Health inspection·November 20, 2025

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete put in place. She said she could not find any documentation showing the physician was notified of resident's refusal. The Regional nurse said her expectation is for all nurses to follow policy and notify the physician of any pattern of refusal to ensure no potential harm came to the residents from not getting ordered treatment or alternative treatment. During an interview on 10/01/2025 at 3:17 p.m., the Administrator said the physician must be notified of any refusals to ensure the residents needs were being met, and no harm came to the residents by not receiving ordered treatment or a potential alternative treatment. Record review of the facility's undated policy Notifying the Physician of Change in Status,indicated: The nurse should not hesitate to contact the physician at any time when an assessment and their professional judgment deem it necessary for immediate medical attention. This facility utilizes the INTERACT tool, Change in Condition - When to Notify the MD/NP/PA to review resident conditions and guide the nurse when to notify the physician. This tool informs the nurse if the resident condition requires immediate notification of the physician or non-immediate/Report on Next Workday notification of the physician.The nurse will notify the physician or their delegated nurse practitioner or physician assistant with change in status. The nurse will document signs and symptoms of significant change, time/date of call to physician, and interventions that were implemented in the resident 's clinical record. Event ID: Facility ID: 675798 If continuation sheet Page 2 of 12 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 11/20/2025 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure individuals with mental health disorders were provided an accurate Preadmission Screening and Resident Review (PASRR) Screenings for 3 of 22 residents (Residents #8, 42, and 59) reviewed for resident assessments. 1. The facility failed to refer Resident #8 for a PASRR review following a new mental illness diagnosis of bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs) on 03/28/25. 2. The facility failed to refer Resident #42 for PASRR review following a new mental illness diagnosis of psychosis (a mental disorder characterized by a disconnection from reality) on 11/04/24. 3. The facility failed to refer Resident #59 for PASRR review following a new mental illness diagnosis of bipolar disorder on 07/22/25. These failures could place residents at risk of not receiving needed assessments (PASRR Evaluation), individualized care, and specialized services to meet their needs.Findings included: 1. Record review of a face sheet dated 10/01/25 indicated Resident #8 was an [AGE] year-old female who admitted to the facility on [DATE]. She had diagnoses included bipolar disorder, cognitive communication deficit (a difficulty in communication caused by impaired thing processes, such as memory, attention, problem-solving, and organization), and dementia (a group of thinking and social symptoms that interfere with daily functioning). Record review of the most recent quarterly MDS assessment dated [DATE] indicated Resident #8 had clear speech and was able to express her needs and comprehend others. She had a BIMS score of 7 indicating she had severe cognitive impairment, required substantial/maximal assistance with most ADLs, and had an active diagnosis of bipolar disorder. Record review of a care plan dated 04/07/25 indicated Resident #8 had a diagnoses of psychosis, bipolar disorder, and attention deficit hyperactivity disorder (a chronic condition including attention difficulty, hyperactivity, and impulsiveness). Interventions included administering medications as ordered by the physician and psych services as indicated. During record review of the physician orders dated September 2025 indicated Resident #8 received Risperdal oral solution at bedtime for attention deficit disorder with start date of 04/09/25. During an interview on 10/01/25 at 9:06 a.m., the MDS Nurse said that Resident #8's diagnosis of bipolar disorder was unknown to the facility until her physician ordered a gradual dose reduction and the discontinuation of her Risperdal (an antipsychotic medication used to treat bipolar disorder). She said Resident #8's family questioned why her Risperdal had been discontinued because the resident had been taking the medication for more than 10 years to manage her bipolar disorder and attention deficit hyperactivity disorder and they did not want the medication discontinued. The MDS Nurse said Resident #8's physician reordered the Risperdal per the family's request. She said the facility failed to complete a 1012 form (a form that assists the NF in determining whether a resident with a negative PASRR level 1 screening needs further evaluation for mental illness). She said the Social Worker was responsible for PASRR evaluations at the facility. During an interview on 10/01/25 at 9:45 a.m., the Social Worker said that she was responsible for coordinating PASRR for the facility. She said she had been doing PASRR for a year and had received PASRR training through webinar classes given by HHSC. She said she