symptoms. Review of Resident #101's admission MDS Assessment, dated 07/21/2024, reflected that Resident #101's Cognitive Skills for Daily Decision Making - C1000 was severely impaired. Resident #101's Quarterly MDS Assessment indicated that the resident was incontinent for bowel and bladder. Review of Resident #101's Comprehensive Care Plan, dated 07/16/2024, reflected that Resident #101 was incontinent for bowel and bladder and required substantial/maximal assistance for toileting hygiene. Observation on 09/24/24 at 9:27 AM revealed during incontinent care of Resident # 101, CNA A retracted the foreskin of the penis, wiped half circle to tip of the penis, then crumpled and re-wiped opposite half circle to tip of the penis using same wipe. She did not use one wipe per swipe. She then replaced the foreskin and completed the rest of perineal care using proper technique and 1 wipe per swipe. CNA A proceeded to cleanse the buttock area. CNA did not doff soiled gloves, sanitize her hands, and don clean gloves when moving from perineal to buttock area. CNA proceeded to cleanse the buttocks area and wiped using 1 wipe per swipe but cleansed from back to scrotum (dirty to clean) one time out of 4 swipes. In an interview with CNA A on 09/24/2024 at 9:55 AM, she stated they must only use one wipe per swipe, they must change gloves after cleansing peri area and prior to cleansing buttocks area and sanitize hands between glove changes. CNA A said they must clean from clean to dirty not from the back to the scrotum. She said that she was just trying to make sure she removed all the BM. She said that she was nervous. She said that she thinks the last skills check-off she completed was about a month ago and they did an infection control training about a week ago. She said there is not a lack of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676206 If continuation sheet Page 5 of 9 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 09/25/2024 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few training because the facility is constantly reminding them of proper techniques and asking if they feel they need more training. She said they even watch videos. She said that if she did not use 1 wipe per swipe, change gloves and hand sanitize between care of peri area and buttocks, or wipe from clean to dirty an infection can happen. 2. Review of Resident #108's Face Sheet, dated 09/25/2024, reflected that the resident was a [AGE] year-old female admitted on [DATE]. Resident #108 was diagnosed with muscle wasting and atrophy (waste away of body tissue or organ), and other abnormalities of gait (manner of walking) and mobility. Review of Resident #108's admission MDS Assessment, dated 09/01/2024, reflected Resident #108 had a moderate impairment in cognition with a BIMS score of 10. The Quarterly MDS Assessment indicated that the resident was incontinent for bladder and bowel. Review of Resident #108's Comprehensive Care Plan, dated 08/30/2024, reflected Resident #108 required supervision/touching assistance for toileting hygiene. Observation on 09/24/2024 at 10:00 AM revealed during incontinent care of Resident # 108, CNA B cleansed top of external pubic area using one wipe per swipe, CNA B doffed soiled gloves and donned clean gloves. CNA did not sanitize between glove changes. CNA B continued cleansing the peri area starting with urethral area then right outer labia using one wipe per swipe. CNA B wiped the left outer labia, then wiped it again using the same wipe. CNA B did not use one wipe per swipe. CNA B continued to wipe the remaining of the peri area from front to back using appropriate technique and one wipe per swipe. She doffed her soiled gloves, washed hands with soap and water for more than 20 seconds, donned clean gloves and began cleansing the buttocks area. CNA B wiped the left side of the buttocks with a wipe, wiped again using the same wipe, then disposed of the wipe. She then grabbed another wipe and wiped the left side again, then wiped again using the same wipe. She repeated the same process to the right side of the buttocks. CNA B did not use one wipe per swipe. In an interview with CNA B on 09/24/2024 at 10:35 PM, CNA B stated she should use one wipe per swipe and always sanitize between glove changes. She said if they did not an infection can happen. She said that she completed a training on infection control about a week ago. She said she had also been checked off on her skills for incontinent care. In an interview with CNA C on 09/24/2024 at 10:40 AM, she stated she was the lead CNA and conducted training for the CNAs. She said wipes were used one time then must be thrown away. She said gloves must be changed between cleaning peri area and buttocks and must always sanitize between glove changes. She said if they don't do that the resident can get an infection. She said the CNAs do receive trainings and get checked off on their skills upon hire and around every 3 months. She said training is ongoing for perineal care and infection control. In an interview with the DON on 09/24/2024 at 10:50 AM, she said the facility trained and provided re-education for incontinent care and infection control monthly to include skills check offs. She said they are instructed to use a wipe once and throw it away because it cannot be used again. The DON said they are instructed to remove dirty gloves and apply clean gloves and sanitize in between. She said they must always change gloves after touching any soiled area. She said CNAs would have to change gloves when moving from care to vaginal area and care of the buttocks. She said that the CNAs must clean from clean to dirty. In an interview with the IP on 09/25/2024 at 10:58 am she said that training was constant and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676206 If continuation sheet Page 6 of 9 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 09/25/2024 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few on-going every day because hand hygiene was the most effective way to prevent cross contamination and infection. She stated that she empowers other administration to observe and re-instruct on hand-hygiene and infection control. She stated they include information on infection control before morning meetings, they ask department heads if during their rounds anything was questionable or out of place so they can fix it right away. She stated they also try to make it fun. She said they have a sink that they take down all the halls and have staff go through the motions of hand washing and hand sanitizing. She said she made sure staff wait for sanitizer to evaporate. She said the facility also provided staff monthly trainings and checked-off in infection control. 