Health inspection·September 11, 2025

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to ensure all alleged violations including abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (which included to the State Survey Agency) in accordance with State law through established procedures for 1 of 4 residents (Resident #1) reviewed for reporting alleged allegation of abuse. The facility failed to report, within 2 hours, when Resident #1 was diagnosed with a nondisplaced proximal fibular fracture on 01/30/25. This failure could place residents at risk for undetected abuse, neglect and/or decline in feelings of safety and well-being. The finding included: Record review of Resident #1's admission sheet dated 09/11/25 reflected a [AGE] year-old female with an admit date of 04/06/21 and an original admission date of 06/12/18. Her relevant diagnoses included vascular dementia ( brain damage caused by multiple strokes), edema (swelling that occurs when fluid builds up in the body's tissue), muscle wasting and atrophy (decrease in size and wasting of muscle tissue), lack of coordination, osteoporosis (a condition in which bones become weak and brittle), and weakness. Record review of Resident #1's quarterly MDS assessment dated [DATE], reflected a BIMS score of 15, which indicated her cognition was intact. Record review of Resident #1's quarterly care plan dated 08/28/25, reflected:Problem:[Resident #1] has a nondisplaced proximal fibular fracture (dated initiated/revised 01/31/25).Goal: will not develop complications or permanent loss of mobility related to fracture (dated initiated/revised 01/31/25).Interventions/Tasks in part included: set up appointments with orthopedic, support injured area with pillows and immobilize part as appropriate, and weigh bearing as tolerated. Record review on 09/08/25 of Resident #1's change in condition completed by the DON dated (late entry) 01/26/2025 4:30 pm which reflected: SN informed by CNA that resident was assisted to restroom and when standing resident up, resident stated her knees gave out and resident was assisted to floor with CNA. Resident did not hit her head. SN performed head to toe assessment, no abnormalities noted. Resident states no pain upon assessment. Resident was transferred by mechanical lift on to chair then back to bed. Resident stated that she did not fall and stated that her knees gave out. Resident complains of no pain. Head to toe assessment performed, resident able to perform active range of motion to upper extremities. Resident able to perform active range of motion to lower extremities. Record review on 09/08/25 of Resident #1's late entry progress note dated 01/30/25 at 4:38 pm, reflected: NP came to round on patients. N.O. for an x-ray of the right leg and ankle due to pain. Record review on 09/08/25 of Resident #1's late entry progress note dated 01/30/25 at 5:54 pm, authored by NP reflected: complaining of some leg pain mainly to the lower part of her knee as per patient she Page 1 of 10 676206 676206 09/11/2025 Windsor Arbor View 218 Baltic Edinburg, TX 78539

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few states that she hit herself in the restroom few days ago. She states that she did not let any of the nursing staff know. Record review on 09/08/25 of Resident #1's x-ray results dated 01/30/25 at 9:50 pm, reflected Resident #1 had a nondisplaced proximal fibular fracture (still broken bones but the pieces didn't move far enough to be out of alignment during the break). Record review on 09/08/25 of Resident #1's progress note dated 01/31/25 at 5:16 am, reflected: Received report from 2-10 nurse regarding patients pending Xray of right leg and ankle due to pain. Results were reviewed and N/O from PA to do repeat of x-ray to the right leg and ankle were ordered and carried out. Record review on 09/08/25 of Resident #1's x-ray results dated 01/31/25 at 1:39 pm, reflected Resident #1 had an age-determinate fracture ( not sure how long ago the fracture occurred) of her right tibia/fibula . Record review on 09/08/25 of TULIP (HHSC online incident reporting application) reflected a self-report from the facility's Administrator on 01/31/25 at 4:20 am, more than 24 hours after Resident #1's diagnosis of a nondisplaced proximal fibular fracture. The allegation was injury of unknown origin. In an interview on 09/04/25 at 3:25 pm, Resident #1 said she did not remember the exact date but said she had an incident while she was being assisted from the toilet to her wheelchair. She said there were 2 CNAs assisting in the transfer, when of all of a sudden she felt her knees giving out. She said she advised the CNAs to sit on the floor because she was not going to make it to the wheelchair. She said one of the CNAs stayed with her and the other went to call the nurse. Resident #1 said between the nurse and