Windsor Arbor View

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

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

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If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/11/2025

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)

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

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.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/11/2025

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)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

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.

Event ID:

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If continuation sheet