Health inspection·February 16, 2023

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of Resident #2's Annual MDS dated [DATE] reflected she had a BIMS score of 5 indicating severe cognitive impairment. Her functional status indicated she required extensive assistance of one-person physical assist for toileting. Observation and interview on 02/14/2023 at 10:08 AM of Resident #2 whose peri-area was noted to be dark pink in color with a strong urine odor. Urine stains were noted surrounding her and soaking the bottom sheet. CNA D stated Resident #2's bed was soaked with urine and We are short staffed. I'm the only aide on 200 and 500 halls. There's supposed to be another aide. We couldn't change the residents at 8:00 AM. Interview on 02/14/2023 at 10:28 AM with LVN B in Resident #2's room who stated the bed linens were soaked through with urine on Resident #2's bed and more frequent rounding was needed. B. Review of Resident #39's Face Sheet reflected she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of Unspecified Sequelae of Cerebral Infarction (residual effects of a brain stroke), Contracture of muscle(tissue tightens or shortens causing a deformity), Major Depressive Disorder (persistent feeling of sadness or loss of interest in activities), Type 2 Diabetes Mellitus (chronic condition that affects the way the body processes blood sugar, body either doesn't produce enough insulin or there is resistance), Hyperlipidemia (high levels of fat particles in the blood). and Hemiplegia (paralysis of one side of the body). Review of Resident #39's Care Plan dated 09/23/2022 and revised on 12/06/2022 reflected she had an ADL self-care deficit related to CVA (Cerebral Vascular Accident - Brain Stroke) and Hemiplegia. Interventions: Bathing: Check nail length and trim and clean on bath day as necessary. Report any changes to the nurse. Review of Resident #39's Quarterly MDS dated [DATE] reflected she had a BIMS score of 11 indicating moderate cognitive impairment. Her functional status indicated she required extensive assistance of one-person physical assist for personal hygiene. Observation and interview on 02/14/2023 at 10:50 AM Resident #39 stated she wanted to get out of bed if someone would help her, but no one was available. She stated she could not tell if she was wet, but the last time she was changed was before breakfast. Resident #39's right hand was contractured and she used her left hand to open her right hand revealing approximately ¾ inch long fingernails. She stated the nails are hurting my hand. Interview on 02/14/2023 at 2:50 PM with the DOR/COTA who stated Resident #39 was getting therapy for a contracture to her right arm. Observation and interview on 02/14/2023 at 2:55 PM of Resident #39's nails to her right hand with DOR/COTA who stated her nails could stand to be cut. C. Review of Resident #22's Face Sheet reflected she was an [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of Alzheimer's Disease (progressive disease that destroys memory and other important mental functions), personal history of Covid, Dementia (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676089 If continuation sheet Page 2 of 16 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 676089 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Winnie L Nursing & Rehabilitation 2104 N Karnes Cameron, TX 76520 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 - Some (mental disorder in which a person loses the ability to think, remember, learn, make decisions and solve problems), Major Depressive Disorder, recurrent severe (persistent feeling of sadness or loss of interest in activities), muscle weakness and Gout (form of arthritis characterized by severe pain, redness and tenderness in joints). Review of Resident #22's Care Plan dated 03/15/2017 and revised 05/01/2017 reflected she had an ADL self-care performance deficit related to Dementia and muscle weakness. Interventions/tasks: the resident requires total one-person assistance with personal hygiene. Review of Resident #22's Quarterly MDS dated [DATE] reflected she was unable to complete a BIMS interview as she was rarely or never understood. Her functional status indicated she required extensive assistance of one-person physical assist for personal hygiene. Observation and interview on 02/14/2023 at 3:10 PM of Resident #22's contractured left hand with DOR/COTA who stated OT is performing ROM to tolerance for Resident #22's left hand. DOR/COTA opened Resident #22's left hand and stated those nails could stand to be cut. When asked why he stated, We don't want them digging into the skin. She has skin irritation and redness. Interview on 02/15/2023 at 9:14 AM DON stated her expectations were that residents would be clean, dry, and checked and changed if needed every two hours. She further stated the potential risk if residents are left wet is MASD and/or a pressure injury. Interview on 02/16/2023 at 8:40 AM LVN C stated during showers