both CNAs, she was transferred back to bed in a mechanical lift. Resident #1 said she did not have any pain at that time and refused medication. She said the following day, she started having pain and was given pain medication and it was alleviated. Resident #1 said days later her doctor visited her and she told him about the incident in the restroom and that she was still experiencing pain to her right lower leg. She said her pain started the day after the incident in the restroom. Resident #1 said at no time was she left with pain. Resident #1 said she had never been abused or neglected while in the facility. An interview on 09/04/25 at 4:08 pm, CNA C said she and CNA D took Resident #1 to the restroom and while assisting her from the toilet to the wheelchair (using a gait belt) she said they both felt Resident #1 was going limb, and her knees were giving out. She said at the same time Resident #1 told them her knees were giving out and to sit her on the floor. CNA C said at that point Resident #1 and both of them decided to assist the resident in sitting her on the floor. She said one of the CNAs stayed with her and the other one went to call LVN E. She said when LVN E arrived, she had done a head-to-toe assessment and Resident #1 was transferred back to bed in a mechanical lift. She said Resident #1 did not have any discolorations, bleeding, or injuries. CNA C said Resident #1 did not complain of pain when she was assessed by LVN E or when she was placed back in bed. CNA C said at no time did Resident #1 hit her legs or head while she was being assisted to the floor. An interview on 09/04/25 at 4:20 pm, CNA D said she and CNA C took Resident #1 to the restroom and while assisting her from the toilet to the wheelchair (using a gait belt) Resident #1 told them that her knees were giving out. She said Resident #1 told them to sit her on the floor. She said Resident #1 was sat on the floor and was assessed by LVN E. CNA D said between the three of them, Resident #1 was transferred back to bed in a mechanical lift. She said Resident #1 had not sustained any injuries while she was being assisted to the floor, and she denied having any pain. CNA D said at no time did Resident #1 hit her legs or head while she was being assisted to the floor. An interview on 09/4/25 at 4:35 pm., LVN E she had been called by either CNA D or CNA C when Resident #1 had requested to be sat in her restroom's floor on 01/26/25. She said when she got to the restroom, Resident #1 in a sitting position on the floor. LVN E said Resident #1 told her that while she was being assisted from the toilet to her wheelchair, her knees started to give out. She said 676206 Page 2 of 10 676206 09/11/2025 Windsor Arbor View 218 Baltic Edinburg, TX 78539

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident #1 said both CNA D and CNA C to sit her on the floor because she was not going to make it to her wheelchair. She said had immediately assessed her and did a ROM of upper and lower extremities and Resident #1 was able to move all limbs. She said Resident #1 told her she had no pain and had not hit her herself while being assisted to the floor. LVN E said after that, she and both CNAs transferred Resident #1 back to her bed in a mechanical lift. She said she re-assessed Resident #1 again while in bed and Resident #1 denied any pain. She said she did not see any discoloration, bleeding, or deformities on Resident #1. She said had not done a change of condition, or any assessment, or an incident report because to her it was not a fall. She said a negative outcome of not doing an incident report, a change in condition and informing her DON could be that Resident #1 would have been treated sooner.An interview on 09/04/25 at 4:44 pm, the DON said that on 01/30/25, Resident #1 had voiced to the NP that she had pain to her lower right extremity. She said the NP ordered x-rays that same day of her right tibia/fibula. She said the finding showed Resident #1 had a non-displace fibular fracture right leg on 01/30/25. She said the NP ordered a second x-ray on 01/31/25 and the findings showed an age-indeterminate fracture of the right tibia/fibula. The DON said LVN E had failed to do an incident report, change of condition, and/or notified herself of the incident. The DON said LVN E had received a counseling for failure to report an incident. The DON said Resident #1's first x-ray on 01/30/25 it showed a non-displaced proximal fibular fracture. The [NAME] said the facility received the first x-ray findings on 01/30/25 at 9:51 pm and was reported to state on 01/31/25 at 4:20 am. She said it had not been reported within the 2 hours window. An interview on 09/04/25 at 5:05 p.m., the Administrator said she had been notified by Resident #1's NP that she was having pain to her right lower extremity. She said on 01/30/25, Resident #1's NP ordered an x-ray of her right tibia/fibular. She said the results of the first x-ray (right tibia/fibula) were received on 01/30/25 and indicated a nondisplaced proximal fibular fracture. She said when Resident #1's NP was notified of the findings on 01/31/25, he ordered a second x-ray of right tibia/fibula. She said those results were received on 01/31/25 which indicated an age-indeterminate fracture. She said she waited for the results of the second x-ray to report it to state. The Administrator said the reason she had not reported Resident #1's nondisplaced proximal fibular fracture on 01/30/25 (within 2 hours of being received) was because her NP had ordered a second x-ray to confirm fracture. The Administrator said they had not done an investigation. During a telephone interview on 09/09/25 at 10:57 am, The NP said when he was doing his rounds on 01/30/25, Resident #1 had complained of having pain to her lower right extremity. He said he ordered an x-ray on 01/30/25 and was informed of the results that same day. He said Resident #1's first x-ray showed she had a nondisplaced proximal fibular fracture. The NP said at that point he accepted the findings of the first x-ray but ordered a second x-ray to confirm the injury. The NP said that was a normal practice for him when the findings showed a fracture to order a second x-ray to have a second set of eyes confirm the injury. Record review of the facility's Abuse, Neglect, and Exploitation policy dated 07/11/25 reflected:Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that exhibit and prevent abuse, neglect, exploitation and misappropriation of resident property. VII. Reporting/Response:A. The facility will have written procedures that include:1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes:a. Immediately by no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or 676206 Page 3 of 10 676206 09/11/2025 Windsor Arbor View 218 Baltic Edinburg, TX 78539

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible and each resident received adequate supervision to prevent accidents for 1 of 3 residents (Resident 21) reviewed for accidents and supervision, in that:The facility failed to ensure Resident #2 received adequate supervision to prevent him from exiting the facility undetected on 06/06/25.The non-compliance was identified as Past Non-Compliance. The Immediate Jeopardy (IJ) began on 06/06/25 and ended on 06/07/2025. The facility corrected the non-compliance before the investigation began.Past Non-Compliance form sent to Administrator on 09/11/25 at 11:49 am.This failure could place the residents at risk for injury or death. The findings included: Record review of Resident #2's admission sheet dated 09/09/25 reflected a [AGE] year-old male with an admission date of 05/26/25 and a discharge date of 06/07/25. His relevant diagnoses included diabetes (too much sugar in the blood), hypertension (a condition in which the force of the blood against the artery walls is too high), abnormalities of gait and mobility (a change in walking pattern), and lack of coordination (impaired balance or coordination). Record review of Resident #2's 5-day Medicare MDS assessment dated [DATE], reflected a BIMS score of 6, which indicated his cognition was severely impaired. MDS further indicated, Resident #2 had not exhibited wandering behaviors. Record review of Resident #2's initial care plan dated 05/29/25, reflected:Problem: [Resident #2] is an elopement risk/wanderer r/t disorientated to place, impaired safety awareness resident wanders aimlessly (date initiated 06/06/25 and cancelled on 06/10/25).Interventions: in place included complete wandering evaluation tool, distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, books (date initiated 06/06/25 and cancelled on 06/10/25). Record review of Resident #2's wandering evaluation dated 05/25/25, reflected he was not a wandering risk. Record review of Resident #2's progress notes dated 06/06/25 at 9:20 pm, authored by LVN F, reflected Upon interviewing [Resident #2] he stated that he exited through the east exit door pushing the bar and door opening. Record review of Resident #2's progress notes dated 06/06/25 at 11:13 pm, authored by LVN F, reflected a change of condition Patient was found outside of facility across the street from facility in the sidewalk. Record review of Resident #2's progress notes dated 06/06/25 at 11:15 pm, authored by LVN F, reflected At 9 pm cna's moved resident to RM [ROOM NUMBER] from 407 due to plumbing issues. At 9:30 pm Med Aide F saw resident in his room. 9:40pm nurse went to check on patient and he was not in room nor in restroom. Activated code pink at 9:45pm. At 9:50pm resident was found across the street on sidewalk and was brought back to facility via wheelchair. At 9:55pm head to toe assessment was performed no