was not aware that if a resident was diagnosed with a new mental illness or the facility learned of a history of mental illness that a 1012 form should be submitted to the physician to determine if a resident should be screened for PASRR services. She said the 1012 form for a new mental illness was probably included in the training she attended, but she missed it. She said she should have submitted a 1012 form to Resident #8's doctor when the facility learned of her bipolar diagnosis, but she didn't. She said she would fill out a 1012 form and send it to Resident #8's physician. She said the possible (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675798 If continuation sheet Page 3 of 12 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 11/20/2025 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some negative outcome of not completing a 1012 form and sending it to the doctor could be that Resident #8 would not receive needed services that she could qualify for through PASRR. During an interview on 10/01/25 at 3:35 p.m., the MDS Nurse said that a 1012 Mental Illness/Dementia Resident Review form had been completed (after surveyor intervention) for Resident #8. Record review of a 1012 form dated 10/01/25 and signed by Physician A indicated that Resident #8 had a primary diagnosis of dementia and a new PL1 was not needed at that time. 2. Record review of a face sheet dated 10/01/25 indicated Resident #42 was an [AGE] year-old female who admitted to the facility on [DATE]. She had diagnoses included cerebral infarction (a condition where blood flow to the brain is interrupted, leading to brain cell damage), psychosis, and dementia. Record review of the most recent MDS assessment dated [DATE] indicated Resident #42 had clear speech and was able to express her needs and comprehend others. She had a BIMS score of 4, indicating she had severe cognitive impairment, required substantial/maximal assistance with most ADLs, and had an active diagnosis psychotic disorder. Record review of a care plan last revised 04/17/25, indicated Resident #42 required anti-psychotic medications related to her dementia with psychosis. Interventions included administering medications as ordered by the physician and psych services. During an interview on 10/01/25 at 1:51 p.m., the Social Worker said that she did not complete the required 1012 form for Resident #42 when she received the new mental illness diagnosis of psychosis. She said the negative outcome of not completing the required 1012 form was that the physician had not reviewed Resident #42 to determine if she should be evaluated for receiving specialized services through PASRR. During an interview on 10/01/25 at 3:35 p.m., the MDS Nurse said that a 1012 Mental Illness/Dementia Resident Review had been completed (after surveyor intervention) for Resident #42. Record review of a 1012 form dated 10/01/25 and signed by Physician A indicated that Resident #42 did not have a primary diagnosis of dementia and a new PL1 was needed so the resident could be evaluated for PASRR services. 3. Record review of a face sheet dated 10/01/25 indicated Resident #59 was an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of bipolar disorder [chronic mental health condition characterized by extreme mood swings between mania high (energy, euphoria, and impulsivity) and depression (low mood, fatigue, and hopelessness)] with onset date of 07/22/25. Record review of the most recent quarterly MDS assessment dated [DATE] indicated Resident #59 had clear speech with a BIMS score of 00 indicating she had severe cognitive impairment and an active diagnosis bipolar disorder. Record review of a care plan dated 07/22/25 indicated Resident #59 requires anti-psychotic medications for diagnosis of bipolar disorder. Interventions included administering medications as ordered by the physician. Record review of a PASRR level 1 screening for Resident #59 dated 01/31/25 indicated Resident #59 was negative for mental illness, intellectual disability, and developmental disability. No PASRR Level II (PE) Screening or a form 1012 (Mental Illness/Dementia Resident Review) was found in the clinical record. During an interview on 10/01/25 at 2:15 p.m., the Social Worker said that she did not complete the required 1012 form for Resident #59 when she received a new mental illness diagnosis of bipolar disorder. While looking at Resident #59's medical record face sheet, the Social Worker stated Resident #59 had a diagnosis of Bi-polar that had an onset date of 07/22/2025. The Social Worker acknowledged Resident #59's PASRR was inaccurate and another PASRR screen or form 1012 would be completed for Resident #59 and uploaded to the portal. She said the negative outcome of not completing the required 1012 form or updating the PASRR could put the resident at risk of not receiving specialized services offered through the PASRR program. In an interview on 10/01/25 at 2:45 p.m. with the Administrator, she said her expectations were for the Social Worker to complete PASRR screenings according to regulatory guidelines and that Residents #8, #42 and #59's PASRR Level 1 screenings needed to be updated to include the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675798 If continuation sheet Page 