CNAs will sometimes tell nurses if a diabetic resident's nails need trimming. She further stated she thought some other system should be put in place and suggested Sunday nail trimmings. She stated two fingernails were long on Resident #22's contractured left hand and the nurses are responsible for ensuring nails are trimmed. She stated nurses' aides should ask the nurses if a resident is a diabetic. Interview on 02/16/2023 at 8:49 AM CNA E stated if a resident has artificial sweetener on their tray is how she knows they are a diabetic. She further stated she did not know nurses were supposed to cut diabetic resident's nails and nurses did not tell her who is a diabetic. She further stated she had not been trained what to do with contractured hands regarding cutting nails and the potential risk to the resident was Nails start growing into their skin and could cause an infection. Interview on 02/16/2023 at 8:51 AM LVN A stated there was no system in place to ensure residents with contractured hands had their nails cut and she trimmed them on Sundays when she was working. Interview on 02/16/2023 at 9:19 AM DON stated she had not conducted any training regarding trimming fingernails for residents with contractured hands. CNAs were trained by her and the ADON to look at the [NAME] to tell if a resident is a diabetic. Interview on 02/16/2023 at 10:12 AM ADON who stated her expectations for changing incontinent residents would be every two hours unless they needed it more frequently. She further stated it was her responsibility along with the DON that there were only two aides working on the morning of 02/14/2023. She further stated they were not able to get agency staff on the 14th. Interview on 02/16/2023 at 11:44 AM with the Administrator who stated he would expect anyone that sees a care issue would report it and nurses are responsible for making sure nails are trimmed. He further stated nurses are the only staff privy to knowing whether residents are diabetic, and a nurse (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676089 If continuation sheet Page 3 of 16 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 676089 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Winnie L Nursing & Rehabilitation 2104 N Karnes Cameron, TX 76520 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 - Some should trim the diabetic resident's nails. Regarding incontinence care his expectation was a resident would be checked and changed a minimum of every two hours or as needed and the potential risk if the resident was not changed is the skin could be compromised. D) Review of Resident #27 face sheet dated 02/16/2023 revealed Resident #27 was a [AGE] year old male admitted to the facility on [DATE] with a diagnoses of a history of a stroke with decreased cognitive function, dysphagia (difficulty swallowing), type 2 diabetes, weakness, unsteadiness on feet, dementia (a group of thinking and social symptoms that interferes with daily functioning), history of urine retention that required a catheter, high blood pressure and partial paralysis of affecting his left side. Review of Resident #27 quarterly MDS assessment dated [DATE] revealed Resident #27 had a BIMS score of eight to indicate moderately impaired condition. Resident #27 required extensive assistance by one staff member with bed mobility, transfer, locomotion on unit, dressing, toilet use and personal hygiene. Resident #27 was totally dependent on staff for bathing. Resident #27 had an indwelling catheter and was frequently incontinent of bowel. Resident #27 was noted to have a g-tube in place. Review of Resident #27 Care Plan dated 08/13/2018 revealed Resident #27 had the potential for pressure ulcer development related to occasionally required assist with bed mobility/repositioning and occasional incontinence. Interventions included education of resident, family and caregivers as to causes of skin breakdown including, transfer/positioning requirements . and frequent repositioning. Resident #27 was noted to have a suprapubic catheter related to urinary retention on 10/06/2022. Resident #27 was noted to have a G-tube in place on 12/09/2022. Resident #27 ADL self care performance deficits were updated on 09/11/2019 and noted Resident #27 required supervision by one staff for toilet use and one person assistance for bathing, personal hygiene, dressing, transfers and bed mobility. Resident #27's g-tube was managed by staff. In an observation and interview on 02/15/2023 at 8:55 AM, Resident #27 was observed to have feces on his socks, bed sheets, blanket and a towel on his bed. There was feces observed on the fall mat that was leaning against the wall next to his bed. Resident #27 stated the feces was from when he had a bowel movement last night and the aide did not fully clean him up. He stated his aide today was about to shower and clean him up, but was waiting for him to finish his breakfast. In an interview on 02/15/2023 at 8:58 AM, CNA