Health inspection·August 20, 2025

F 0689 Level of Harm - Actual harm Residents Affected - Few bathroom. Her legs gave out and she was lowered to the floor. Resident #1 sustained a 2-inch abrasion with redness discoloration to left buttocks during the fall. Resident #1 denied pain or discomfort. RP and PA notified of the incident. Record review of Resident #1's physician's order dated 04/23/2025 for x-ray to right lower extremity due to pain post fall with start date of 04/23/2025 and end date of 04/25/2025. Cleanse abrasion to left buttock with normal saline, pat dry and apply TAO LOTA daily on day shift for 5 days with start date of 04/23/2025 and end date of 04/29/2025. May wear walking boot to right foot x 1 week on day and night shift for 7 days with start date of 04/28/2025 and end date of 05/06/2025. Weight bearing as tolerated and bed rest as needed for 1 week with start date of 04/28/2025 and end date of 05/05/2025. Apply ice to right ankle/leg as needed; every 2 hours as needed for edema; pain for 1 week start date of 04/28/2025 and end date of 05/05/2025. Tramadol 50 mg give 2 tablets by mouth every 6 hours as needed for moderate pain with start date of 11/16/2024. Acetaminophen Extra Strength Tablet 500 mg give 500 mg by mouth every 6 hours as needed for mild pain with start date of 05/23/2017. Record review of Resident #1's medication administration record indicated she received Tramadol 50 mg 2 tablets by mouth every 6 hours as needed for moderate pain on 04/22/2025 at 9:31 p.m., 04/23/2025 at 5:41 p.m., 04/23/2025 at 2:30 p.m., and 04/24/2025 at 8:00 a.m. with effectiveness. She received Acetaminophen Extra Strength 500 mg 1 tablet every 6 hours as needed for mild pain on 04/23/2025 at 2:03 a.m. with effectiveness. Record review of Resident #1's nursing follow-up injury note dated 04/22/2025 at 9:30 p.m. she complained of a dull pain to her right upper and lower leg, and ankle relieved with PRN pain medication of tramadol. PA was notified of the pain and x-ray to the right upper and lower extremity was ordered. Record review of Resident #1's social service progress note dated 04/23/2025 at 8:14 a.m. indicated SW spoke with resident regarding the incident which occurred on 04/22/2025. Resident stated a CNA was changing her, and her legs went out on her and she was lowered to the ground. She said her right side was hurting and she was supposed to get an x-ray that day. Resident #1 was lying in her bed at the time and said she did not feel the CNA was intentionally trying to harm her. Resident #1 denied abuse and neglect. Record review of Resident #1's right ankle and right tibia/fibula x-ray results dated 04/23/2025 at 11:40 a.m. indicated right ankle 2 view findings: intramedullary rod with nail (internal fixation technique originally mainly used for the surgical management of long bone fractures) seen traversing a healing fracture deformity along the distal tibia (shinbone). A suspected hairline (fracture without separation of the fragments) cortical (outer layer) fracture lucency (areas that appear darker due to lower density) faintly and partially visualized along the distal fibula (lower end of the calf bone). No dislocation, or bony destructive lesions are noted. Talar dome (ankle bone) and ankle mortise (ankle joint) appear normal. The bony mineralization is unremarkable. Right ankle impressions: stable postprocedural status, internally fixed healing distal diaphyseal fracture (break of the shaft of the bone) of the right tibia (shinbone) noted. A suspected hairline (fracture without separation of the fragments) cortical (outer layer) fracture lucency (areas that appear darker due to lower density) faintly and partially visualized along the distal fibula (lower end of the calf bone), no acute osseous findings. Right tibia/fibula (lower leg bones) 2 view findings: there is an intramedullary rod transfixing (internal fixation technique originally mainly used for the surgical management of long bone fractures) distal 3rd tibial (Shinbone) fracture. No evidence of hardware failure or new fracture seen. There is a healed fracture of the distal fibula (calf one). Soft tissues are unremarkable. Right tibia/fibula impression: slightly osteopenia bone but intact normally aligned distal tibial and fibular fractures with hardware in good alignment. Record review of Resident #1's weekly skin assessment dated [DATE] at 10:17 a.m. indicated abrasion present: red abrasion noted to left upper buttocks (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675798 If