Health inspection·June 28, 2023

F 0558 Level of Harm - Minimal harm or potential for actual harm During an interview on 06/27/23 at 02:14 PM, NA K said the call lights should be close to the resident in case they need assistance. NA K said everyone was responsible for ensuring the call lights were within reach of the resident. NA K said Resident#52 was not mobile but he could move his hands. NA K said by not having his call light next to him he could be at risk for falls or be in pain. NA K did not know why Resident 52's call light was not within reach. Residents Affected - Few During an interview on 06/28/23 at 01:15 PM, LVN C said she expected the call lights to be within reach of the resident. LVN C said all staff were responsible for ensuring the residents had their call lights within reach. LVN C said by not having their call light within reach the resident could be choking, in pain, or have fallen and not be able to call for help. During an interview on 06/28/23 at 01:57 PM, ADON O said she expected the residents to always have the call lights within reach. The ADON said everyone who entered the resident's room was responsible for ensuring the resident had their call light within reach. The ADON said not by having the call light within reach, the resident could have fallen or be in trouble and not be able to notify staff. During an interview on 06/28/23 at 02:06 PM, the DON said she expected the call lights to be within reach of the resident. The DON said all staff was responsible for ensuring the call light were within reach of the resident. The DON said not having their call light within reach the resident could have fallen, fractured something, they might have an accident or needing to go to the bathroom. During an interview on 06/28/23 at 02:20 PM, the Administrator said she expected the call lights to be answered timely and within reach. The Administrator said the CNAs and hall supervisor (ADONs) were responsible for ensuring the call lights were within reach of the resident when doing their rounds. The Administrator said not having their call light within reach the resident could not be able to call for help and not receive the attention they need. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675798 If continuation sheet Page 2 of 22 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 06/28/2023 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 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents, and misappropriation of resident property and establish policies and procedures to report and investigate such allegations, for 1 of 20 residents reviewed for abuse. (Resident #77) Residents Affected - Few The facility failed to follow their policy when they did not report Resident #77's allegation of sexual assault on 4/10/2023 at 3:06 p.m. to HHSC. This failure could cause residents to have continued abuse, sexual abuse, and neglect. Findings included: Record review of the facility's abuse policy dated 03/29/2018 indicated the resident has a right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in the subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Residents should not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the residents, family members or legal guardians, friends, or other individuals. The facility will provide and ensure the promotion and protection of resident rights. It is each individual's responsibility to recognize, report, and promptly investigate actual or alleged abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property abuse and situations that may constitute abuse or neglect to any resident in the facility. 4. Sexual abuse: non-consensual sexual contact of any type with a resident. Reporting: 3. Facility employees must report all allegation of: abuse, neglect, exploitation, mistreatment of residents, misappropriation of resident property or injury of unknown source to the facility administrator. The facility administrator or designee will report to HHSC all incidents that meet the criteria of Provider Letter 19-17 dated 7/10/2019. a. If the allegations involve abuse or result in serious bodily injury, the report is to be made within 2 hours of the allegation. b. If the allegation does not involve abuse or serious bodily injury, the report must be made within 24 hours of the allegation. Record review of Resident #77's face sheet dated 06/28/2023 indicated she was a [AGE] year-old female with an original admission date of 01/27/2023 with the diagnosis of seizures (burst of uncontrolled electrical activity between the brain cells that causes temporary abnormalities with the muscle tone or movement) and dementia (a group of thinking and social symptoms that interferes with daily functioning). Record review of the admission MDS dated [DATE] indicated Resident #77 was able to make herself understood, and she was usually understood others. The MDS indicated Resident #77 had severe cognitive (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675798 If continuation sheet Page 3 of 22 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 06/28/2023 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 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few impairment. The MDS in the section of Delirium indicated she had disorganized thinking. The MDS indicated Resident #77 had not demonstrated any physical, verbal, or other behavioral symptoms. Record review of the comprehensive care plan dated 01/30/2023 indicated Resident #77 had a communication problem the intervention was to validate Resident #77's message by repeating aloud, use communication techniques to enhance interaction by allow Resident #77 adequate time to respond, do not rush, request feedback and clarification. The comprehensive care plan did not address any history of physical of sexual abuse by others in Resident #77's past. The comprehensive care plan did not address Resident #77's behaviors, delusions, or hallucinations. Record review of a social history note dated 01/27/2023 was left blank in the areas of emotional and mental health, behavioral problems, history of mental illness, verbal or physically aggressive behaviors, sexually inappropriate behaviors, and socially inappropriate behaviors. The social history notes in the area of Trauma Informed Care indicated Resident #77 had no previously documented diagnosis, no Post-Traumatic Stress Disorder, she had not been in a situation that was extremely frightening, she had not witnessed any extremely frightening situation, or she had not had a close relationship with someone who experienced any extremely frightening situations. Record review of a progress note dated 04/10/2023 at 3:06 p.m., the SW documented she was made aware Resident #77 had made a statement about men coming into her room and sexually assaulting her . The SW documented Resident #77 was confused as evidenced by her rambling semi-incoherently. The note indicated Resident #77 was asked if any men or women had been in to see her and she stated no. The note indicated the SW asked Resident #77 if she had said men came into her room and done something bad and Resident #77 said yes. The SW note indicated she asked Resident #77 what happened, and she stated paper over and over. Then the note indicated Resident #77 said brother and sister. The SW documented Resident #77 was not making statements. The note also indicated the SW asked Resident #77 if this occurred recently, or it had been a while and Resident #77 stated 3 years. The SW note indicated due to her BIMS (cognitive