Inspection·December 2, 2025

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 reviews, the facility failed to maintain medical records in accordance with accepted professional standards and practices that were complete and accurately documented for 1 of 3 residents (Resident #1) reviewed for accuracy of records. The facility failed to ensure LVN B documented on Resident #1's electronic medical record that her foley catheter was re-inserted on 11/24/25. This failure could place residents at risk of not receiving appropriate care through inadequate documentation resulting in deterioration in condition, exacerbation of disease process, overmedication, and increased risk of harm or injury. The Findings included:Record review of Resident #1's admission sheet dated 12/02/25 reflected a [AGE] year-old female with an admit date of 10/26/25 and initial admission date of 09/28/25. Her relevant diagnoses included sepsis (a life-threatening medical emergency where the body's overwhelming response to an infection damages its own tissues and organs), vascular dementia (changes to memory, thinking, and behavior resulting from conditions that affect blood vessels in the brain). Record review of Resident #1's 5-Day MDS assessment dated [DATE] reflected a BIMS score of 4, which indicated her cognition was severely impaired. Record review of Resident #1's initial care plan dated 10/28/25 reflected a problem of [Resident #1] is at risk for falls r/t gait/balance problems (date initiated/revised 10/07/25). Interventions included to be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The Resident needs prompt response to all request for assistance, provide resident with mobility device: WC, walker, cane.(date initiated 10/04/25)Record review of Resident #1's progress notes dated 11/24/25 at 2:37 pm, authored by RN A reflected I heard a scream come from the patient's room when I walked into the patient's room patient was sitting down on the floor and foley had been pulled out, patient was unable to tell us what happened, assessed patient and took vitals, skin was intact, patient was able to move both upper and lower extremities without difficulty, patient was able to walk to bed had no complaint of pain, notified md patient just ordered for us to monitor patient, notified rp and don. In a telephone interview on 12/02/25 at 3:43 pm, RN A said that on 11/24/25, between 2:00 pm and 2:45 pm, while she was giving report to the incoming nurse (LVN B) they heard a scream coming from Resident #1's room. She said they both immediately made their way to Resident #1's room and found her in a sitting position on the floor. She said Resident #1 had both legs extended and her foley had been pulled out. She said a head-to-toe assessment was completed, and no injuries were noted. RN A said she asked Resident #1 how she fell but she was not able to say what happened. RN A said Resident #1 was transferred back to bed and where she was assessed for trauma or bleeding at the site where the foley catheter had been pulled out and no trauma or bleeding was observed. RN A said since it was towards the end of her shift, LVN B agreed to re-insert the foley catheter. She said she notified Resident #1's NP but no new orders were given. RN A said she initiated the neurological checks on Resident #1. RN A said Resident #1's foley had been (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 676206 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 12/02/2025 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)