L stated she was about to shower Resident #27 but wanted him to finish his breakfast. She stated she had not changed his brief yet this morning because he did not have a bowel movement and has a catheter for urine. She stated she had not noticed the feces on his bed and fall mat when she checked on him upon arrival at 6:00 AM. She stated the feces must be from a brief change overnight or the night before last. She stated Resident #27 had not told her about the feces in his bed or on his fall mat. In an interview on 02/15/2023 at 9:03 AM, the DON stated it was unacceptable for Resident #27 to be in bed with feces on his socks, bed sheets, blanket and towel. She stated his bed should have been fully changed and he should have been cleaned following his last bowel movement. She stated he should have been cleaned up immediately and definitely before eating breakfast. She stated the feces could cause skin breakdown and infection especially since he has a catheter and g-tube. She stated staff should have been checking him every two hours since his last bowel movement and they would have noticed the condition of his bed and fall mat. In an interview on 02/16/2023 at 12:20 PM, CNA J stated she worked with Resident #27 on the evening (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676089 If continuation sheet Page 4 of 16 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 676089 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Winnie L Nursing & Rehabilitation 2104 N Karnes Cameron, TX 76520 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 of 02/14/2023 and did change his brief as he had a large bowel movement. She stated he did not have feces on him or in his bed after she changed his brief. She stated he may have had another bowl movement overnight that resulted in the feces on him and his bed. She stated when she checked him prior to leaving her shift that night Resident #27 did not have feces on him or his bed. She stated they check residents every two hours or more frequently as needed for the need to change their brief. Residents Affected - Some Review of Resident #27's Bowel and Bladder Elimination record dated 02/14/2023 at 8:52 PM revealed Resident #27 had a large bowel movement and it was documented by CNA J. On 02/15/2023 at 3:23 AM it was documented by another CNA that Resident #27 had no bowel movement. Review of a facility Policy Statement titled Activities of Daily Living (ADLS), Supporting reflected Appropriate care and services will be provided for resident's who are unable to carry out ADLs independently in accordance with the plan of care, including appropriate support and assistance with hygiene (bathing, dressing, grooming and oral care. Elimination (toileting). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676089 If continuation sheet Page 5 of 16 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 676089 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Winnie L Nursing & Rehabilitation 2104 N Karnes Cameron, TX 76520 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 - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for six (Resident #13, #14, #18, #20, #28, #200 and #201) of 14 residents reviewed for accidents and hazards and resided on the locked unit within the facility. The facility failed to ensure adequate supervision for six (Resident #13, #14, #18, #20, #28, #200 and #201) of 14 residents who resided on the locked unit and were supervised by one CNA. This failure could place residents at risk for injury and decreased quality of life. Findings included: A. Review of Resident #201 Face Sheet dated 02/16/2023 revealed Resident #201 was an [AGE] year-old female admitted to the facility on [DATE] with a diagnoses of colon cancer, dementia (thinking disorder that affects daily functioning), dysphagia (difficulty swallowing), history of falls and recent fall with multiple fractures of ribs and vertebrae with routine healing. Review of Resident #201 Care Plan dated 01/18/2022 revealed Resident #201 was an elopement risk/wanderer and was admitted to the secure unity for exit seeking behaviors. Resident #201 was at risk for fall related to history of falls, unsteady balance and incontinence. Resident #201 was noted to have had falls on 12/21/2022 (suffered abrasion to forehead), 01/20/2023 and 02/06/2023. Interventions included on 02/06/2023 visual observe until she is ready for bed. Resident #201 required supervision and cueing for ADL's as of 01/18/2022. Review of Resident #201 Quarterly MDS assessment dated [DATE] revealed Resident #201 had a BIMS score of three to indicate severely impaired cognition. Resident #201's return from hospital MDS assessment dated [DATE] revealed Resident #201 required extensive assistance for bed mobility, dressing, eating, personal hygiene and was totally dependent for bathing. In an interview on 02/15/2023 at 10:30 AM, Resident #201's RP stated he was concerned about his mother's care because she suffered