noted injuries, patient denies falling while not at facility, denies pain or discomfort. Resident shows no signs of distress or discomfort, resident in good spirits. Notified family. Notified NP and ordered a cbc, cmp, and a ua to be collected . In an interview on 09/10/25 at 2:24 pm, CNA U said the last time she saw Resident #2 on 06/06/25 was around 8:00 pm. She said around 9:30 pm, she and CNA B went to his room to check on him and they discovered he was not in his room. She said she immediately notified LVN A (Charge Nurse), who activated code pink. She said at that time all staff started looking for him. She said by the time she checked her assigned hall/rooms; she was told Resident #2 had been found outside. She said she immediately went outside to see if staff needed help. She said by that time, Resident #2 was being escorted by LVN A and CNA B and were already in the facility's parking lot. She said she noticed Resident #2 was not wearing shoes, only socks. She said the weather was not too hot and not too cold. She said once Resident #2 was back in his room, she gave him water. CNA U said Resident #2 was confused and kept saying 676206 Page 4 of 10 676206 09/11/2025 Windsor Arbor View 218 Baltic Edinburg, TX 78539

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few he was going home. She said at no point did she hear the door alarm go off. She said when the maintenance director was checking the door alarms after the incident (that same night), they were working. CNA U said the facility had provided in-services on the topics of elopement and responding to door alarms. CNA U said the facility also had monthly elopement drills. CNA U said Resident #2 was placed on a 1:1 for supervision immediately after he was found. CNA U said Resident #2 had not displayed any exit seeking behaviors since he was admitted . An interview on 09/10/2025 at 2:37 pm, CNA B said on 06/06/25, she last saw Resident #2 at about 8:00 pm. Resident #2 when she and CNA U had gone to his room to do their final round around 9:40 pm she noticed Resident #2 was not in his room. She said she checked down his hall and enclosed patio near his room, but he was not found. CNA B said she immediately notified LVN A (Charge Nurse) who activated code pink via the intercom. She said LVN A named the resident, what he was wearing and had his picture available for staff for that did not know who he was. She said she was assigned a certain hall and rooms to search for Resident #2. She said by the time she searched her assigned hall and rooms; she headed outdoor through the east side entrance. She said the east side entrance was the closest door to Resident #2's room. She said as soon as she went outside; she noticed other staff members were already out there searching for Resident #2. She said at some point she and LVN A saw Resident #2 directly across the street from the facility on the sidewalk. CNA B said when Resident #2 was identified, LVN A told her to go back to the facility to get a wheelchair. CNA B said by the time she went back outside with the wheelchair; Resident #2 was being escorted back to the facility by LVN A. She said she saw Resident #2 talking with two unidentified persons while he was standing on the sidewalk. She said once the resident was back in the room, she went in check on him. She said Resident #2 was thirsty and confused. She said she never heard any alarms go off. She said if she had heard the alarm, they are trained to stop what they are doing and go check on the door. She said they had received in-service on elopement and responding to door alarms days after the incident. CNA B said the facility also conducted practice elopement drills.In an interview on 09/10/25 at 2:45 pm, LVN A said on 06/06/25 at about 9:40 pm, CNA B and CNA U went to check on Resident #2 before their shift ended. LVN A said CNA B and CNA U told her that Resident #2 was not in his room. She said she and both CNAs checked his hallway and an enclosed patio but was not found. LVN A said she activated code pink via intercom at 9:45 pm and the search continued ensured both indoors and outdoors. LVN A said she and CNA B exited the facility through the east side entrance and combed the parking lot and that's when they saw Resident #2 on the sidewalk directly across the facility. She said the distance was about 50 yards from the facility. LVN A said Resident #2 was seen conversing with a couple that lived at a nearby apartment complex. LVN A said Resident #2 was wearing his own personal clothes and socks (no shoes). LVN A said Resident #2 had not sustained any injuries and Resident #2 kept saying he wanted to go home. LVN A said immediately after Resident #2 was [NAME] back to the facility, he was placed on a 1:1 for supervision until he was discharged on 06/07/2025. LVN A said the door alarm was not activated