continuation sheet Page 2 of 6 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 08/20/2025 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 0689 Level of Harm - Actual harm Residents Affected - Few approximately 3 inches. Record review of Resident #1's nursing progress note dated 04/23/2025 at 4:02 p.m. indicated x-ray images obtained, PA, DON and RP aware of finding. PA instructed to call orthopedic clinic and schedule a follow up appointment with Resident #1's established orthopedic to determine if findings on x-rays are new or old injuries. Orthopedic appointment scheduled regarding right leg discomfort and clarification of x-ray results for 04/28/2025 at 3:20 p.m. Record review of Resident #1's nursing note dated 04/23/2025 at 4:46 p.m. indicated an abrasion present on left buttocks cheeks and complaining of pain/discomfort in right leg and pain was being addressed. Record review of Resident #1's nursing progress note dated 04/23/2025 at 9:45 p.m. indicated a 7cm x 1cm abrasion/bruise present on left buttocks cheeks and no pain present during assessment. She was being monitored Q shift with follow up assessments. Record review of Resident #1's nursing progress note dated 04/24/2025 at 1:23 p.m. indicated a 7cm x 1cm abrasion/bruise present on left buttock. Record review of Resident #1's nursing progress note dated 04/24/2025 at 10:50 p.m. indicated a 7cm x 1cm blue/purple bruise present on left buttocks cheeks and no pain present during assessment. Record review of Resident #1's nursing progress note dated 04/25/2025 at 12:55 p.m. indicated a 7cm x 1cm blue/purple bruise present with a 2cm x 2cm abrasion in bruised area on left buttock and no dressing, s/s of infection or pain present during assessment. Record review of Resident #1's nursing note dated 04/25/2025 at 11:19 p.m. indicated a 7cm x 1cm blue/purple bruise present with a 2cm x 2cm abrasion in bruised area on left buttock and no dressing, s/s of infection or pain present during assessment. Record review of Resident #1's nursing progress note dated 04/28/2025 at 6:13 p.m. indicated resident had an appointment at orthopedic clinic and returned to the facility with no concerns or discomforts. The report stated there was a possible small avulsion fracture (a ligament or tendon pulls away a small piece of a bone) off the distal fibula and right ankle sprain and the resident may have to wear a boot for a week or two for support. Record review of Resident #1's orthopedic visit note dated 04/28/2025 at 3:20 p.m. present illness indicated [Resident #1] was an established patient with orthopedic clinic and well known to physician and underwent intramedullary nail fixation of right tibia fracture on 11/20/2024 and was doing well until a few days ago when she had an incident at facility. They got a portable x-ray there are some concerns for fracture so referred her for further evaluation with pain primarily about the right lateral ankle. The assessment/plan indicated plain films of the right tibia (shinbone)/fibula (calf bone) obtained and indicated orthopedic implants with subacute fractures (a bone break that has occurred recently, usually several weeks or months ago, and is in the healing process) of the tibia and fibula and a possible small avulsion fracture (a ligament or tendon pulls away a small piece of a bone) off the distal fibula. Status post intramedullary fixation of right tibia/fibula fracture, now with likely right ankle sprain will treat this conservatively. She can go into her boot for a week or so. She will elevate, ice and rest. Then advance her activity as tolerated, if unable to do that will need to contact clinic, otherwise follow-up as needed. Record review of Resident #1's treatment administration record dated April 2025 indicated cleanse abrasion to left buttock with normal saline, pat dry and apply TAO LOTA daily. She may wear walking boot to right foot x 1 week every day and night shift for 7 days and apply ice to right ankle/leg as needed every 2 hours for edema and pain for 1 week starting 04/29/2025. During an interview on 08/18/2025 at 11:10 a.m., Resident #1 said the day of the incident she was needing to be changed and was in her bathroom in preparation to have her brief changed. She stated CNAT C entered her bathroom, and she requested to be changed. She said CNAT C assisted her to stand up, she held onto the grab bars, when she was reapplying the new brief, her knees became weak and gave way. She said with the assistance of CNAT C, she was lowered to the floor. She said she