ability) score and her altered mental status, she will be evaluated by her nurse to ensure she is physically healthy. Record review of the incident reports for the January 2023 to June 2023 there was not an incident report for Resident #77. Record review of a progress note dated 04/10/2023 at 3:10 p.m., indicated LVN E assessed Resident #77. LVN E documented there were no further statements of an attack mentioned. LVN E documented she completed a head-to-toe assessment and there were no unusual marks noted, no complaints of pain, or distress. During an interview on 06/27/2023 at 10:23 a.m., the SW indicated the Administrator notified her of Resident #77's allegation of sexual abuse. The SW said she interviewed Resident #77 concerning the allegation of men sexually assaulting her. The SW said Resident #77 was very confused, but denied anyone being in her room, but she said she could not get a clear answer if the allegation occurred in the past. The SW said she was a mandatory reporter, but she was unaware if this allegation was reported to HHSC. The SW said without reporting and investigating the abuse could continue to occur. During an interview on 06/27/2023 at 10:29 a.m., the Administrator said she did not report Resident #77's allegation of sexual abuse to HHSC. The Administrator said she felt the sexual abuse occurred in the past. The Administrator said she did not feel Resident #77's statement was a current allegation. The Administrator said with any allegation of suspected abuse she would complete an (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675798 If continuation sheet Page 4 of 22 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 06/28/2023 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 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few investigation and report any suspected allegation of abuse. The Administrator said she had not notified the local police of Resident #77's allegation. During an interview on 06/27/2023 at 2:57 p.m., LVN E said she was aware Resident #77 made an allegation to a NA . LVN E said she never heard the allegation directly from Resident #77, but she reported the NA's report of an allegation. LVN E said the NA no longer worked at the facility. An attempt was made to interview the NA but the provided phone number was disconnected During an interview on 06/27/2023 at 3:29 p.m., the DON said she was aware of Resident #77's statement to the NA who reported to the Administrator the abuse coordinator. The DON said Resident #77 did not say anyone hurt her. The DON said Resident #77 was not offered any psychological therapy. The DON said not reporting abuse could cause depression, feel endangered, and could be harmful if abuse was continuing. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675798 If continuation sheet Page 5 of 22 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 06/28/2023 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 interview, and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but no later than 2 hours after the allegation was made, for 1 of 20 residents (Resident #77) reviewed for abuse and neglect. The facility failed to report Resident #77's allegation of sexual assault on 4/10/2023 at 3:06 p.m. to HHSC. This failure could cause residents to have continued abuse, sexual abuse, and neglect. Findings included: Record review of Resident #77's face sheet dated 06/28/2023 indicated she was a [AGE] year-old female with an original admission date of 01/27/2023 with the diagnosis of seizures (burst of uncontrolled electrical activity between the brain cells that causes temporary abnormalities with the muscle tone or movement) and dementia (a group of thinking and social symptoms that interferes with daily functioning). Record review of the admission MDS dated [DATE] indicated Resident #77 was able to make herself understood, and she was usually understood others. The MDS indicated Resident #77 had severe cognitive impairment. The MDS in the section of Delirium indicated she had disorganized thinking. The MDS indicated Resident #77 had not demonstrated any physical, verbal, or other behavioral symptoms. Record review of the comprehensive care plan dated 01/30/2023 indicated Resident #77 had a communication problem the intervention was to validate Resident #77's message by repeating aloud, use communication techniques to enhance interaction by allow Resident #77 adequate time to respond, do not rush, request feedback and clarification. The comprehensive care plan did not address any history of physical of sexual abuse by others in Resident #77's past. The comprehensive care plan did not address Resident #77's behaviors, delusions, or hallucinations. Record review of a social history note dated 01/27/2023 was left blank in the areas of emotional and mental health, behavioral problems, history of mental illness, verbal or physically aggressive behaviors, sexually inappropriate behaviors, and socially inappropriate behaviors. The social history notes in the area of Trauma Informed Care indicated Resident #77 had no previously documented diagnosis, no Post-Traumatic Stress Disorder, she had not been in a situation that was extremely frightening, she had not witnessed any extremely frightening situation, or she had not had a close relationship with someone who experienced any extremely frightening situations. Record review of a progress note dated 04/10/2023 at 3:06 p.m., the SW documented she was made aware Resident #77 had made a statement about men coming into her room and sexually assaulting her . The SW documented Resident #77 was confused as evidenced by her rambling semi-incoherently. The note indicated Resident #77 was asked if any men or women had been in to see her and she stated no. The note indicated the SW asked Resident #77 if she had said men came into her room and done something bad and Resident #77 said yes. The SW note indicated she asked Resident #77 what happened, and she stated paper over and over. Then the note indicated Resident #77 said brother and sister. The SW (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675798 If continuation sheet Page 6 of 22 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 06/28/2023 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 documented Resident #77 was not making statements. The note also indicated the SW asked Resident #77 if this occurred recently, or it had been a while and Resident #77 stated 3 years. The SW note indicated due to her BIMS (cognitive ability) score and her altered mental status, she will be evaluated by her nurse to ensure she is physically healthy. Record review of the incident reports for the January 2023 to June 2023 there was not an incident report for Resident #77. Record review of a progress note dated 04/10/2023 at 3:10 p.m., indicated LVN E assessed Resident #77. LVN E documented there were no further statements of an attack mentioned. LVN E documented she completed a head-to-toe assessment and there were no unusual marks noted, no complaints of pain, or distress. During an interview on 06/27/2023 at 10:23 a.m., the SW indicated the Administrator notified her of Resident #77's allegation of sexual abuse. The SW said she interviewed Resident #77 concerning the allegation of men sexually assaulting her. The SW said Resident #77 was very confused, but denied anyone being in her room, but she said she could not get a clear answer if the allegation occurred in the past. The SW said she was a mandatory reporter, but she was unaware if this allegation