Inspection·May 11, 2023

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few and legs were exposed. She had no other clothes or pants on and appeared naked except for an incontinent brief. She appeared upset. She was not smiling. During an interview on 05/10/23 at 2:30 p.m., HA C said she arrived in Resident #1's room after 2:00 p.m. on 05/09/23 to give her a bath. She said NA A had come into Resident #1's room. She said NA A showed her the picture of Resident #1 being naked with a red dress hanging off her right shoulder. She said she recognized it as the dress she had put on Resident #1 after her bath on 05/08/23. During observation and interview on 05/10/23 at 3:18 p.m., Resident #1 was sitting on her bed in a hospital gown. She said she was fine when asked how she was doing. Her speech was not clear and concise. She did not respond to questions with appropriate answers. During an interview on 05/11/23 at 9:52 a.m., NA A said she was close to the family of Resident #1 and had sent them the pictures she had taken. She said on 05/08/23 between 5:00 p.m. and 6:00 p.m., she was assisting CNA E to transfer another resident across the hall from Resident #1. She said she heard CNA E yelling you are going to have to wait a minute and you have it all over you. She said she came out of the room across the hall from Resident #1's room and CNA E slammed Resident #1's door. She said CNA E said she could not deal with Resident #1 because she had spilled melted chocolate ice cream all over the place. NA A said she went into Resident #1's room and found her distraught, half-clothed, and crying. She said that was when she took the picture of Resident #1 half-clothed. She said she called the facility on 05/09/23 to speak with the DON but the DON was busy. She said she talked to the SW and told her about the pictures. She said the SW sent her an email and then she sent a return email with the pictures and her statement. During an interview on 05/11/23 at 11:12 a.m. SW B said she talked to NA A on 05/09/23 because the DON was busy. She said NA A told her (SW) about what occurred on 05/08/23. She said NA A called CNA E a nut job. She said NA A said she was in the resident's room across the hall from Resident #1 and heard yelling. She said she left that room and went to Resident #1's room and pulled the privacy curtain aside and saw CNA E yelling and screaming in Resident #1's face because Resident #1 had spilled ice cream on herself. She said when CNA E saw her (NA A), CNA E said I am done. I can't. I can't. and left Resident #1's room. The SW said she asked NA A what she did next and NA A said she took a picture of Resident #1 and a picture of the wipes on the floor. She said NA A said it was close to 6:00 p.m. and she left the facility as it was the end of her shift. She said she texted NA A on 05/09/23 and asked for the pictures. She said NA A sent her the pictures via email on 05/09/23. During an interview on 05/11/23 at 11:59 a.m., CNA E said she was collecting the dinner trays on 05/08/23 between 5:00 p.m. and 6:00 p.m. She said Resident #1 had spilled her chocolate ice cream. She said Resident #1 was upset and hollering. She said she asked Resident #1 what was going on. She said Resident #1 would get upset if there was a mess. She said staff have to stay calm when Resident #1 gets upset. She said Resident #1 kept repeating it was a mess. She said she gathered the tray and left the room. She said NA A had come in the room and she (CNA E) said she was going to get some wash clothes. She said NA A made the statement I'll do it and grabbed the wipes because the wipes were closer. She said staff were not supposed to take pictures of residents with their cell phones. Record review of the facility's Resident Rights policy signed and dated by NA A on 03/21/23 indicated . Respect and Dignity-the resident has the right to be treated with respect and dignity, .Privacy and Confidentiality-The resident has a right to personal privacy . Record review of the facility's Employee Handbook Acknowledgment form dated and signed by NA A on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675798 If continuation sheet Page 2 of 7 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 675798 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arboretum Nursing and Rehabilitation Center of Win 1215 Highway 124 Winnie, TX 77665 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 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 03/29/23 and the Employee Handbook revised 09/20/19 indicated Personal Communication Devices-Use of personal communication devices during scheduled work hours is not permitted at the facility. These devices include but are not limited to cell phones . The facility prohibits the use of any type of cell phone camera, digital camera, video camera, or other form of image-recording device without the express permission of the facility and of each person whose image is recorded. the phone may not be used in the resident area or used in an unprofessional manner. Reviewed Resident Right's policy dated 11/2021 reflected: The Resident has a right to be treated with dignity, courtesy, consideration, and respect. Record review of the facility's Videotaping, Photographing, and other imaging of Residents policy dated 2001 (revised 04/17) indicated Residents will be protected from invasion of privacy and/or abuse that might occur from photographs, videotapes, digital images, and recordings during resident care or other facility activities. Policy Interpretation and Implementation-1. For the purpose of this policy, resident image means the likeness of a resident though photography, videotaping, digital imaging, scans, audio recordings, etc. 2. Staff may not take or release images or recordings of any residents without the explicit written consent. Written consent must be obtained from the resident or representative prior to obtaining images or recordings of the resident for any purposes other than investigation of abuse, neglect, or emergencies, and photography obtained for personal/family use at the verbal request of the resident or family. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675798 If continuation sheet Page 3 of 7 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 675798 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arboretum Nursing and Rehabilitation Center of Win 1215 Highway 124 Winnie, TX 77665 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 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 observation, interview, and record review the facility failed to ensure all alleged violations involving abuse or mistreatment were reported to the to the administrator of the facility and other State Survey Agency 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 for 1 of 10 (Resident #1) residents reviewed for abuse and neglect. NA A did not report immediately to the Administrator allegations of verbal abuse. NA A alleged she witnessed CNA E yell and scream at Resident #1 on 05/08/23 between 5:00 p.m. and 6:00 p.m. She did not report the verbal abuse to the facility until 05/09/23. This failure could place residents at risk of emotional, physical, and mental abuse. Findings included: Record review of a face sheet dated 05/11/23 indicated Resident #1 was an [AGE] year-old female admitted on [DATE]. Her diagnoses included COPD (group of diseases that cause airflow blockage and breathing-related problems), hemiplegia (paralysis of one side of the body) and hemiparesis (weakness or the inability to move on one side of the body) following cerebral infarction (lack of adequate blood supply to brain cells deprives them of oxygen and vital nutrients which can cause parts of the brain to die off) affecting right dominant side , anxiety (a feeling of fear, dread, and uneasiness), depression (serious mood disorder), and dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities). Record review of an MDS dated [DATE] indicated Resident #1 had a BIMS score of 6 (severe cognitive impairment). Resident #1 required extensive assist of 1 staff for dressing and eating. Record review of a care plan dated 04/14/23 indicated Resident #1 had ADL Self-Care deficit. Interventions included resident required extensive assist for personal hygiene and dressing. She required limited assist for eating. Record review of a skin assessment dated [DATE], completed by LVN H indicated Resident #1's cheek had 3 dark spots brown in color. During an interview on 05/10/23 at 12:30 p.m., the Administrator said NA A did not report CNA E yelled at or verbally abused Resident #1 on 05/08/23. She said when she became aware of the incident on 05/09/23, CNA E was not working but was suspended pending the facility investigation. She said NA A was also suspended but had told the SW she quit before the completion of the investigation. She said NA A should have reported the verbal abuse immediately in order to protect the residents. During an interview on 05/10/23 at 1:50 p.m., Resident #1's family member said on 05/08/23 NA A let her know CNA E was in Resident #1's face yelling at her. She said the door to the room was open because Resident #1 preferred the door open. She said NA A went from across the hall just as CNA E was leaving Resident #1's room. She said the next day on 05/09/23, HA C asked NA A how Resident #1 got bruises on her face and asked if she had fallen. She said HA C reported the bruises to the hospice agency. She said the facility was not aware of the incident on 05/08/23. She said another family (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675798 If continuation sheet Page 4 of 7 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 675798 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arboretum Nursing and Rehabilitation Center of Win 1215 Highway 124 Winnie, TX 77665 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few member was at the facility on 05/08/23 and there were no bruises. She said LVN G and LVN H looked at Resident #1 and said there were no bruises. During an interview on 05/10/23 at 2:30 p.m., HA C said she arrived in Resident #1's room after 2:00 p.m. on 05/09/23 to give her a bath. She said she noticed what looked like bruises on Resident #1's face. She said NA A had gone into Resident #1's room. She said she asked NA A if Resident #1 had fallen. NA A said there was something else going on and showed her the picture of Resident #1 being naked with a red dress hanging off her right shoulder. She said she recognized it as the dress she had put on Resident #1 after her bath on 05/08/23. She said Resident #1 had no bruises on 05/08/23. She said she reported the bruises to LVN G and to her direct supervisor. She said her supervisor told her to report to the state. She said she reported to the state (there was no intake #) She said the hospice nurse came out and assessed Resident #1 and there were no bruises. She said the facility nurse and the hospice nurse said the bruises were age spots. During an interview on 05/10/23 at 3:00 p.m., the Administrator said she became aware of the allegations of verbal and physical abuse at 4:30 p.m. on 05/09/23. She said she received a call from Resident #1's hospice agency. She said she reported the allegation of abuse to the state on 05/09/23 at 6:59 p.m. She said CNA