did not have any pain at the time of the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675798 If continuation sheet Page 3 of 6 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 08/20/2025 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 0689 Level of Harm - Actual harm Residents Affected - Few incident, but later that evening, her right lower leg started hurting and an x-ray was obtained. She said she went to the orthopedic doctor for treatment. She said she had weakness in her lower extremities and that was why she was receiving therapy. She said only one staff member was assisting her at the time of the incident, but now two staff members assist her with all transfers and toileting hygiene. She said her right lower leg and ankle hurt for 2 or 3 days after incident, and she wore a boot to help keep stable, but it was better now. During an interview on 08/18/2025 at 1:10 p.m., Resident #4 (roommate) said the day of the incident, she was in the room and heard Resident #1 say her knees were getting weak. She said the bathroom door was closed so she did not see the incident. She said only one staff was assisting Resident #1 that day and usually there was two staff. She said several staff entered the room after the incident to assist Resident #1. During an interview on 08/19/2025 at 11:43 a.m., CNAT C said she was completing her clinical rotation for her CNA certification at the facility, and on 04/22/2025 she was instructed by her trainer to answer call lights on the hall. She said Resident #1 call light alarmed, so she went to answer and found Resident #1 in her bathroom damaging to be changed immediately. She said she stood the Resident #1 up, had her hold the grab bars on the wall, and while completing the hygiene task and applying her new brief, Resident #1's knees gave away and she began to lower toward the floor. She said she attempted to but the wheelchair under her, but she slid down grazing wheelchair with her buttocks/hip, and she then assisted her by lowering her to the floor and called for assistance. She said Resident #1 said she was not injured and started cussing at her to get her off the fucking floor. She said two nurses and a CNA entered Resident #1's bathroom so she left. She said the clinical educator had informed the trainees not to perform hands on care until approval by trainer or clinical educator, but she had received training on transfers and been checked off, so thought she could assist with the requested transfer. She said she was not aware Resident #1 was a 2 person assist with transfers and had she been aware, she would not have attempted to transfer her by herself. She said as a CNA trainee she was not provided access to the Kardex, so would have to ask her trainer if the resident required 2-person transfer. She said she had provided care to other residents under the supervision or guidance of the trainer or clinical educator. CNA trainee C said she received one on one training from clinical educator, DON and administrator regarding the incident on abuse, neglect, incontinent care, safe transfers, Kardex use, and expectations and proved task a clinical trainee and trainer can/should perform. CNA C trainee said she should not have transferred Resident #1 by herself. During an interview on 08/19/2025 at 11:43 a.m., CNA D said she was the trainer for CNAT C at the time of the incident with Resident #1. She said she had told CNAT C to answer the call light and do minor task like give ice, water, or report complaints to the CN. She said she had told CNAT C several times during her clinical rotation not to provide hands on care without her as the trainer or clinical educator present. CNA D said Resident #1 could be demanding and manipulative to get her way. CNA D said she assisted the LVN to get Resident #1 back to her wheelchair after the LVN assessed her after the incident and she denied pain when facility staff ask about pain. During an interview on 08/19/2025 at 2:15 p.m., LVN E said she was one of the LVNs that assessed Resident #1 after the incident and she, another LVN and CNA D assisted her to her wheelchair after the incident. LVN E said she walked in the resident's room observed resident #1 on the bathroom floor sitting on her butt, with her right leg under her left leg and CNAT C was holding her in the upright sitting position. She said CNAT C said her knees gave out and she lowered her to the floor. She said it appeared Resident #1 was holding onto the grab bars and had to be lowered to the floor. She said Resident #1 denied