a fall on 01/20/2023 and subsequently declined and was now under hospice care. He stated the locked unit where Resident #201 lives used to have two CNA's but in January (2023) the number of CNA's was reduced to one and there was now an activity assistant part-time with the CNA. He stated he felt like the reduction in staffing contributed to Resident #201 falling. He stated the nurse for the hallway did not remain on the hallway and sat at the nurse's station outside of the locked unit. He stated on the weekends there was no activity assistant and only one CNA for the whole locked unit. He stated the residents on the locked hallway had very high needs and did not feel one CNA was sufficient to meet their needs. In an observation on 02/15/2023 at 11:15 AM, seven residents were observed in the activity room with one staff member and three residents were observed in their wheelchairs moving around in the hallway with a CNA observing them. In an interview on 02/15/2023 at 11:21 AM, CNA N stated about a month ago the number of CNA's on the locked unit was reduced from two CNA's to one CNA. She stated she did not feel it was safe to only (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676089 If continuation sheet Page 6 of 16 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 676089 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Winnie L Nursing & Rehabilitation 2104 N Karnes Cameron, TX 76520 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 - Minimal harm or potential for actual harm Residents Affected - Some have one CNA for the fourteen residents on the locked unit. She stated there was an activity assistant who helped with supervision during the week, but she was only there for part of the day from 8:00 AM to 3:00 PM. She stated the nurse and medication aide would help but they were not there all of the time because they also covered other hallways. She said if she was showering a resident the other residents could be left unattended. She said the other residents could fall, experience resident to resident conflict or wander into another resident's room. She said they had five residents on the locked unit who required a two-person transfer. She said Resident #20 did not like if another resident wandered into her room and would become upset and throw things if another resident came into her room. She said today they have two CNA's assigned to the locked unit because of surveyors being in the building. In an interview on 02/15/2023 at 11:30 AM, CNA P stated he worked the locked unit for the last few months with always two CNA's and recently it was reduced to one CNA. He stated he did not feel it was safe because if he was showering a resident, there was no one assigned to supervise the other residents on the weekends. He stated there was an activity assistant during he week until 3:00 PM, but she could not help with anything as far as care. He stated the residents on the locked unit had the highest needs of any of the hallways and required the most supervision but had the same amount of staffing as the other three hallways. He said there was a nurse and medication aide that would help but they were not on the hallway 100% of the time. In an interview on 02/15/2023 at 2:20 PM, LPN Q stated she did not feel the staffing on the locked unit was adequate and safe because there was only one CNA assigned to the locked unit. She said about a month ago it was reduced from two CNA's to one CNA. She stated she was the charge nurse assigned to the locked unit, but she also covered another hallway. She said she assisted and would go back there when needed but could not be back there all of the time. She stated on the weekend when the activity assistant was not there, they all tried to provide additional supervision, but she could not say there was someone back there if the CNA was giving a shower. She said the activity assistant could only provide supervision and could not help with resident care and was only there during the week until 3:00 PM. She said there five residents on the locked unit who required two people to transfer and multiple residents with high behaviors at times. She said Resident #20 threw her tray at another resident one time for coming in her room. She said this put residents at risk for falls, getting into things they should not, wandering into other resident's rooms or resident conflict. She said Resident #201 experienced falls before the fall in January 2023 but the fall in January 2023 resulted in the more serious injuries of rib fracture and vertebrae fracture. She said Resident #201 was not hospitalized for the fractures but for a UTI after the fractures. In an interview on 02/15/2023 at 3:35 PM, CNA M stated the locked unit needed two CNA's but since last month there had only been one CNA scheduled for the locked unit. She said the census at the facility was down overall but not on the locked unit. She said the census on the locked unit was up to 14 from