was reported to HHSC. The SW said without reporting and investigating the abuse could continue to occur. During an interview on 06/27/2023 at 10:29 a.m., the Administrator said she did not report Resident #77's allegation of sexual abuse to HHSC. The Administrator said she felt the sexual abuse occurred in the past. The Administrator said she did not feel Resident #77's statement was a current allegation. The Administrator said with any allegation of suspected abuse she would complete an investigation and report any suspected allegation of abuse. The Administrator said she had not notified the local police of Resident #77's allegation. During an interview on 06/27/2023 at 2:57 p.m., LVN E said she was aware Resident #77 made an allegation to a NA . LVN E said she never heard the allegation directly from Resident #77, but she reported the NA's report of an allegation. LVN E said the NA no longer worked at the facility. An attempt was made to interview the NA but the provided phone number was disconnected During an interview on 06/27/2023 at 3:29 p.m., the DON said she was aware of Resident #77's statement to the NA who reported to the Administrator the abuse coordinator. The DON said Resident #77 did not say anyone hurt her. The DON said Resident #77 was not offered any psychological therapy. The DON said not reporting abuse could cause depression, feel endangered, and could be harmful if abuse was continuing. Record review of the facility's abuse policy dated 03/29/2018 indicated the resident has a right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in the subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Residents should not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the residents, family members or legal guardians, friends, or other individuals. The facility will provide and ensure the promotion and protection of resident rights. It is each individual's responsibility to recognize, report, and promptly investigate actual or alleged abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property abuse and situations that may constitute abuse or neglect to any resident in the facility. 4. Sexual abuse: non-consensual sexual contact of any type with a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675798 If continuation sheet Page 7 of 22 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 06/28/2023 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 resident. Reporting: 3. Facility employees must report all allegation of : abuse, neglect, exploitation, mistreatment of residents, misappropriation of resident property or injury of unknown source to the facility administrator. The facility administrator or designee will report to HHSC all incidents that meet the criteria of Provider Letter 19-17 dated 7/10/2019. Residents Affected - Few a. If the allegations involve abuse or result in serious bodily injury, the report is to be made within 2 hours of the allegation. b. If the allegation does not involve abuse or serious bodily injury, the report must be made within 24 hours of the allegation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675798 If continuation sheet Page 8 of 22 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 06/28/2023 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 0659 Provide care by qualified persons according to each resident's written plan of care. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that the services provided or arranged by the facility, as outlined by the comprehensive care plan were provided by qualified persons in accordance with each resident's written plan of care for 1 of 21 residents sampled (Resident #33). Residents Affected - Few The facility NA applied a medication cream to bilateral buttocks of Resident #33 without qualifications to do so. This failure could place residents at risk for not receiving appropriate care and treatment outlined in their comprehensive care plan. Findings included: Record review of Resident #33's face Sheet dated 07/05/23 indicated that resident was an 89year old female who originally admitted to the facility on [DATE] and re-admitted on [DATE] with the diagnoses Dementia (decline in cognitive abilities), Heart failure (impaired heart blood pumping), chronic obstructive pulmonary disease (a lung disease that blocks the air flow making it difficult to breathe, and depression. Record review of Resident #33's MDS dated [DATE] indicated that resident had a BIMS score of 8 (which indicated she had moderately impaired cognition). The MDS also indicated that Resident #33 required extensive assist of two staff for bed mobility, transfers, dressing, toileting, and total assist with bathing. Record review of Resident #33's Care Plan revised on 02/24/23 indicated that resident required assistance with toileting due to resident had a foley catheter related to neurogenic bladder and bowel incontinence that required incontinent care. It also indicated that Resident #33 had actual impairment to skin integrity and facility was to administer medications per physician orders. During an observation of incontinent care on 06/27/23 at 03:47 PM CNA L and NA K provided incontinent care for Resident #33. NA K applied a cream to Resident #33's left inner thigh and buttocks. When asked to see the cream that was applied, it was Clotrimazole & Betamethasone Dipropionate 1/0.05% cream. During an interview with NA K on 06/28/23 at 02:25 PM she said she thought the cream that she applied to Resident #33's buttocks and inner thigh was a type of barrier cream that she had been placing on the resident for the last week to 2 weeks and it was given to her by the charge nurse. NA K said the charge nurse kept the medication and gave it to the nurse aides to use on Resident #33 when they provided incontinent care. NA K said she requested the barrier cream from the charge nurse and that's what the nurse gave her to apply on resident. NA K said her applying the cream not knowing what it was could cause problems, but when the nurse gave her something to apply on a resident, that was what she applied. During an interview on 06/28/23 at 02:36 PM LVN M said a CNA or NA could basically apply non medicated or over the counter medications like barrier cream to residents. He said he gave Clotrimazole & Betamethasone Dipropionate 1/0.05% cream to the NA to apply to the Resident #33 on 06/27/23. LVN M said he should have been present when the NA applied the medication on the resident. LVN M said the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675798 If continuation sheet Page 9 of 22 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 06/28/2023 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 0659 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few biggest issue of allowing the NA to apply the medication to Resident #33 was the resident could have had an allergic reaction. LVN M said it was out of the NA's scope of practice to apply the prescription cream to the resident. During an interview on 06/28/23 at 02:51 PM ADON D said a CNA or NA could only apply barrier cream and body lotion to residents. She said that a CNA or NA should not have been applying prescription medications to residents. ADON D said applying prescription medications was out of a CNA's or NA's scope of practice. She said the NA or CNA applying the medications could have placed Resident #33 at risk for adverse side effects, adverse reactions, and allergic reactions that may have occurred when the medication was applied. During an interview on 06/28/23 at 