E was off work and not in the building at the time she was made aware of the allegations. She said CNA E was immediately suspended pending the investigation. She said NA A quit prior to the completion of the investigation. She said CNA E reported Resident #1 hollered out due to spilling ice cream. She said CNA I and NA A were in a room with another resident when NA A left the room to see what was going on and CNA E was in the hallway. She said CNA I did not confirm NA A's allegation. She said there had been no complaints about CNA E. CNA E denied the allegations. She said HA C did not report the allegation of the bruises to her (the Administrator) as she should have but she did report to the charge nurse. During observation and interview on 05/10/23 at 3:18 p.m., Resident #1 was sitting on her bed in a hospital gown. She had age spots on her face. There were no bruises on her face. She said she was fine when asked how she was doing. Her speech was not clear and concise. She did not respond to questions with appropriate answers. During an interview on 05/11/23 at 9:52 a.m., NA A said on 05/08/23 between 5:00 p.m. and 6:00 p.m., she was assisting CNA I to transfer another resident across the hall from Resident #1. She said she heard CNA E yelling you are going to have to wait a minute and you have it all over you. She said she went out of the room across the hall from Resident #1's room and CNA E slammed Resident #1's door. She said CNA E said she could not deal with Resident #1 because she had spilled melted chocolate ice cream all over the place. NA A said she went into Resident #1's room and found her distraught, half-clothed, and crying. She said that was when she took the picture of Resident #1 half-clothed. She said CNA J knew she (NA A) was mad about how CNA E treated Resident #1. She said CNA J said CNA E was something else. She said she was off work on 05/09/23 but went to the facility to pick up her check. She said after she got her check, she went to visit with Resident #1. She said HA C asked her (NA A) about the bruises on Resident #1's face and if she had fallen. She said she started taking more pictures of Resident #1's face. She said HA C said she was going to report the bruises to the facility nurses and her supervisor. She said she left the facility. She said she did not report the verbal abuse or that she took pictures while she was at the facility. She said she called the facility on 05/09/23 to speak with the DON but the DON was busy. She said she talked to the SW and told her about the pictures. She said the SW sent her an email and she sent a return email with the pictures and her statement. She said CNA E was loud with the residents all the time and had a bad attitude. She said everyone said that was just how she (CNA E) is. She said she was trained on abuse, neglect, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675798 If continuation sheet Page 5 of 7 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 675798 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arboretum Nursing and Rehabilitation Center of Win 1215 Highway 124 Winnie, TX 77665 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 0609 Level of Harm - Minimal harm or potential for actual harm and reporting. She said she was trained on resident rights and privacy. She said she should have reported CNA E was screaming in Resident #1's face immediately to the charge nurse and the administrator. She said she did not report immediately because she was gathering evidence. She said she felt she had to gather evidence because she reported staff for not doing their job previously and felt she was treated poorly by the facility. Residents Affected - Few Record review of NA A statement sent to the SW on 05/09/23 at 7:03 p.m. indicated the following: CNA I and I (NA A) were in (another resident's room) getting ready to transfer when we heard a scream. I pulled the privacy curtain back and could see CNA E yelling in Resident #1's face. I leave CNA I with the other resident to see what's going on and when I am walking across the hall CNA E came out slamming the door saying how she can't deal with Resident #1. Resident #1 had spilled her ice cream on herself. She (CNA E) always talks about how hard Resident #1 is to deal with. When I walked in the room Resident #1 was half naked, crying, and distraught. I started cleaning her up and CNA E came back with a completely different attitude. She started helping me change Resident #1 and talking sweet to her. It was past 6 pm already and my shift had ended. The next day I go to pick up my check and walk in to see how Resident #1 is doing and her hospice nurse (HA C) was asking her (Resident #1) where she got the bruises on her face from. I asked her (HA C) where she saw them and she pointed them as I took the pictures. The hospice nurse (HA C) was there the day before giving Resident #1 a bed bath and there were no bruises then. Before I left I heard CNA E say I and (another resident) are gonna fight tonight. I have attach pictures from when her hospice nurse (HA C) was pointing out the bruises. There are bruises on each cheek and on her nose. During an interview on 05/11/23 at 10:40 a.m. CNA I said she had started doing a transfer of another resident with NA A across the hall from Resident #1. She said CNA E was in the hallway. She said CNA E came in and took over the transfer and NA A left the room. She said she never heard CNA E yelling and did not hear any door slam. She said she left the room across from Resident #1's room and saw both NA A and CNA E in Resident #1's room. She said it looked like they were changing the bed. She said