hitting her head, pain, and refused any pain medications during the assessment. She said Resident #1 did have a discoloration with an abrased area (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675798 If continuation sheet Page 4 of 6 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 08/20/2025 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 0689 Level of Harm - Actual harm Residents Affected - Few to her left buttocks which was in proximate of hitting the wheelchair arm. During an interview on 08/19/2025 at 4:00 p.m., LVN G said she provided care for Resident #1 on 6 p.m. to 6 a.m. shift after the incident 04/22/2025. She said around 9:30 p.m., Resident #1 complained of pain/discomfort to right upper and lower leg, and dull pain to right ankle. She said she administered PRN pain medication of Tramadol with effectiveness. She said she notified the PA of the complaint of pain to right upper and lower leg and ankle and he ordered an x-ray. She said she send an x-ray requested to the mobile x-ray unit. She said Resident #1 had pain the evening and night of the incident and maybe the next day but after that did not recall her complaining of pain or giving her any PRN pain medications related to her right lower leg or ankle. During an interview on 08/20/2025 at 11:15 a.m., RN F said she was the clinical educator, and she does the training and oversees the CNA trainees while they are in the facility for their clinical rotation. She said the CNA trainee contacts her to be placed on the clinical rotation schedule; she verifies they have completed their 60 hours of on-line education and received a certificate. She says they are in the facility for 40 hours to be trained on different task a CNA may be responsible for completing. She said the rotation is usually five 8-hour days totaling 40 hours. She said the first 1/2 of the day usually consist of classroom training, demonstrating with mannequin certain task and then the trainee would shadow a trainer completing the task assignment. She said trainee was provided transfer training and competency check off by facility physical therapy staff. She said the trainees are told not to provide any hands-on task/care unless the trainer or herself was present. She said the trainees are not provided logins to the electronic medical records to access task or ADL care because facility staff trainer should be accessing and instructing the trainee. Unsuccessful attempts to interview orthopedic physician on 08/19/2025 at 3:11 pm and 08/20/2025 at 8:00 a.m. During an interview on 08/20/2025 at 1:25 p.m., the DON stated the CNA trainee should not have been performing task without trainer or clinical educator present. She said the facility staff have been in-serviced CNA trainer were not allowed to allow student nurses aide or CNA trainees to perform direct resident task without supervision. The DON said all facility staff should follow policy regarding transferring a resident and if the resident requires two persons assist that two staff members were to transfer the resident, no exceptions. The DON said if the transfer assist task needs to be updated then the staff should notify the CN or DON for review. The DON said facility therapist provided transfer training and competency check offs. The DON said the residents may be injured if proper assistants not provided during transfer. During an interview on 08/20/2025 at 1:45 p.m., the Administrator said she expected facility staff, CNA students and trainees to follow facility policies and CNA trainees and students were not to be allowed to provide ADL care or task until approved by clinical educator or trainer. The Administrator said not utilizing 2 staff members for a resident requires a 2-person transfer could result in a fall or injury. During an interview on 08/20/2025 at 4:15 p.m., the Orthopedic physician nurse said she clarified with the orthopedic physician and Resident #1 did have a small avulsion fracture (a ligament or tendon pulls away a small piece of a bone) of the distal fibula and right ankle sprain possibility from the incident, but he would prescribe the same treatment for both injuries, which included an immobilizer boot and elevate, ice and rest. Record review of the facility's nursing policy and procedure titled, Moving a resident, bed to chair/chair to bed. Purpose: The purposes of this procedure are to allow the resident to be out of his or her bed as much as possible and to provide for safe transferring of the resident. Steps in the Procedure. Note: This