03:00 PM the DON said the CNAs and NAs were only allowed to apply barrier cream to residents. The nurse should have applied the medication to the resident because that was out of a NA or CNA scope of practice. The DON said nurse knew better and all nurses were responsible for ensuring CNA or NA provide proper care. The DON said the nurse allowing a NA or CNA to apply prescription medication issue could have caused the NA to give too much medication or it could have caused an adverse reaction. During an interview on 06/28/23 at 03:25 PM the Administrator said a CNA or NA should have only been allowed to apply over the counter barrier cream to residents. She said NA or CNA could not apply prescription medications to residents because they were not licensed. She said the failure could have caused the NA or CNA to apply medications to the incorrect areas or even could have caused Resident #33 to have an allergic or adverse reaction. Record review of the Medication Administration Procedures revised 10/25/2017 indicated 1. All medications are administered by licensed medical or nursing personnel FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675798 If continuation sheet Page 10 of 22 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 06/28/2023 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident who was unable to carry out activities of living received services to maintain grooming and personal hygiene for 1 of 2 residents reviewed for ADLs (Resident #10). Residents Affected - Few The facility did not ensure Resident #10's contracted hands were free from odor and her fingernails trimmed. These failures could place residents at risk for not receiving services/care and decreased quality of life. Findings included: Record review of a face sheet dated 07/28/2023 indicated Resident #10 was a [AGE] year-old female who originally admitted on [DATE] and readmitted on [DATE] with the diagnoses of seizures (burst of uncontrolled electrical activity between the brain cells that causes temporary abnormalities with the muscle tone or movement) and dementia (a group of thinking and social symptoms that interferes with daily functioning) and contracture of left hand (condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints). Record review of a comprehensive care plan dated 02/03/2017 with a revision date of 01/05/2023 indicated Resident #10 had an ADL self-care deficit. The care plan goal was to have Resident #10's ADL needs met with the interventions of total personal hygiene and bathing care provided by 1 staff member. The comprehensive care plan included an alteration in musculoskeletal status related to a left- and right-hand contracture. The care plan goal was to be free of any complications related to the contractures of both hands. The intervention included to keep Resident #10's fingernails short. Record review of the Significant Change MDS dated [DATE] indicated Resident #10 usually was understood and usually understands others. The MDS indicated Resident #10's cognition was severely impaired. The MDS indicated Resident #10 had not refused care. The MDS indicated Resident #10 required extensive care of one staff with personal hygiene, and total dependence of one staff with bathing. The MDS indicated Resident #10 had an impairment on one upper extremity. Record review of the nursing electronic medical record dated June 2023 did not indicate nursing provided Resident #10 with care to the bilateral hand contractures. The record only was marked with an X. Record review of the ADL documentation record dated June 28, 2023, indicated Resident #10 received personal hygiene daily and was totally dependent. During an observation on 06/26/2023 at 9:39 a.m., Resident #10 was sitting up in her chair in her room. Resident #10's fingernails on both hands were ½ inch long, the palm of her left hand had a brownish colored material and there was a foul odor coming from the hand. During an observation and interview on 06/27/2023 at 8:33 a.m., Resident #10 hand contractures to her right and left hands. Resident #10's fingernails to both hands were ½ inches long and her hands had a foul odor. LVN E assisted Resident #10 with opening of her hands. LVN E said the nurse (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675798 If continuation sheet Page 11 of 22 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 06/28/2023 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few aides were responsible for ensuring Resident #10's hands were cleansed, and nails trimmed daily. LVN E said the nurses were responsible for monitoring for nail care while making their rounds. During an interview on 06/28/2023 at 2:52 p.m., CNA N said she was responsible for ensuring Resident #10's fingernails were trimmed and her hands free of odors. CNA N said she needed the assistance of another staff member to complete the task. CNA N said she needed someone to help hold Resident #10's hand open was a reason she had not completed the personal hygiene task. CNA N said not cleaning Resident #10's hand could cause an infection and the long nails could make a sore in her hand. During an interview on 06/28/2023 at 3:19 p.m., the Administrator said she expected the resident's nails to be trimmed. The Administrator said the hands should be cleansed to prevent infection and sores. The Administrator said the DON, and nurses were responsible for monitoring. During an interview on 06/28/2023 at 3:34 p.m., the DON said nails should be trimmed ideally on shower days. The DON said the nurses were responsible for ensuring the nurse aides complete the personal hygiene tasks. The DON said she was unsure why Resident #10's personal hygiene to her hands was not completed. The DON said maceration, fungal infections, odors, and dignity issues could arise from not receiving personal ADL care. Record review of a Nail Care policy dated 2003 indicated nail management was the regular care of the toenails and fingernails to promote cleanliness, and skin integrity of tissues, to prevent infection, and injury from scratching by fingernails or pressure of shoes on toenails. It includes cleansing, trimming, smoothing, and cuticle care and is usually done during the bath .Goals 1. Nail care will be performed regularly and safely. 2. The residents will be free from abnormal nail conditions. 3. The resident will be free from infection. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675798 If continuation sheet Page 12 of 22 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 06/28/2023 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 0808 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure food was prepared in a form designed to meet individual needs and as prescribed by the physician for 1 of 21 residents (Resident #77) reviewed for therapeutic diets. The facility failed to ensure Resident #77 received finger foods as ordered by the physician. This failure could place residents at risk for poor intake, weight loss, unmet nutritional needs, and a loss of dignity. Findings included: Record review of Resident #77's face sheet dated 06/28/2023 indicated she was a [AGE] year-old female with an original admission date of 01/27/2023 with the diagnosis of seizures (burst of uncontrolled electrical activity between the brain cells that causes temporary abnormalities with the muscle tone or movement) and dementia (a group of thinking and social symptoms that interferes with daily functioning). Record review of the consolidated physician orders dated 02/17/2023 indicated