4 of 12 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 11/20/2025 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete new diagnosis. The Administrator stated that not having an accurate Level 1 put the resident at risk of not getting psych services and/or not getting the treatment they needed that was offered through the PASRR program. During an interview on 10/01/25 at 3:35 p.m., the Social Worker said that a 1012 Mental Illness/Dementia Resident Review had been completed (after surveyor intervention) for Residents #8, #42 and #59. Record review of the facility's undated policy titled Form 1012 Policy & Procedure with Instructions read in part: Purpose: Form 1012 assists nursing facilities (NF) in determining whether a resident with a negative Preadmission Screening and Resident Review (PASRR) Level I(PL1) Screening form submitted into the Long-Term Care (LTC) Portal, needs further evaluation for Mental Illness (MI).Section C. Mental Illness (MI) Indication. Examples of MI are: .mood disorder(bipolar disorder.). Event ID: Facility ID: 675798 If continuation sheet Page 5 of 12 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 11/20/2025 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure residents who enter the facility without limited range of motion does not experience reduction in range of motion unless the resident's clinical condition demonstrates that a reduction in range of motion is unavoidable for 1 of 4 (Resident #10) reviewed for range of motion. 1.The facility failed to implement interventions to prevent the decline of Resident #10's range of motion to her left hand on 10/1/2 025. 2. The facility failed to document Resident #10's change of condition to her left hand from within functional limit to a decreased range of motion. These failure could place residents at risk for decline in range of motion, decreased mobility, and worsening of contractures. Findings included: Record revied of Resident #10's face sheet dated 10/01/2025 indicated she was a [AGE] year-old female that was admitted to the facility on [DATE], with diagnoses of muscle weakness (generalized), Dementia (a decline in cognitive abilities, such as memory, thinking, problem-solving, and language), Alzheimer's disease (loss of cognition), Osteoporosis (weakens bones, making them more prone to fractures). Record review of Resident #10's Quarterly minimum data set assessment dated [DATE] indicated she had no upper extremity impairment (shoulder, elbow, wrist, hand). In Section O of the MDS entitled- Special Treatments, Procedures, and Programs indicated Resident #10 started Occupational therapy 08/14/2025. Record review of Resident #10's therapy screen dated 08/13/2025 at 5:12 p.m., indicated Resident #10 exhibited a decrease in her upper extremities range of motion and strength. In section C- (Immobilizing Device) indicated Resident #10 did not have a splint, brace, nor a placed cast on any extremity. The Occupational therapist registered #1 made a recommendation for Resident #10 to have an Occupational therapist registered and Physical therapist evaluation. Record review of Occupational therapy evaluation & plan of treatment dated 08/18/2025 at 12:55 p.m., indicated the reason for referral to occupational therapy was due to her decline in ability to perform functional activities without physical assistance, activities of daily living participation and strength. The Musculoskeletal System Assessment section indicated Resident #10's upper extremity range of motion and strength was within functional limits on both her left and right side. She also had no contractures present. In the Assessment Summary it listed risk factors such as further decline in her function and compromised general health to Resident #10 if she does not receive Occupational therapy. Record review of Resident #10's treatment administration record for the month of September 2025 did not reflect that any resting hand splint had been used on Resident #10's left hand. Record review of Resident #10's current physician orders did not indicate an order for a soft resting hand splint or hand roll for her left hand. Record review of Resident #10's Occupational therapy treatment encounter notes dated 08/14/2025- 09/27/2025 did not mention any updates on Resident #10's left hand to reflect her current decrease in range of motion. An observation on 09/29/2025 at 9:20 a.m., indicated Resident #10 did not have a hand roll or splint in her left hand. Resident #10's left hand was balled in a tight fist while sitting in her wheelchair during activities. An observation on 09/29/2025 at 3:45 p.m., indicated Resident #10 did not have a hand roll or splint in her left hand. Resident #10's left hand was balled in a tight fist resting on her lap while sitting in her wheelchair at the dining table. An observation on 09/30/2025 at 8:45 a.m., indicated Resident #10 did not have a hand roll or splint in her left hand. Resident #10's left hand was balled in a tight fist resting on her lap while sitting in her wheelchair. An observation on 09/30/2025 at 3:00 p.m., indicated Resident #10 did not have a hand roll or splint in her left hand. Resident #10's left hand was balled in a tight fist resting on her lap. An observation on 10/01/2025 at 12:00 