when Resident #2 exited the facility. LVN A said the maintenance Supervisor was called back to the facility that same night and checked all the door alarms and all were working.In an interview on 09/10/25 at 11:00 am, the Administrator said she had been notified the evening of 06/06/25 that Resident #2 had exited the facility sometime between 9:30 pm and 9:45 pm. She said Resident #2 was found at around 9:50 pm directly across the street from the facility on the sidewalk talking to two unidentified persons. She said she did not call the local police department because, he was found within 5 minutes. The Administrator said LVN A had conducted a head-to-toe assessment and no injuries were found. She said Resident #2 was immediately placed on a 1:1 for supervision. She said staff had told her that they did not hear any door 676206 Page 5 of 10 676206 09/11/2025 Windsor Arbor View 218 Baltic Edinburg, TX 78539

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few alarms when Resident #2 had exited the facility. The Administrator said she was told by staff that the east side door entrance alarm had not been activated when R#2 exited the facility. She said when she interviewed R#2, he told her he had not heard any noise when he opened the door. The Administrator said she called Resident #2's RP the night of the incident and had given her the option to place Resident #2 in a secured unit at another facility. She said Resident #'2 RP had refused placing Resident #2 in a secured unit. The Administrator said Resident #2's RP opted to take him back home on [DATE]. The Administrator said on 06/06/25 sometime in the afternoon, the Maintenance Supervisor had called in a service request to a local electronic engineering company to service the same door Resident #2 used to exit the facility. She said before the technician left the facility, he ensured the door alarm and 15 second egress were functioning properly. The Administrator said the same night of the incident, the Maintenance Supervisor had gone to check all the door alarms, and all were working properly. She said she had called the same local electronic engineering company on 006/07/25 to inspect all the door alarms and install battery powered screamers to all doors. The Administrator said all staff had been in-serviced on the topic of elopements, responding to door alarms, and ANE. She said the facility's social worker had conducted a wander/elopement assessment on all residents. The Administrator said she was told by staff that the east side door entrance alarm had not been activated when Resident #2 exited the facility. In an interview on 09/09/25 at 4:49 pm, the Maintenance Supervisor said on 06/06/25 around 10:00 pm, he had received a call from the Administrator to report back to the facility due to an elopement. He said the DON and ADON were already in the facility. He said the first thing he did was change the codes to the alarm panels on all doors and check all door alarms and the 15 second egress. He said all were working. He said he went to the place where Resident #2 was found, and it was between 40 to 50 yards from the facility. He said the place where Resident #2 was found was directly across the facility and in front of an apartment complex. He said the following day (Saturday) he went back to the facility to recheck all the door alarms, and all were working. He said he also called a local electronic engineering company to come and check all doors alarms and all were working. He said earlier the day of 06/06/25 around 2:00-2:30 pm, a local electronic engineering company was called to service (as a priority call) for the same door it was believed Resident #2 had exited. He said the issue was that one of the bolts on the door was loose and making the maglock not have contact with the magnet. He said before the technician left both he and the technician had checked the door, and the alarm was working it was back to normal. The maintenance Supervisor said while the technician was in the building he had him check all doors alarms. He said he had no idea why the door alarm had not gone off when Resident #2 exited the facility. He said he would daily checks on all door/alarms to ensure they were working properly.Record review on 09/09/25, of the Maintenance Supervisor's daily door/alarm inspection log for the week of 06/02/25 to 06/06/25 and all doors passed the checks.Record review on 09/09/25 of a local electronic engineering company's invoice dated 06/06/25 reflected: That around 2:13 pm, technician call was made to investigate and correct maglock mounting problem to door frame. Screws are stripping out of door frame. The following was done: removed maglock and adjusted position slightly for new holes to be drilled and threaded in an unused portion of the door frame. Remounted maglock with bigger screws threading into the doorframe. Job completed. Record review on 09/10/25 of the facility's elopement drill logs for 2025 reflected they were done on:January 27, February 27, March 28, April 15, May 30, June 27, July 23, August 20, and September 5. Record review of the facility's Elopement and Wandering Residents policy dated 11/21/22 reflected:Policy:This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in 676206 Page 6 of 10 676206 09/11/2025 Windsor Arbor View 218 Baltic Edinburg, TX 78539