Resident #77 was ordered a regular diet, with regular texture, regular consistency, finger foods for assisted dining. Record review of the comprehensive care plan dated 01/30/2023 and a revision date of 02/17/2023 indicated Resident #77 had a potential risk for malnutrition and was provided a regular diet with finger foods. The goal was Resident #77 would maintain a stable weight and nutritional parameters with the intervention of offer diet as ordered by the physician. The care plan also indicated Resident #77 had an ADL self-care deficit. The intervention included to be provided limited assistance by one staff for meals. Record review of an admission MDS dated [DATE] indicated Resident #77 was understood by others and was usually able to understand others. The MDS indicated Resident #77's cognition was severely impaired. The MDS indicated Resident #77 required limited assistance of one staff for eating. During an observation, interview, and record review on 06/27/2023 at 7:48 a.m., Resident #77 was grabbing her oatmeal with her hands. The oatmeal was running down Resident #77's chain and onto her clothing. Resident #77's tray tag indicated she was to be served regular finger foods. The items listed on the tray tag were 1 hardboiled egg, toast, finger food cereal, and breakfast sausage. CNA H said they have spoken to dietary about receiving finger foods. During an interview on 06/28/2023 at 1:38 p.m., the DM said Resident #77 was supposed to receive finger foods with her meals. The DM said Resident #77 should have received a boiled egg and dry cereal. The DM said oatmeal and scrambled eggs were not finger foods as they were served. During an interview on 06/28/2023 at 1:45 p.m., the cook said she missed reading the tray tag and sent Resident #77 scrambled eggs and oatmeal instead of finger foods. During an interview on 06/28/2023 at 2:00 p.m., ADON D said to her knowledge the assisted dining (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675798 If continuation sheet Page 13 of 22 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 06/28/2023 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 0808 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few trays were not checked by a nurse. The ADON said not receiving finger foods could make Resident #77 feel embarrassed by eating eggs and oatmeal with her fingers. During an interview on 06/28/2023 at 3:08 p.m., the DON said the cook should follow the tray ticket. The DON said Resident #77 could be bothered by eating oatmeal and scrambled eggs with her fingers instead of finger foods. During an interview on 06/28/2023 at 3:15 p.m., the ADM said the nursing staff should be checking the trays for accuracy. The ADM said the DON was responsible for ensuring nursing monitored the trays for accuracy. Record review of a Dietary Services Policy and Procedure dated 2012 indicated the policy was to ensure correct understanding and interpretation of therapeutic diets, all diets were ordered as stated in the Diet Manual. The physician will prescribe diets in accordance with the approved Diet Manual. A written order must appear on the medial record before the resident may be served. 5. Physicians will be asked to order only those diets appearing on the daily spreadsheet. If another diet is requested, the registered dietician will be contacted. The following list of commonly used diets included the regular diet. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675798 If continuation sheet Page 14 of 22 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 06/28/2023 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 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** 3). Record review of a face sheet dated 6/28/2023 indicated Resident #12 was a [AGE] year-old male who originally admitted on [DATE] and readmitted on [DATE] with the diagnoses of a stroke, and absence of the right toes (surgically removed). Residents Affected - Some Record review of the consolidated physician's orders dated June 28, 2023, indicated Resident #12 to cleanse arterial wound to left 2nd digit, great toe, and 5th digit with normal saline, pat dry and apply skin prep leave open to air. Record review of the admission MDS dated [DATE] indicated Resident #12 could make himself understood and he understood others. Resident #12's cognition was moderately impaired. The MDS indicated Resident #12 required extensive assistance of one staff with bed mobility and toilet use, transferred and completed personal hygiene with limited assistance of one staff. The MDS indicated he was at risk for pressure injuries. Record review of the comprehensive care plan dated 6/16/2023 indicated Resident #12 had a DTI to his left heel. The goal of the care plan was the pressure injury would heel and remain free of infection with the intervention of administer treatments as ordered. During an observation and interview on 6/27/2023 at 9:08 a.m., the treatment nurse entered Resident #12's room and washed her hands. The treatment nurse with gloved hands removed the heel protector from Resident #12's left foot and then his sock. The treatment nurse then cleansed Resident #12''s DTI wound to his left heel with normal saline, then she removed her gloves and used hand sanitizer. The treatment nurse applied clean gloves and applied the skin prep to the DTI to the left heel. The treatment nurse then removed her gloves and exited the room. The treatment nurse did not use hand sanitizer or wash her hands prior to exiting the room. The treatment nurse returned to the room, washed her hands, applied gloves, and applied the kerlix to Resident #12's left foot. The treatment nurse said she should have sanitized her hands prior to exiting Resident #12's room to obtain the kerlix. The treatment nurse said not washing your hands or using hand gel could spread infection. Record review of a hand hygiene check off dated 1/12/2023 indicated the treatment nurse was checked off on hand hygiene which included: (washing hands) wet hands with water, lather hands by rubbing them together with soap, scrub your hands for 20 seconds, rinse your hands well under clean running water, dry your hands using lean towel, turn the faucet off with dry paper towel. Hand hygiene (hand washing with hand sanitizer): apply product to the palm of the hand, rub hands together covering all surfaces until hands were dry, include areas around and under the fingernails. The form indicated she passed the check off. The check off was signed by the infection preventionist. During an interview on 6/28/2023 at 3:15 p.m., the Administrator said she expected the treatment nurse to wash her hands or use hand sanitizer prior to exiting Resident #12's room. The Administrator said the infection preventionist was responsible for evaluating staff and infection control practices. The Administrator said the DON was responsible for the annual nursing check offs including wound care and hand hygiene. The Administrator said infection could spread when hands were not washed after resident care. During an interview on 6/28/2023 at 3:33 p.m., the DON said not cleansing hands prior to exiting a resident room was a big thing. She said the treatment nurse should sanitizer her hands and change (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675798 If continuation sheet Page 15 of 22 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 06/28/2023 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 0880 Level of Harm - Minimal harm or potential for actual harm her gloves as much as possible. The DON said she was responsible for annual check offs of the nursing staff for hand hygiene practices. The DON said the infection preventions was responsible for the monitoring for more education related to hand hygiene practices. 