a couple of months ago when it was closer to 11-12 residents. She stated if they were showering people there was only the activity assistant during the week to supervise the other residents, but she could not assist with care. She said the nurse will try to help but could not be there all of the time. She said if a resident fell staff could not hear anything while showering another resident because of the water running. She stated there could be resident conflict like Resident #28 could become impatient and had been combative towards staff in the past. She stated Resident #20 became upset if the wanderers came in her room and could be aggressive. In an interview on 02/16/2023 at 9:05 AM, the SW stated her office was on the locked unit and she tried to provide supervision for the residents if there was no other staff available if the assigned (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676089 If continuation sheet Page 7 of 16 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 676089 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Winnie L Nursing & Rehabilitation 2104 N Karnes Cameron, TX 76520 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 - Minimal harm or potential for actual harm Residents Affected - Some CNA was in a resident room or showering a resident. She stated there used to be two aides on the locked unit but now there was only one with an activity assistant during the week. She stated on the weekends the nurse and medication aide were supposed to help supervise the locked unit. She said she was not sure if on the weekends there was someone assisting with supervision. She stated they have several wanderers on the locked unit and five resident who were totally or almost totally dependent on staff for care. She stated the overall census of the facility was down and therefore the second CNA for the locked unit was eliminated. She stated the census for the locked unit was stable and usually remained between 11-15 residents. She did not think it was safe to have only one staff member providing care and supervision to the 14 residents during daytime hours. In an interview on 02/16/2023 at 9:15 AM, Resident #13's RP stated Resident #13 was totally dependent on staff for her care. She said she felt the locked unit needed two CNA's to ensure the safety of the residents and to ensure their needs were met. She said the staff they do have were great and provided excellent care, but one person could not provide for all of the needs and supervision for the residents on the locked unit. In an interview on 02/16/2023 at 10:11 AM, the ADON stated she scheduled the staff for the facility and in January 2023 the number of CNA's for the daytime shift was reduced and the second CNA on the locked unit was eliminated. She stated there was an activity assistant scheduled Monday thru Friday 8:00 AM to 3:00 PM who assisted with supervision of the residents. She stated the nurse and medication aide helped to provide care and supervision of the residents when the CNA on the locked unit needed help for transfers or resident care. She said she could not say with 100% certainty on the weekends or after 3:00 PM on the weekdays if a resident was being showered that another staff member supervised the residents. She stated it would not be safe if another staff member did not assist with supervision while the assigned CNA was showering a resident because a resident could fall, wander into other resident rooms, getting into something they should not or there could resident to resident conflict. In an interview on 02/16/2023 at 10:37 AM, the DON stated there was only one CNA assigned to the locked unit starting in January 2023. She said during the week there was an activity assistant that helped with supervision. She stated they try to schedule a second CNA for the weekends, but that has not always happened. She stated the other staff including the charge nurse and medication aide were supposed help and supervise when the activity assistant was not there. She could not say with 100% certainty that the other staff were present when the assigned CNA had to provide resident care behind closed doors or showers. She stated there were five residents who required two person transfers and the assigned CNA would ask for help from other staff when transferring them. She said it was not safe if there was only one CNA and they were behind closed doors, and the other residents were left unattended. In an interview on 02/16/2023 at 10:51 AM, the ADMIN stated they used one aide and a second set of eyes for the locked unit. He said the activity assistant was the second set of eyes on the weekdays and the nurse was the second set of eyes on the weekend. He said the assigned CNA should not leave the residents unattended to provide care unless someone else was on the locked unit at the time. He said he could not verify that there was always a second set of eyes on the weekend or after 3:00 PM during the