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. Definitions:Elopement occurs when a resident leaves the premises or a safe area without authorization (e.g., an order for discharge or leave of absence) and/or any necessary supervision to do so. Policy Explanation and Compliance Guidelines:2.Alarms are not a replacement for necessary supervision. Staff are to be vigilant in responding to alarms in a timely manner.4.Monitoring and managing residents at risk for elopement or unsafe wandering: d. adequate supervision will be provided to help prevent accidents or elopements.5. Procedure for locating missing residents:a. Any staff member becoming aware of a missing resident will alert personnel using facility approved protocol (e.g., internal alert code.)b. The designated facility staff will look for the resident.c. If the resident is not located in the building or on the grounds, Administrator or designee will notify the policy department and serve as the designated liaison between the facility and the policy department. 6. Procedure Post-Elopement:a. A nurse will perform a physical assessment, document, and report finding to physician.b. Any new physician's orders will be implemented and communicated to the family/authorized representative.c. A social service designee will re-assess the resident and make any referrals for counseling or psychological/psychiatric consults.d. The resident and family/authorized representative will be included in the plan of care.g. Documentation in the medical record will include findings from nursing and social services assessments, physician/family notification, care plan discussions, and consultant note as applicable. Record review on 09/10/25 of the facility's in-services reflected the following in-services were conducted with staff after the incident on 06/06/25, 06/07/25, 06/08/25, 06/09/25, and 06/10/25:Topic: elopement prevention (code pink, acknowledge door alarms, do not only put the code on keypad but check outside/surroundings)Topic: abuse/neglect/exploitationTopic: resident supervision (monitor residents frequently) An interview on 09/10/25 and 09/11/25 with CNAs: B, C, D, F, G, H, I, J, L, U, V, X, Y, AA reflected all had been in-serviced on the topics of elopement prevention, resident supervision, and ANE. All knew the facility's elopement code and facility's protocols when a resident went missing. An interview on 09/10/25 and 09/11/25 with LVNs and RNs: A, E, M, N, O, P, Q, S, T, Z reflected all had been in-serviced on the topics of elopement prevention, resident supervision, and ANE. All knew the facility's elopement code and facility's protocols when a resident went missing. Record review on 09/10/25 of the facility's Social Worker's wander/elopement assessment conducted on 06/07/25 for 100% of residents. Record review on 09/11/25 of the facility's invoice on a service call done by a local electronic engineering company on 06/07/25 reflected checked all doors for functionality. All door maglocks were holding. Delayed egress was working as intended and annunciator was ringing. Maintenance added battery powered screamers to every door as additional alarms. System normal. Record review on 09/10/25 of the facility's elopement binder on the east and west side nurse's station reflected they were up to date. During an observation on 09/10/25, the Maintenance Supervisor was observed testing Door #6, #7, #10,#1, # 2, and #5. The alarms and the 15 second egress were working. The non-compliance was identified as Past Non-Compliance. The Immediate Jeopardy (IJ) began on 06/06/25 and ended on 06/07/25. The facility corrected non-compliance before the investigation began. 676206 Page 7 of 10 676206 09/11/2025 Windsor Arbor View 218 Baltic Edinburg, TX 78539