p.m., with Registered (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675798 If continuation sheet Page 6 of 12 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 11/20/2025 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Occupational therapist and the Director of Rehabilitation indicated Resident 10's left hand was balled up in a tight fist resting on top of her lap. Resident #10 was unable to open her left hand on her own. The Registered Occupational therapist attempted to open Resident #10's left hand but was met with resistance. She massaged Resident #10's left arm to relax the arm muscle to open her hand. The Registered Occupational therapist was unable to completely open her hand. An observation on 10/01/2025 at 1:45 p.m., indicated Resident #10 had a soft resting hand splint on her left hand. An interview on 10/1/2025 at 12:20 p.m., indicated the Registered Occupational therapist said she had not documented any decreased range of motion to Resident #10's left hand in her notes. She said she should have documented the change and reported it to the Director of Rehabilitation to ensure Resident #10 received a resting hand splint to prevent further limited range of motion. An interview on 10/1/2025 at 12:45 p.m., indicated the Director of Rehabilitation was not aware that Resident #10 had a decreased range of motion in her left hand that required a resting hand splint. She said she had expected the Registered Occupational therapist to report any change of conditions on any resident to her and document it in her notes. The Director of Rehabilitation said by Resident #10 not receiving a resting arm splint could potentially worsen her range of motion and overall health. An interview on 10/1/2025 at 2:15 p.m., indicated the Administrator said she expected therapy staff to follow facility policy by documenting resident's' changes, communicating resident needs to nursing staff/ management, and ordering needed resting arm splints. She said not following the policy could potentially cause limited range of motion that residents did not previously have. Record review of the facility's policy Immobilization Devices, Splints/ Slings/ Collars/Straps. dated year 2003 indicated: Splints are rigid devices that can be used to treat a bone fracture, dislocation, or to prevent further damage of bones, joints, and muscles following injury or during acute phases of chronic diseases such as arthritis.15. Document all care and the residents response to treatment in the clinical record. Event ID: Facility ID: 675798 If continuation sheet Page 7 of 12 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 11/20/2025 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure residents who were incontinent of bowel and bladder received appropriate treatment and services to prevent urinary tract infections for one (Resident #76) of 22 resident reviewed for incontinent care. The facility failed to ensure that CNA C cleaned under the foreskin (the retractable roll of skin covering the tip of the penis) for Resident #76 while incontinent care was provided on 09/29/2025. This failure could place the residents at risk of cross-contamination and development of urinary tract infections.Findings included: Record review of face sheet, dated 10/01/25, indicated Resident #76 was a [AGE] year-old male admitted on [DATE] with diagnoses which included Parkinson's disease (a disorder of the central nervous system that affects movement) and dementia (disease of the brain with impairment of memory and abstract thinking). Record review of quarterly MDS assessment dated [DATE] indicated Resident #76 was severely impaired with cognition and was frequently incontinent for bladder and bowel. Resident #76 required partial/moderate assistance with toileting hygiene. Record review of comprehensive care plan dated 08/08/25 indicated Resident #76 required extensive assistance of 1 person for occasionally incontinent of bladder and bowel. Resident #76 had an ADL self-care performance deficit and required staff to provide incontinent care after each episode. During an observation on 09/30/25 at 10:30 a.m., CNA C and CNA D washed their hands, donned gowns and gloves. CNA C cleaned the pubis area (below the abdomen) and the genital area. CNA C did not push back the foreskin and did not clean under the foreskin. CNA C changed her gloves and CNA D turned Resident #76 on his left side. CNA C cleaned Resident #76's buttocks and placed a clean brief on the resident. During an interview on 09/30/25 at 10:45 a.m., CNA C said she had been trained on incontinent care for males. She said she should have pushed the foreskin back,cleaned, and then replaced the foreskin. She said normally she did push back the foreskin, but said she was nervous. She said cleaning under the foreskin could prevent infections. During an interview on 09/30/25 at 11:15 a.m., the ADON B said her expectation was for the CNAs to pull back the foreskin and clean and dry for the uncircumcised male residents to prevent infections. Then put the foreskin back in place. She said all CNAs are trained on incontinent on hire and annually. Record review of the Perineal Care Male dated 12/08/09 indicated . I.Wipe across the pubis area. Retract foreskin of uncircumcised