Resident #1 had covers around her. She said no one reported any yelling or bruises. She said staff are not supposed to take pictures of the residents. She said all allegations of abuse should be reported to the charge nurse or the administrator immediately. During an interview on 05/11/23 at 11:12 a.m. SW B said she talked to NA A on 05/09/23 because the DON was busy. She said she told NA A the facility was reporting bruising on Resident #1 and that was when NA A told her (SW) about what occurred on 05/08/23. She said NA A called CNA E a nut job. She said NA A said she was in the resident's room across the hall from Resident #1 and heard yelling. She said she left that room and went to Resident #1's room and pulled the privacy curtain aside and saw CNA E yelling and screaming in Resident #1's face because Resident #1 had spilled ice cream on herself. She said when CNA E saw her (NA A), CNA E said I am done. I can't. I can't. and left Resident #1's room. The SW said she asked NA A what she did next, and NA A said she took a picture of Resident #1 and a picture of the wipes on the floor. She said NA A said she got some wipes and continued to clean Resident #1. She said NA A told her CNA E returned and her attitude had changed, like she knew she did something wrong. She said NA A said CNA E said, I can do this and they both cleaned up Resident #1. She said NA A said it was close to 6:00 p.m. and she left the facility as it was the end of her shift. She said NA A went to the facility on [DATE] around 2:00 p.m. to pick up her check. She said NA A said she went down to visit with Resident #1 and HA C asked where the bruises on Resident #'s face came from. She said NA A told HA C what had happened the previous evening on 05/08/23. The SW said she texted NA A on 05/09/23 and asked for the pictures. She said NA A sent her the pictures via email on 05/09/23. The SW said she told NA A she should have reported immediately. She said NA A said, she was gathering (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675798 If continuation sheet Page 6 of 7 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 675798 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arboretum Nursing and Rehabilitation Center of Win 1215 Highway 124 Winnie, TX 77665 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 0609 evidence. Level of Harm - Minimal harm or potential for actual harm During an interview on 05/11/23 at 11:40 a.m., the DON said she was notified by hospice on 05/09/23 that HA C said Resident #1 had bruises on her face. She said HA C reported to the nurses the bruises were not there the day before (05/08/23). She said the nurses assessed Resident #1, and she assessed Resident #1 and there were no bruises on her face or body. She said LVN G reported HA C said there was bruises and she (LVN G) assessed Resident #1 and there were no bruises. She said hospice reported a disgruntled employee at the facility was telling HA C that staff would fight with Resident #1. Residents Affected - Few During an interview on 05/11/23 at 11:59 a.m., CNA E said she was collecting the dinner trays on 05/08/23 between 5:00 p.m. and 6:00 p.m. She said Resident #1 had spilled her chocolate ice cream. She said Resident #1 was upset and hollering. She said she asked Resident #1 what was going on. She said Resident #1 appeared to not hear very well and she had to speak loud and clear. She said she was not screaming in Resident #1's face. She said Resident #1 would get upset if there was a mess. She said staff had to stay calm when Resident #1 got upset. She said Resident #1 kept repeating it was a mess. She said she gathered the tray and left the room. She said NA A had come in the room and she (CNA E) said she was going to get some wash clothes. She said NA A made the statement I'll do it and grabbed the wipes because the wipes were closer. She said NA A had a look on her face but she did not know what the issue was. She said NA A was new and did not take criticism or suggestions. She said she did not see any bruises on Resident #1. She said she was trained on abuse and neglect. She said she would report immediately to the charge nurse or administrator. She said staff were not supposed to take pictures of residents with their cell phones. During an observation and interview on 05/11/23 at 12:30 p.m., Resident #1 was sitting in her bed. She laughed and made a face when asked if staff were mean or yelled at her. She called her mattress a horse. There were no suspicious bruises on her face. During an interview on 05/11/23 at 1:20 p.m., LVN G said HA C came to the nurse station on 05/09/23 and reported Resident #1 had bruises on her face. She said she assessed Resident #1 and said there were age spots but there were no bruises. She said she immediately reported HA C's concerns of bruises on Resident #1's face to the DON. Record review of the facility's Abuse/Neglect policy dated 03/29/18 indicated The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation .Reporting: 1. Any person having reasonable cause to believe an elderly or incapacitated adult is suffering from abuse or neglect must report this to the DON, administrator, state, and/or adult protective services. 2. When a suspected abused, neglected, exploited, mistreated or potential victim of misappropriation of property comes to the attention of any employee, that employee must make an immediate report to the Abuse Preventionist or designee. If the discovery occurs outside of normal business hours, the Abuse Preventionist and/or designee will be called. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675798 If continuation sheet Page 7 of 7