procedure may require two (2) persons. f. If the resident requires, two persons (one on each side) should grasp the gait belt and gently stand and turn the resident and sit him or her on the edge of the bed/chair. Record review of the facility's policy titled, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675798 If continuation sheet Page 5 of 6 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 08/20/2025 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 0689 Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Preventive Strategies to reduce fall risk undated 10/05/2016, indicated Policy: The goal of fall prevention strategies is to design interventions that minimize fall risk by eliminating or managing contributing factors while maintaining or improving the resident's mobility. Procedure: After risk is assessed, individualize nursing care plans will be implemented to prevent falls. The resident and/or family members will be educated on methods to prevent falls. Interventions will focus on manipulating the environment, educating the resident/family's, implementing rehabilitation programs to improve functional ability, and care monitoring of medication side effects. The facility implemented the following interventions before the survey entrance on 08/18/2025. During an interview on 08/20/2025 at 1:00 p.m., RN F, Clinical educator, said she now stressed to all CNA trainees they were not to provide any hands-on skills unless approval from her as the clinical educator. Record review of in-service training titled, Incontinent care dated 04/22/2025 for nursing staff indicated 39 staff in attendance. Summary: Provide incontinent care on all residents with lower extremity weakness, requires two-person assistance with transfers and/or utilize mechanical lift for transfers in the bed only. Record review of in-service training titled, CNA trainers dated 04/22/2025 for CNA's indicated 36 staff in attendance. CNA trainers do not allow student nurses' aides or trainees to perform direct resident task without supervision. Record review of in-service training titled, How to use Kardex to communicate resident information and needs to the CNAs. Ensure you follow all care planned interventions including how much staff is required to perform an ADL. If unable to have the proper number of staff to assist a resident, do not perform the task until the proper amount is present. Do not rush. If for any reason the amount of staff assistance needed is not listed for bathing, bed mobility, transferring, walking, incontinent care, then you should contact the charge nurse, ADON and/or DON. If more assistance is required than what is on the Kardex, report to the DON, ADON or MDS case manager immediately so Kardex can be adjusted. Charge nurse- through assessment of affected residents for injury or pain and report findings to the NP/MD dated 04/22/2025 with 38 staff in attendance. Record review of in-service training titled, Transfer training dated 04/23/2025 for all nursing staff indicated 40 staff in attendance. Summary safe, effective transfer training with demonstrations. Interviews with 36 staff members from all shifts from 08/18/2025 at 8:50 a.m. to 08/20/2025 at 2:30 p.m. the following staff LVN A, CNA B, CNAT C, CNA D, LVN E, RN F, LVN G, RN H, RN J, LVN K, LVN L, LVN M, LVN N, LVN O, LVN P, LVN Q, CNA R, CNA S, CNA T, CNA U, CNA V, CNA W, CNA X, CNA Y, CNA Z, CNA AA, CNA BB, CNA CC, COTA LL, ST MM, OT NN, SNA OO, CNAT PP, CNAT QQ, CNAT RR, CNA SS, and CNA/MA TT confirmed completion of in services/training of incontinent care, always follow the plan of care, care plan and Kardex when providing resident care, look at the Kardex for resident required assistance, transfer training, and if a trainer with the CNA trainees or student do not allow student nurses' aides or trainees to perform direct resident task without supervision. The staff, CNA trainees and students were able to verbalize understanding and information provided in the in-service/training. During an observation on 08/19/2025 at 1:30 p.m. SNA OO was observed providing one person transfer with Resident #5 using correct procedure. During an observation on 08/20/2025 at 9:35 a.m. CNA/MA TT and CNA AA were observed providing a two person transfer with Resident #6 using correct procedure. The non-compliance was identified as past non-compliance. The PNC began on 04/22/2025 and ended on 04/23/2025. The facility had corrected the non-compliance before the survey began. Event ID: Facility ID: 675798 If continuation sheet Page 6 of 6