male. Wash the urethal area in a circular motion. Continue to wash down the penis and the rest of the perineal area . Event ID: Facility ID: 675798 If continuation sheet Page 8 of 12 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 11/20/2025 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with the professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation: 1. The facility failed to ensure opened food items stored in the walk-in dry pantry area were properly sealed in plastic bags to prevent exposure to the air. 2. The facility failed to ensure food items in the facility walk-in dry storage were dated or labeled.3. The facility failed to ensure that spoiled food items were discarded.4. The facility failed to ensure the outside of food containers were free of food particles.5. The facility failed to ensure dishes were sanitized properly prior to being stored in clean area. These failure could place residents at risk of food-borne illnesses.Findings Included: Observation and initial tour of the kitchen on 09/29/2025 at 8:30 a.m. indicated inside the dry food pantry were 1 gallon bottle of apple cider vinegar with an expiration date of 06/30/2025. Inside the bottle of vinegar there was dark brown and grey colored clumpy sediment inside. An opened 16-ounce bag of Fresh gourmet wonton strip inside an opened plastic bag with a best buy date of August 20,2024. An opened 35-ounce bag of Crisp [NAME] Cereal with a best buy date of November 17, 2024. An opened 2.2-pound bag of Cacao powder had a use before date of 03/16/2024. A 6-quart container with multi-colored circle cereal was unlabeled and had no date. An opened 16- ounce bag of uncooked noodles was not sealed inside a plastic bag, labeled, or dated. There were 13 unused bowls of cereal on a tray unlabeled. There were 2 of 10 food containers that had hard and sticky clumps of food on the outside of the containers. A 1- quart container labeled Thicker had no date on label. Observation on 09/29/2025 at 9:36 a.m. indicated the dishwasher had an internal temperature of 110 degrees Fahrenheit. Dishwasher A took 6 cups from the dishwasher and placed them on the tray of clean cups. The instructions on the dishwasher read for dishes to be washed and rinsed at 120 degrees or higher to ensure kitchenware were properly disinfected. Observation on 09/29/2025 at 10:00 a.m. indicated 6 large white debris spots located on the mixer counter. An interview on 09/29/2025 at 10:15 a.m., indicated the Dietary Supervisor said there shouldn't be any food items in kitchen past 6 months of the listed date on the product. She said the outside of all food containers should be wiped down after usage to prevent food borne illnesses. The Dietary Supervisor said all food items in the kitchen should be labeled and dated. She said the dishwasher must be at a temperature of 120 degrees Fahrenheit or greater to effectively disinfect kitchenware. The Dietary supervisor said she trained the kitchen staff on labeling items, discarding expired food items, cleaning the mixing station after use, and the dishwasher needing to be at 120 degrees Fahrenheit for the dishes to disinfected. She said her expectation was for all kitchen staff to follow facility policy and the training they have received on labeling and disinfecting kitchenware. An interview on 10/1/2025 at 2:13 p.m., indicated the Administrator said all expired food items or items past a year of the listed date should be thrown away to prevent residents being served expired food items. She said she expected kitchen staff to follow the facility's policy. The Administrator said if dishes were not washed at 120 degrees, the residents could potentially be harmed by cross contamination. An interview on 10/1/2025 at 2:45 p.m., indicated the Regional Nurse said residents could potentially be served expired food items because it's in the dry storage pantry with non-expired food items. She said if the residents were to consume the expired food items, they could potentially experience stomach issues, and diarrhea. The Regional Nurse said all dishes should be washed and rinsed at a temperature of 120 degrees Fahrenheit or higher. She said her expectation was for kitchen staff to follow facility policy. Record Review of the FDA Food and Code dated year of 2022 entitled: Mechanical Ware washing Equipment, Wash Solution (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675798 If continuation sheet Page 9 of 12 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 11/20/2025 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Temperature. indicted: :The temperature of the wash solution in spray type ware washers that use hot water to SANITIZE may not be less than: The temperature of the wash solution in spray-type ware washers that use chemicals to SANITIZE may not be less than 49 C (120 F). Record Review of the facility's policy entitled Dietary Services Policy & Procedure Manual 2012 indicated (in part):Food Storage and Supplies- 3. Containers are labeled. Containers are cleaned regularly.4. Open packages of food are stored in closed containers with covers or in sealed bags and dated as to when opened.6. If an item does not have a date designated by the manufacturer as an expiration date, then the item should be