2.Record review of the undated face sheet indicated Resident #2 was admitted on [DATE]. Residents Affected - Some Record review of the physician's orders dated June 2023 indicated Resident #21 was an [AGE] year-old male with diagnoses that included: Dementia (progressive loss of intellectual functioning), and Cerebral Infarction (a disrupted blood supply and restricted oxygen to the brain). Record review of the Care Plan dated 12/28/22 indicated Resident #21 required the assistance of 1 staff for bed mobility and transfer. The Care Plan indicated he was incontinent of bowel and bladder and wore briefs. Resident #21 had Dementia and a Cerebral Infarction. Record review of the quarterly MDS dated [DATE] indicated Resident #21 had clear speech, usually understood others, and was usually understood by others. The MDS indicated he had severe cognitive impairment and required the extensive assistance of one staff for bed mobility and transfer. Resident #21 was always incontinent of bowel and bladder. During an observation on 6/27/23 at 2:17 p.m., CNA B and CNA A performed incontinent care on Resident #21. CNA B began incontinent care with clean gloves and a basin with warm clean water that had clean washcloths in it. She grabbed a washcloth and wiped Resident #21's front perineal area, then discarded the dirty washcloth. She did not change her gloves, then reached into the clean water basin, grabbed a washcloth and rung water out of it over the basin. She wiped his front area again and discarded the washcloth. CNA B did this two more times without changing her gloves. She then got a dry washcloth and dried his front perineal area without changing her gloves. She then assisted Resident #21 to roll on his side by placing her dirty gloves on his right hip and upper right back. She removed and discarded her dirty gloves, washed her hands, and donned clean gloves. CNA B grabbed a washcloth out of the same basin, rung the water out over the basin, then wiped Resident #21's backside, folded the washcloth, wiped again and discarded the washcloth. She put her dirty gloves back into the water basin and grabbed a washcloth, rung it out and cleaned Resident #21's backside again. She repeated this three times. She then grabbed a dry washcloth and dried Resident #21's backside. At that time, she discarded her dirty gloves, washed her hands, and donned clean gloves. CNA B's gloves were not visibly soiled at any time during peri care. During an interview on 6/27/23 at 2:29 p.m., CNA B said she did not change her dirty gloves before putting them in the clean water basin. She said when she did that, she contaminated the clean water. She said doing that could cause a risk of infection. She said she had also put her dirty gloves on Resident #21 to turn him and should have changed her gloves and washed her hands prior to touching him. She said she did not remember when her last incontinent care in-service was, but it had been in the last year. She said putting dirty gloves in a clean water basin and on a resident could cause spread of infection. She said she knew she was not supposed to put dirty gloves in a clean water basin or on a resident. During an interview on 6/27/23 at 2:32 p.m., CNA A said she did not realize CNA B did not change her gloves before she put her dirty gloves in the clean water basin with the washcloths. She said she did not realize CNA B touched Resident #21 with dirty gloves. She said CNA B should have changed her gloves and washed her hands before touching the resident and before putting her hands in the clean water basin. She said what CNA B did was contamination and that presented a danger of infection (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675798 If continuation sheet Page 16 of 22 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 06/28/2023 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 0880 control. Level of Harm - Minimal harm or potential for actual harm During an interview on 6/28/23 at 7:31 a.m., LVN C said she expected CNA's to change their gloves during peri care after any contact with feces, urine, or bodily fluids. She said gloves would be considered dirty after touching any of those things. She said if staff put dirty gloves, whether visibly soiled or not in a water basin with clean washcloths and water, it would contaminate the water basin and that could cause major issues with infection. LVN C said if you touched a resident with dirty gloves that would also have been potential for the spread of infection. Residents Affected - Some During an interview on 6/28/23 at 7:33 a.m., ADON D said she expected CNA's to change their gloves when they were soiled meaning they had touched something dirty, not necessarily visibly soiled. She said if a CNA had dirty gloves on and she put those gloves in a clean water basin with washcloths, she would have contaminated the water basin and washcloths. ADON D said if a CNA touched a resident with dirty/contaminated gloves that would also cause major infection control issues. During a record review and interview on 6/28/23 at 9:27 a.m., the DON showed this surveyor the CNA Proficiency Audit for CNA B on 7/19/22. She said she was proficient with peri care and there were no problems with her competency. She said she had signed off that CNA B was proficient. The CNA Proficiency Audit included: Perineal care, Infection Control awareness including proper handwashing, preventing cross-contamination and Universal Precautions. During an interview on 6/28/23 at 9:43 a.m., LVN E said she expected CNA's to change their gloves when they were contaminated or had touched something dirty. She said gloves did not have to be visibly soiled to need to change them. LVN E said if a CNA put dirty gloves in a clean water basin with wash cloths, she had contaminated the water basin and the washcloths. She said a CNA should not touch a resident with dirty gloves. LVN E said those things would cause a risk of infection, spread of infection, and could cause UTI's. During an interview on 6/28/23 at 10:10 a.m., CNA F said she would change her gloves anytime they were contaminated, meaning touching anything considered dirty. She said gloves must be changed and hands washed when going from dirty to clean. CNA F said if the gloves were not changed you would contaminate whatever surface you touched. She said putting dirty gloves into a clean water basin or a resident would be risking the spread of infection. During an interview on 6/28/23 at 10:16 a.m., CNA G said she had worked at the facility for one year. She said she was taught to change her gloves during peri care after wiping the resident's peri area. She said she would change her gloves before putting her hands in a clean water basin to get a clean washcloth and before touching a resident after wiping that resident. She said not changing gloves when going from dirty to clean could cause a risk of infection and spread of infection. She said she had her last skills check off less than a year ago, but she did not remember the date. During an interview on 6/28/23 at 12:30 p.m., the DON said she expected CNA's to change their gloves during peri care when they were contaminated or when they had touched something, dirty whether or not gloves were visibly soiled. She said putting a dirty glove in a