3. Record review of Resident#1's face sheet revealed a [AGE] year-old male originally admitted on [DATE]. Resident#1 had primary/admitting diagnosis of alzheimer's disease (a progressive disease that destroys memory and other important mental functions), obstructive and reflux uropathy (when flow of urine is blocked in the bladder, ureter urethra), retention of urine (a disorder characterized by accumulation of urine within the bladder because of the inability to urinate). Record review of Resident #1's MDS dated [DATE], Section C-Cognitive patterns revealed Resident #1 had a BIMS score of 2 which indicated Resident #1 had severely impaired cognition. Section H-Bladder and bowel revealed resident #1 has an indwelling catheter. Record review of Resident #1's care plan revealed Resident #1 has a foley catheter Obstructive and reflux uropathy Date initiated 03/13/24 and revised on 03/20/24 and Resident #1 has (indwelling/foley) Catheter Obstructive and Reflux uropathy date initiated 03/13/24 and revised on 03/20/24 Intervention/tasks listed Provide catheter care every shift and Position catheter bag and tubing below the level of the bladder and away from entrance room door initiated and revised on 03/10/24. Record review of Order Summary has order printed 09/24/24 revealed order to Change Foley Catheter 16 # FR with 30mL/cc balloon q month and if plugged out or dislodged PRN. Order Foley catheter check q shift and PRN start dated 03/13/24. During an observation on 9/22/24 at 12:30 PM, Resident #1 foley catheter bag was noted laying on the floor under the Resident #1 wheelchair in the dining area. Resident #1 was non interviewable. During interview with LVN A on 09/22/24 at 1:00 PM, LVN A was informed and shown catheter bag laying on the floor. She stated it that she was taking Resident #1 to his room to have his midline check. She stated that she checked earlier around 11:00 AM and foley catheter bag was not touching the floor at that time when he was in his wheelchair. LVN A stated that she did not notice the foley bag dragging on the floor because she was preoccupied with getting Resident #1 to his room and back to the dining area. LVN A stated if Resident's #1 foley bag is dragging on the floor, it is an infection control issue. LVN A stated that foley bag should never be touching the floor because it could get pinched, or it could cause a leakage if the foley bag is dragging on the floor. During an interview with LVN B on 9/24/24 at 10:20 AM, LVN B stated that when a foley catheter bag is dragging the floor is a high risk for cross contamination, and Resident #1 was at risk to get an infection. LVN B stated that was a tripping hazard. During an interview with LVN C on 9/24/24 at 10:30 AM, LVN C stated that when foley catheter bag was on the floor bacteria could enter the bag and Resident #1 could be getting an infection. During interview with RN A on 09/24/24 at 10:45 AM, she stated that the foley catheter bag should (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676206 If continuation sheet Page 7 of 9 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 09/25/2024 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few not be on the floor because it could cause a urinary tract infection to Resident #1. RN A stated that residents were susceptible and by dragging the bag on the floor the risk of infection was higher. Record Review of Policy Titled Infection Prevention and Control Program with implemented date 5/13/2023, This facility has established and maintains 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 disease and infections as per accepted national standards and guidelines. Review of the facility's Infection Control Policy implemented 5/13/23 revealed, Policy: This facility has established and maintains 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 as per accepted national standards and guidelines. Policy Explanation and Compliance Guidelines: . 4. Standard Precautions: a. All staff shall assume that all residents are potentially infected or colonized with an organism that could be transmitted during the course of providing resident care services. b. Hand hygiene shall be performed in accordance with our facility's established hand hygiene procedures. c. All staff shall use personal protective equipment (PPE) according to established facility policy governing the use of PPE. Policy for Incontinent Care requested on 09/24/2024 at 10:50 AM and the DON provided a copy of pages from Lippincott Nursing Procedures, 7th Edition. The DON said they follow Lippincott Nursing Procedures. Review of documents revealed, Perineal Care: Perineal care, .includes care of the external genitalia and the anal area .promotes cleanliness and prevents infections. Standard precautions must be followed when providing perineal care . Implementation: Perform hand hygiene and put on gloves. Put on gloves to comply with standard precautions. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676206 If continuation sheet Page 8 of 9 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 09/25/2024 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 0880 For a female patient: Level of Harm - Minimal harm or potential for actual harm Clean, rinse, and dry the anal area, .wiping from front to back. For a male patient: Residents Affected - Few Clean the bottom of the scrotum and the anal area. Completing the procedure: Remove and discard your gloves. Perform hand hygiene. Reviewed Incontinent Care Proficiency Checklist provided by CNA C for CNA A and CNA B both dated 5/6/24. The checklists revealed the following: .Put on gloves. Turn resident to side away from you and cleaning from front to back clean the rectal area (for women clean from the vaginal area to the rectum). Use more than one washcloth, if needed (wipe) . Wash hands before performing peri care. Use hand gel between glove changes. If heavily soiled, wash hands with soap and water. Wash hands after cleaning the resident and before touching clean linens. Wash hands after peri care is completed and before leaving the room. Wash hands any time you are unsure if you touched something dirty. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676206 If continuation sheet Page 9 of 9