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 interviews and record review, the facility failed to maintain clinical records on each resident that were complete and accurately documented in accordance with accepted professional standards and practices for 1 (Resident #1) of 3 residents by 1 of 1 nurse (LVN E) reviewed for accuracy and completeness of clinical records.The facility failed to ensure LVN E correctly completed Resident #1's assessment on 01/26/25 after her knees gave out and resident was assisted to the floor. This failure could place residents at risk for not receiving nursing services by adequately trained nurses and could result in a decline in health. The findings included:Record review of Resident #1's admission sheet dated 09/11/25 reflected a [AGE] year-old female with an admit date of 04/06/21 and an original admission date of 06/12/18. Her relevant diagnoses included vascular dementia (brain damage caused by multiple strokes), edema (swelling that occurs when fluid builds up in the body's tissue), muscle wasting and atrophy (decrease in size and wasting of muscle tissue), lack of coordination, osteoporosis (a condition in which bones become weak and brittle), and weakness.Record review of Resident #1's quarterly MDS assessment dated [DATE], reflected a BIMS score of 15, which indicated her cognition was intact.Record review of Resident #1's quarterly care plan dated 08/28/25, reflected:Problem:[Resident #1] has a nondisplaced proximal fibular fracture (dated initiated/revised 01/31/25).Goal: will not develop complications or permanent loss of mobility related to fracture (dated initiated/revised 01/31/25).Interventions/Tasks in part included: set up appointments with orthopedic, support injured area with pillows and immobilize part as appropriate, and weigh bearing as tolerated.Record review on 09/04/25 of Resident #1's change in condition completed by the DON dated (late entry) 01/26/2025 4:30 pm which reflected: SN informed by CNA that resident was assisted to restroom and when standing resident up, resident stated her knees gave out and resident was assisted to floor with CNA. Resident did not hit her head. SN performed head to toe assessment, no abnormalities noted. Resident states no pain upon assessment. Resident was transferred by Hoyer lift on to chair then back to bed. Resident stated that she did not fall and stated that her knees gave out. Resident complains of no pain. Head to toe assessment performed, resident able to perform active range of motion to upper extremities. Resident able to perform active range of motion to lower extremities.In an interview on 09/04/25 at 3:25 pm, Resident #1 said she did not remember the exact date but said she had an accident while she was being assisted from the toilet to her wheelchair. She said there were 2 CNAs assisting in the transfer, when of all of a sudden she felt her knees giving out. She said she told the CNAs to sit on the floor because she was not going to make it to the wheelchair. She said one of the CNAs stayed with her and the other went to call the nurse. Resident #1 said between the nurse and both CNAs, she was transferred back to bed in a Hoyer lift. Resident #1 said she did not have any pain at that time and refused medication. She said the following day, she started having pain and was given pain medication and it helped. Resident #1 said days later her doctor visited her and she told him about the incident in the restroom and that she was still experiencing pain to her right lower leg. She said her pain started the day after the incident in the restroom but was controlled with pain medication.An interview on 09/04/25 at 4:08 pm, CNA C said she and CNA D took Resident #1 to the restroom and while assisting her from the toilet to the wheelchair (using a gait belt) she said they both felt Resident #1 was going limb, and her knees were giving out. She said at the same time Resident #1 told them her knees were giving out and to sit her on the floor. CNA C said at that point Resident #1 and both of them decided to assist the resident in sitting her on the floor. She said one of the CNAs stayed with her and the other one went to call LVN E. She 676206 Page 8 of 10 676206 09/11/2025 Windsor Arbor View 218 Baltic Edinburg, TX 78539

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few said when LVN E arrived, she had done a head-to-toe assessment and Resident #1 was transferred back to bed in a Hoyer lift. She said Resident #1 did not have any discolorations, bleeding, or injuries. CNA C said Resident #1 did not complain of pain when she was assessed by LVN E or when she was placed back in bed. CNA C said at no time dis Resident #1 hit her legs or head while she was being assisted to the floor.An interview on 09/04/25 at 4:20 pm, CNA D said she and CNA C took Resident #1 to the restroom and while assisting her from the toilet to the wheelchair (using a gait belt) Resident #1 told them that her knees were giving out. She said Resident #1 told them to sit her on the floor. She said Resident #1 was sat on the floor and was assessed by LVN E. CNA D said between the three of them, Resident #1 was transferred back to bed in a Hoyer lift. She said Resident #1 had not sustained any injuries while she was being assisted to the floor, and she denied having any pain. CNA D said at no time dis Resident #1 hit her legs or head while she was being assisted to the floor.An