clean water basin would contaminate the clean water and the washcloths. She said CNA's should not touch residents with dirty gloves. She said dirty gloves can spread infection and contaminate what they came in contact with. During an interview on 6/28/23 at 12:36 p.m., the Administrator said she expected CNA's to change their gloves anytime they were contaminated. She said if dirty gloves touched a resident or were put (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675798 If continuation sheet Page 17 of 22 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 06/28/2023 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 0880 in a water basin it would be cross-contamination. She said that could cause an infection control problem. Level of Harm - Minimal harm or potential for actual harm During a record review and interview on 6/28/23 at 1:53 p.m., ADON D said CNA's learn when to change their gloves when they learn their skills and get their CNA certification. She showed this surveyor a Hand Hygiene Checkoff dated 2/10/22 for CNA B indicating she had met all expectations of hand washing. The Hand Hygiene Checkoff did not indicate when to change gloves. She said she had misdated the checkoff and it should have been 2/10/23. Residents Affected - Some Based on observation, interview, 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 4 of 4 residents (Resident #33, Resident #21, Resident #12 and Resident #280) reviewed for infection control. NA K did not change gloves and perform hand hygiene appropriately while performing the perineal care of Resident #33. CNA B failed to change gloves and perform hand hygiene during incontinent care for Resident #21. The treatment nurse failed to perform hand hygiene prior to exiting Resident #12's room. The treatment nurse failed to perform hand hygiene while providing wound care to Resident #280. These failures could affect all residents and place them at risk for infection. The findings were: 1.Record review of Resident #33's face Sheet dated 07/05/23 indicated that resident was an 89year old female who originally admitted to the facility on [DATE] and re-admitted on [DATE] with the diagnoses of Dementia (decline in cognitive abilities), Heart failure (impaired heart blood pumping), chronic obstructive pulmonary disease (a lung disease that blocks the air flow making it difficult to breathe, and depression. Record review of Resident #33's MDS dated [DATE] indicated that resident had a BIMS score of 8 (which indicated she had moderately impaired cognition). The MDS also indicated that Resident #33 required extensive assist of two staff for bed mobility, transfers, dressing, toileting, and total assist with bathing. Record review of Resident #33's Care Plan revised on 02/24/23 indicated that resident required assistance with toileting due to resident had a foley catheter related to neurogenic bladder and bowel incontinence that required incontinent care. It also indicated that Resident #33 had actual impairment to skin integrity and facility was to administer medications per physician orders. During an observation and interview on 06/27/23 at 03:47PM NA K and CNA L entered Resident #33's room with hands already gloved. NA K and CNA L said they washed their hands prior to donning gloves. Both Aides talked to Resident #33 throughout the process. CNA L was on the left of Resident #33 and NA K was on the right side of Resident #33. NA K rolled Resident #33 to her left side to remove the dirty draw sheet from under resident. NA K then placed a clean draw sheet from under the resident. NA (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675798 If continuation sheet Page 18 of 22 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 06/28/2023 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some K placed wipes on the bed beside the resident to use. NA K removed a wet wipe from the wipe container and cleaned the left peri area and threw it in the trash at foot of Resident #33's bed. NA K then grabbed another wipe from the box using the same gloves and wiped the right inner peri area. She then threw the wipe in the trash. NA K pulled another wipe from the box using the same gloves and cleaned the middle peri area from front to back and threw the wipe in the trash. NA K then unstrapped the catheter from Resident #33's left thigh, pulled a wipe from the box with same gloves and wiped the catheter tubing from the resident away and threw the wipe in the trash. CNA L placed Resident #33's catheter back into the strap. NA K and CNA L rolled Resident #33 to left side and NA K pulled a wipe from the box and cleaned resident's buttocks. They rolled resident back on her back. NA K grabbed a box with cream with same gloves on and opened the tube. NA K then squeezed an unmeasured amount of cream into the gloved hand that she was using and applied the cream to Resident #33's left inner thigh. CNA L assisted NA K to turn resident to left side. NA K squeezed more cream into cream covered gloves and applied to Resident #33's buttocks. NA grabbed the clean brief and placed it on the bed. NA K then grabbed the cream, pulled a wipe out of box, cleaned the cream container with the wipe, placed it back in the box, and threw the wipe in the trash. NA K removed gloves for the first time during the entire process, walked out of the room, and retrieved clean gloves. NA K walked back into the room donning new gloves without hand hygiene. She then placed a new gown on Resident #33 and covered her up. CNA L and NA K removed all wipes and dirty linen, removed gloves, washed hands, and exited the room. During an interview on 06/27/23 at 04:10PM CNA L said she thought she provided the proper peri care. She said she may have missed some steps or hand hygiene. CNA was asked if she should change her gloves when going from a dirty area of the body to a clean area and she said yes. CNA L said she was taught to change her gloves and use hand sanitizer when the gloves became visibly dirty. She said the failure in using proper hand hygiene and glove changes could place the resident at risk for infection. During an interview on 06/27/23 at 04:15PM NA K said that she felt she did not do a good job. She said she should have gathered her supplies, extra gloves, extra bags, and pulled the wipes from the container and placed in a bag like she learned in school. NA K said she was checked off in school for peri care but had never been checked off at the facility. She said she knew the correct way to provide care but was in a hurry and had been doing what other CNAs she worked with had been doing. NA K said improper peri care could cause infection control issues. During an interview on 06/28/23 at 02:54PM ADON D said CNAs and NAs should wash their hands before and after they glove, change gloves when they are torn or contaminated, and before touching a clean brief they should hand sanitize and place new gloves on to continue care. ADON D said the CNA and NA not providing proper hand hygiene could place all residents at risk for infection. She said she was responsible for ensuring the CNAs and NAs were providing the proper care. She said she normally provided proficiency checks annually. She said she taught the CNAs and NAs the proper way to provide care, but their forms do not go into detail. During an interview on 06/28/23 at 03:04 PM the DON said CNAs and NAs should change gloves and sanitize between clean and dirty and apply new gloves. The DON said ADON D was responsible CNA and NA proficiency check offs. She said it was performed annually and ADON D does handwashing check off and peri care check offs often. The DON said the failure places Resident #33 and other residents at risk for infection and or worsening infection. During an interview on 06/28/23 at 03:30PM the Administrator said she expected the CNAs and NAs to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675798 If continuation sheet Page 19 of 22 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 06/28/2023 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some follow the infection control policy. She said they should not have touched anything with dirty gloves or gloves that had touched residents. The Administrator said ADON D was responsible for ensuring the NAs and CNAs provided care with proper handwashing and infection control. She said the failure could cause an increase in infections. 