week. He said he would work back there if needed to provide supervision. He said staff should call him at home if there was not enough staff to provide supervision on the weekends and no one had called him. Review of staffing schedules dated 01/25/2023 - 02/14/2023 revealed one aide scheduled and assigned (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676089 If continuation sheet Page 8 of 16 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 676089 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Winnie L Nursing & Rehabilitation 2104 N Karnes Cameron, TX 76520 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 to the locked unit. There were three additional aides scheduled for the rest of the facility. Level of Harm - Minimal harm or potential for actual harm Review of Incident Reports dated 01/25/2023- 02/14/2023 revealed five incidents involving residents on the locked unit including four unwitnessed falls (one with skin tear) and a witnessed fall. Residents Affected - Some Review of Locked Units Residents ADL requirements by care plans revealed: Resident #13 required total assistance for ADL's and was a two-person transfer. Resident #28 required extensive assistance by two staff and was a two-person transfer for most staff members. Resident #18 required extensive assistance by two staff and was a two-person transfer. Resident #14 required extensive assistance by two staff and was a two-person transfer. Review of Locked Units Residents with behaviors included: Resident #20 was diagnosed as schizophrenic and had a history of high behaviors. Resident #200 was a wanderer and wheeled herself around the unit. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676089 If continuation sheet Page 9 of 16 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 676089 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Winnie L Nursing & Rehabilitation 2104 N Karnes Cameron, TX 76520 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide services by sufficient numbers of each of the following types of personnel on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans and the facility assessment for residents reviewed for care and services. (Residents #2, and #39) The facility did not provide sufficient staff on the 6 am-6 pm shift on 02/14/2023. The facility failed to ensure Resident #2 received incontinent care frequently enough to prevent sheets saturated with urine, strong odor smell and redness to peri-area. The facility failed to ensure Resident #39's brief was checked after breakfast and failed to assist her out of bed at her preferred time. This failure could place residents who required assistance from staff for ADLs at risk for skin breakdown, discomfort, urinary tract infection, low self-esteem, and/or depression. Findings included: Review of Resident #2's Face Sheet with an admission date oof 08/02/2022 reflected she was a [AGE] year-old female with diagnoses of Alzheimer's Disease (progressive disease that destroys memory and other important mental functions), Cognitive Communication deficit (difficulty with any aspect of communication), muscle weakness, Hyperlipidemia (high levels of fat particles in the blood), Unspecified Dementia (mental disorder in which a person loses the ability to think, remember, learn, make decisions and solve problems), Major Depressive Disorder (persistent feeling of sadness or loss of interest in activities), and Urinary Tract Infection. Review of Resident #2's Care Plan dated 01/31/2023, reflected she had a terminal prognosis related to Alzheimer's disease and indicated her comfort should be maintained through the review date of 05/15/2023. Intervention: Keep linens clean, dry and wrinkle free. She was at high risk for falls related to incontinence dated 08/12/2022. Her goal was to remain free of falls. Interventions: Anticipate and meet the resident's needs. Review of Resident #2's annual MDS dated [DATE] reflected she had a BIMS score of 5 indicating severe cognitive impairment. Her functional status indicated she required extensive assistance of one-person physical assist for toileting. Review of Resident #2's Care Plan dated 01/31/2023, reflected she had a terminal prognosis related to Alzheimer's disease and indicated her comfort should be maintained through the review date of 05/15/2023. Intervention: Keep linens clean, dry and wrinkle free. She was at high risk for falls related to incontinence dated 08/12/2022. Her goal was to remain free of falls. Interventions: Anticipate and meet the resident's needs. Observation and interview on 02/14/2023 at 10:08 AM of Resident #2 whose peri-area was noted to be dark pink in color with a strong urine odor. Urine stains were noted on the sheet under her. CNA D stated Resident #2's bed was soaked with urine and We are short staffed. I'm the only aide on 200 and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676089 If continuation sheet Page 10 of 16 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 