interview on 09/4/25 at 4:35 pm., LVN E she had been called by either CNA D or CNA C when Resident #1 had requested to be sat on the floor on 01/26/25. She said when she got to the restroom, Resident #1 in a sitting position on the floor. She said had immediately assessed her and did a ROM of upper and lower extremities. She said Resident #1 told her she did not have pain and had not hit her head. LVN E said after the head-to-toe assessment, she and both CNAs transferred Resident #1 back to her bed. She said she assessed Resident #1 again while in bed and Resident #1 denied any pain. She said she did not see any discoloration, bleeding, or deformities. LVN E said at that time, she had not done a change of condition or incident report, because to her it was not a fall. LVN E said on 01/31/25 she was counseled for failure to report the incident Resident #1 had on 01/26/25. She said she was told that even if a resident was guided to the floor, it was considered a fall. LVN E said she had completed a change in condition on 01/31/25 effective 01/26/25. She said a negative outcome of not doing an incident report, a change in condition, and notified her ADON, DON, and/or the Administrator would be that Resident #1 would not be tended to sooner. Record review on 09/04/25 of Resident #1's eMAR for the month of 01/2025 reflected on 01/27/25 the following was administered: at 12:14 am, she was administered 2 Acetaminophen tablet 325 mg due to having pain at level of 5 out of 10. A follow-up at 1:14 am, her pain level had dropped to a 1. At 7:56 am, Resident #1's pain level was at a 10 out of 10 and was administered 2 Acetaminophen tablet 325 mg. A follow-up at 8:58 am, her pain had dropped to a 3 out of 10. An interview on 09/04/25 at 4:44 pm, the DON said on 01/26/25, LVN E had been called to Resident #1's restroom in response to a guided fall. The DON said LVN E assessed Resident #1, and no injuries were reported. The DON said LVN E had failed to do an incident report, a change of condition, and notify her ADON/DON/Administrator when the incident occurred. She said LVN E had also failed to document Resident #2's head-to-toe assessment done after the guided fall. She said she and the Administrator found out about the incident on 01/30/25, by Resident #1's NP. The DON said she had done a change in condition for Resident #1 on 01/31/25 effective 01/26/25 at 4:30 pm. The DON said If LVN E had reported the incident when it occurred, we would have been able to assess the resident for pain and if the resident had voiced pain at that time, they would have notified the NP. The DON said it was her and the ADONs responsibility to ensure the nursing staff complete the required assessments for residents. She said she and the ADON review resident's electronic medical record on a daily basis to ensure nothing was missed. She said she and/or the ADON must have missed the documentation where nursing staff documented Resident #1 was having pain. An interview on 09/04/25 at 5:05 p.m., the Administrator said on 01/30/25, she had been notified by Resident #1's NP she had complained of having pain to her right lower extremity due to an incident she had on 01/26/25. She said on 01/30/25, Resident #1's NP ordered an x-ray of her right tibia/fibular. She said the results of 676206 Page 9 of 10 676206 09/11/2025 Windsor Arbor View 218 Baltic Edinburg, TX 78539

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the first x-ray (right tibia/fibula) indicated a nondisplaced proximal fibular fracture. She said when Resident #1's NP was notified of the findings that same day, he ordered a second x-ray, and those results were received on 01/31/25 which indicated an age-indeterminate fracture. The Administrator said LVN E had been counseled for failure to report an incident when Resident #1 was guided to the floor. She said LVN E had been re-education on falls and reporting incidents as soon as they occur. The Administrator said a negative outcome of LVN E not reporting Resident #1's incident was her not being treated sooner.Record review of the facility's Documentation in Medical Record policy dated 10/24/22 reflected:Policy: Each residence medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the residents progress through complete, accurate, and timely documentation.Policy Explanation and Compliance Guidelines:1. Licensed staff and interdisciplinary team members shall document all assessments, observations, and services provided in the resident's medical record in accordance with state law and facility policy. 2. Documentation shall be complete at the time of service, but no later than the shift in which the assessment, observation, or care service occurred.4. When documentation occurs after the fact, outside acceptable time limits, the entry shall be clearly indicated as late entry. 676206 Page 10 of 10