dated as to when it is received, and shelf- stable items will be stored in a first in, first out manner, to be used within one year. After one year, any product that is shelf stable will be inspected by the dietary manager to ensure that it is good quality before it is used. Any product with a stamped expiration date will be discarded once that date passes. Record Review of the facility's policy entitled Dishwashing Preparation and Dishwashing dated: year of 2012 indicated (in part): The facility will complete the dishwashing process in a sanitary manner to provide clean and sanitary dishes and utensils. Procedure:2. c. The wash period shall be at least 40 seconds with a temperature of 120 degrees Fahrenheit in the dish machine. The sanitizing rinse period shall be at least 20 seconds with minimum temperature of 120 degrees Fahrenheit. Event ID: Facility ID: 675798 If continuation sheet Page 10 of 12 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 11/20/2025 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 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** Based on observations, interviews, and record reviews, the facility failed to establish and 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 one (Resident #76) of 22 residents reviewed for infection control. The facility failed to ensure CNA C performed hand hygiene before she applied clean gloves during incontinent care for Resident #76. This failure placed residents at risk for healthcare associated cross contamination and infections.Findings included: Record review of face sheet, dated 10/01/25, indicated Resident #76 was a [AGE] year-old male admitted on [DATE] with diagnoses which included Parkinson's disease (a disorder of the central nervous system that affects movement) and dementia (disease of the brain with impairment of memory and abstract thinking). Record review of quarterly MDS assessment dated [DATE] indicated Resident #76 was severely impaired with cognition and was frequently incontinent for bladder and bowel. Resident #76 required partial/moderate assistance with toileting hygiene. Record review of comprehensive care plan dated 08/08/25 indicated Resident #76 required extensive assistance of 1 person for occasionally incontinent of bladder and bowel. Resident #76 had an ADL self-care performance deficit and required staff to provide incontinent care after each episode. During an observation on 09/30/25 at 10:30 a.m., CNA C and CNA D washed their hands, donned gowns and gloves. CNA C cleaned the pubis area (below the abdomen) and the genital area of Resident #76. CNA C did not push back the foreskin and did not clean under the foreskin. CNA C changed her gloves and did not perform hand hygiene. CNA D turned Resident #76 on his left side. CNA C cleaned Resident #76's buttocks and placed a clean brief on the resident. During an interview on 09/30/25 at 10:45 a.m., CNA C said she had been trained on incontinent care for males. She said she should have used hand sanitizer with a glove change. She said not cleaning her hands could spread germs. During an interview on 4/7/25 at 11:15 a.m., the ADON B said her expectation was for all the staff to perform hand hygiene when gloves were removed to prevent infections. She said all of the nursing staff had been trained on hand hygiene when they removed gloves on hire and at least annually. Record review of The Perineal Care Male policy dated 12/08/09 indicated . if gloved , remove and discard gloves. Wash hands. Provide for resident's comfort . Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675798 If continuation sheet Page 11 of 12 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 11/20/2025 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public, for 1 (Hall B) of 4 hallways reviewed for environment. The facility failed to ensure the janitor closet, that contained potentially unsafe chemicals, on Hall B was secured on 09/29/25. This failure could result in residents coming into contact with potentially unsafe items.The findings were: During an observation on 09/29/25 at 9:35 a.m., during the initial tour on hall B, a janitor's closet's door knob was locked , however the door just opened when pushed on. The closet contained a 1/2 full bottle of multipurpose cleaner on the floor. The container had a label which indicated to keep out of the reach of children and animals. There was no staff in sight. During an interview on 09/29/25 at 9:45 am, the Maintenance Supervisor walked down the hall and met the surveyor at the unlocked room. He said someone must have forgotten to pull the door hard so the lock would latch. He said all chemicals should be in the sight of the staff or locked up to prevent residents from having accidents. The Maintenance Supervisor said all the staff was responsible for securing chemicals. During an interview with the Administrator on 09/30/25 at 1:30 p.m., the Administrator said the maintenance supervisor tightened the self-shutting mechanism to shut the door so it would lock and adjusted the lock. Record review of the Daily Common Area Cleaning policy dated 2021 indicated . Housekeeping carts/chemical must be locked when not within eyesight of a staff member. Event ID: Facility ID: 675798 If continuation sheet Page 12 of 12