4.) Record review of Resident #280's face sheet dated 06/27/23, indicated she was an [AGE] year-old female who initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #280's diagnoses included herpes zoster eye disease (commonly known as shingles, a viral infection of the nerve that supplies sensation to the eye surface, eyelids, forehead, and nose), delusional disorder (a type of serious mental illness called psychotic disorder), type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar, dementia (a group of thinking and social symptoms that interfere with daily functioning). Record review of Resident #280's quarterly MDS assessment dated [DATE], indicated she was sometimes understood and sometimes understood others. The MDS indicated Resident #280's had a BIMS score of 6, indicating she had severe cognitive impairment. Resident #280 required extensive assistance with bed mobility, transfers, dressing, toileting, personal hygiene and was totally dependent on staff with bathing. The MDS indicated Resident #280 was at risk for pressure ulcers/injury. The MDS indicated Resident #280 had no unhealed pressure ulcers or injuries. Record review of Resident #280's comprehensive care plan dated 06/21/23, indicated she had a stage 2 (sore that has broken through the top layer of the skin and part of the layer below) to right buttock with the goal for resident to be free of infection by/through the review date. The care plan interventions included to administer treatments as ordered and monitor for effectiveness. Record review of Resident #280's order summary report dated 06/27/23, indicated she had an order to cleanse stage 2 to right buttock with normal saline, pat dry, apply collagen powder, cover with non-stick bandage, and secure with tape daily for wound healing with an order date of 06/26/23. During an observation and interview on 06/26/23 at 01:46 PM, the Treatment Nurse entered Resident #280's room to provide treatment to her right buttock wound. During the procedure the Treatment Nurse did not perform hand hygiene after she cleansed Resident #280's wound and removed her gloves. The Treatment Nurse donned clean gloves and completed the treatment. The Treatment Nurse said she was responsible for providing proper wound care as well as performing hand hygiene. The Treatment nurse said failure to perform hand hygiene in between glove changes placed Resident #280 at risk for cross contamination and infection. The Treatment Nurse said she was nervous as to why she failed to perform hand hygiene in between glove changes. The Treatment Nurse said she had been checked off on wound care administration. Record review of the Treatment Nurse's wound care skill competency evaluation indicated she had completed it on 07/13/22. Record review of the Treatment Nurse's hand hygiene checkoff dated 01/12/23, indicated she had passed the skill evaluation. During an interview on 06/28/23 at 01:57 PM, ADON O said she expected wound care to be performed as ordered and hand hygiene be performed after removing gloves and before donning clean gloves. The ADON said failure to perform proper hand hygiene could place Resident #280 at risk for cross contamination and infection. The ADON the person who was performing the wound care was responsible for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675798 If continuation sheet Page 20 of 22 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 06/28/2023 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 0880 ensuring proper hand hygiene was performed. Level of Harm - Minimal harm or potential for actual harm During an interview on 06/28/23 at 02:06 PM, the DON said she expected wound care to be done as ordered and proper hand hygiene performed to prevent infection. The DON said the Treatment Nurse should have performed hand hygiene after removing her gloves and prior to donning clean gloves. The DON said failure to perform hand hygiene before donning clean gloves placed Resident #280 at risk for wound infection. Residents Affected - Some During an interview on 06/28/23 at 02:20 PM, the Administrator said the Treatment Nurse should have performed hand hygiene in between glove changes and by not doing so placed Resident #280 at risk for infection. The Administrator said the Treatment Nurse was responsible for ensuring she performed proper wound care and hand hygiene. Record review of a policy titled Nursing: Personal Care, Perineal Care dated 4/27/22 provided by the DON indicated: Doffing and discarding of gloves are required if visibly soiled. The policy did not indicate when to change gloves. Record review of an Infection Control Plan Overview policy dated 3/2023 provided by the DON indicated: The facility will require staff to wash their hands after each direct resident contact for which hand washing is indicated by accepted professional practice . The intent of this policy is to assure that the facility develops, implements, and maintains an Infection Prevention and Control Program in order to prevent, recognize, and control, to the extent possible, the onset and spread of infection within the facility . Implement hand hygiene (hand washing) practices consistent with accepted standards of practice, to reduce the spread of infections and prevent cross-contamination. Implement PPE usage practices consistent with accepted standards of practice to reduce the spread of infections and prevent cross-contamination. Record review of a Fundamentals of Infection Control Precautions, undated, provided by the DON indicated: Hand Hygiene Hand hygiene continues to be the primary means of preventing the transmission of infection. The following is a list of some situations that require hand hygiene: When hands are visibly soiled (hand washing with soap and water); Before and after direct resident contact (for which hand hygiene is indicated by acceptable professional practice) . After contact with a resident's mucous membranes and body fluids or excretions (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675798 If continuation sheet Page 21 of 22 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 06/28/2023 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 0880 Before and after changing a dressing Level of Harm - Minimal harm or potential for actual harm After removing gloves . After handling soiled or used linens, dressings, bedpans, catheters, and urinals . Residents Affected - Some Consistent use by staff of proper hygiene practices and techniques is critical to preventing the spread of infections . The policy did not address when to change gloves. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675798 If continuation sheet Page 22 of 22