676089 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Winnie L Nursing & Rehabilitation 2104 N Karnes Cameron, TX 76520 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 0725 500 halls. There's supposed to be another aide. We couldn't change the residents at 8:00 AM. Level of Harm - Minimal harm or potential for actual harm Interview on 02/14/2023 at 10:28 AM with LVN B in Resident #2's room who stated the bed linens were soaked through with urine on Resident #2's bed and more frequent rounding was needed. She further stated they were short-staffed, only had two CNAs for the whole building and one was assigned to the secure unit. She further stated there was not enough help and that all staff were pitching in but they needed more help to properly take care of everyone. Residents Affected - Some Review of Resident #39's Face Sheet reflected she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of Unspecified Sequelae of Cerebral Infarction (residual effects of a brain stroke), Contracture of muscle(tissue tightens or shortens causing a deformity), Major Depressive Disorder (persistent feeling of sadness or loss of interest in activities), Type 2 Diabetes Mellitus (chronic condition that affects the way the body processes blood sugar, body either doesn't produce enough insulin or there is resistance), Hyperlipidemia (high levels of fat particles in the blood). and Hemiplegia (paralysis of one side of the body). Review of Resident #39's Care Plan dated 09/23/2022 and revised on 12/06/2022 reflected she had an ADL self-care performance deficit related to CVA (brain stoke) and Hemiplegia. Goal: Resident #39 will maintain current level of function with minimal decline in transfers and toilet use. Interventions: requires extensive assist of 1-2 staff to use toilet. Requires extensive assist of 1-2 staff participation with transfers. Review of Resident #39's Qquarterly MDS dated [DATE] reflected she had a BIMS score of 11 indicating moderate cognitive impairment. Her functional status indicated she required extensive assistance of two-person physical assist for transfers and extensive assistance of one-person physical assistance for toileting. Review of Resident #39's Care Plan dated 09/23/2022 and revised on 12/06/2022 reflected she had an ADL self-care performance deficit related to CVA (brain stoke) and Hemiplegia. Goal: Resident #39 will maintain current level of function with minimal decline in transfers and toilet use. Interventions: requires extensive assist of 1-2 staff to use toilet. Requires extensive assist of 1-2 staff participation with transfers. Observation and interview on 02/14/2023 at 10:50 AM Resident #39 stated she wanted to get out of bed if someone would help her, but no one was available. She stated she could not tell if she was wet, but the last time she was changed was before breakfast. Interview on 02/15/2023 at 9:14 AM DON stated it was not normal for there to be only two aides on the morning shift. She stated her expectations were that residents would be clean, dry and checked and changed if needed every two hours. She further stated the potential risk if residents are left wet is MASD and/or a pressure injury. Interview on 02/16/2023 at 10:12 AM ADON stated it was her responsibility along with the DON that there were only two aides working on the morning of 02/14/2023. Review of a facility Policy Statement titled Departmental Supervision dated 2001 and revised August 2006 reflected The Director of Nursing Services and/or Nurse Supervisor/Charge Nurse is responsible for assigning work schedules and staffing to meet the needs of residents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676089 If continuation sheet Page 11 of 16 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 676089 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Winnie L Nursing & Rehabilitation 2104 N Karnes Cameron, TX 76520 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 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews the facility failed to use the services of a registered nurse for at least 8 consecutive hours, 7 days a week. The facility had been without full-time weekend RN coverage for six months. This failure placed residents at risk for lack of continuity of care. Findings included: Interview on 2/15/2023 at 11:01 AM RCN stated the DON was the designated weekend RN, but she doubted she worked eight hours a day on the weekends. She further stated they were trying to hire someone for the weekend RN position. Interview on 02/15/2023 at 11:20 AM DON stated I am the RN here. We run an ad in the local paper for a weekend nurse. I was here full-time from [DATE]st (2023) through [DATE]th (2023) due to the ice storm. I don't spend eight hours a day here on the weekend. I pop in and out. I can't work seven days a week. Interview on 02/16/2023 at 11:06 am ADMIN stated the facility had been without a weekend RN for six months. He further stated they have put ads in the local paper and online. He was aware the facility should have an RN in the facility 7 days a week, 8 hours a day. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676089 If continuation sheet Page 12 of 16 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 676089 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Winnie L Nursing & Rehabilitation 2104 N Karnes Cameron, TX 76520 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 0732 Post nurse staffing information every day. Level of Harm - Potential for minimal harm Based on observation, interview and record review the facility failed to post the nurse staffing data that reflected the actual hours worked for the unlicensed staff for 1 of 3 days during the annual survey. Residents Affected - Some The facility did not update the actual staffing for 02/14/2023. This failure could place residents, their families and facility visitors at risk of not having access to information regarding accurate staffing data. Findings included: Observation on 02/14/2023 at 11:34 AM of the Report of Nursing Direct Care Staff posted on the wall next to the first nurses station reflected there were 3 CNAs working the 6:00 AM to 2:00 PM shift for a total of 24 hours. Interview on 02/14/2023 at 10:08 AM with CNA D who stated she was one of two aides working in the building for the 6:00 AM to 2:00 PM shift and there was supposed to be a third aide. Interview on 02/14/2023 at 10:28 AM with LVN B who stated there were two CNAs in the building working the 6:00 AM to 2:00 PM shift. Interview on 02/16/2023 at 11:06 AM the ADMIN stated he was unaware posting of staff needed to be updated if the number of staff was incorrect. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676089 If continuation sheet Page 13 of 16 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 676089 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Winnie L Nursing & Rehabilitation 2104 N Karnes Cameron, TX 76520 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 0755 Level of Harm - Minimal harm or potential for actual harm Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interview and record review, the facility failed to ensure expired/discontinued medications were removed and destroyed for 1 of 1 medication storage rooms reviewed for medications. Residents Affected - Few The facility failed to remove two bottles of expired medication from the medication storage room. This failure could place all residents at an increased risk of receiving expired medication resulting in adverse health consequences. Findings include: Observation and interview on 02/14/2023 at 2:00 PM in the medication storage room revealed two bottles of Vitamin E 180 mg with expiration dates of 09/2022. LVN A stated she checked the medications for expiration dates, but she must have missed a couple. She stated she was not assigned to check for expiration dates, but she wasn't aware of anyone else doing it. Interview on 02/16/2023 at 10:00 AM DON stated the ADON is responsible for ensuring meds are not expired and was supposed to do it every week and rotate the stock. She further stated the potential risk of expired medications is the potency would be decreased. Interview on 02/16/2023 at 10:12 AM ADON stated she was ultimately responsible for ensuring expired medications were removed and tried to check them one time a month but there was no set schedule. She further stated the potential risk of expired medications was they could lose their potency and would not do what they were intended to do. Interview on 02/16/2023 at 11:44 AM with the ADMIN who stated the ADON, and a pharmacy consultant were responsible for ensuring meds are not expired. He further stated there was a chance the expired meds would not be as effective if given to a resident. Review of a facility policy titled Storage of Medication dated 2001 and revised November 202 reflected The facility stores all drugs and biologicals in a safe, secure, and orderly manner. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676089 If continuation sheet Page 14 of 16 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 676089 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Winnie L Nursing & Rehabilitation 2104 N Karnes Cameron, TX 76520 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 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure each resident received appealing options of similar nutritive value to residents who choose not to eat food that is initially served or who request a different meal choice for one resident (Resident #17) out of 12 residents reviewed for substitutes. The facility failed to offer Resident #17 an appealing option of similar nutritive value when he did not eat the food initially served to him. These failures could place residents at risk for weight loss, decreased oral intake and poor quality of life. Findings included: Review of Resident #17's face sheet dated 02/16/2023 revealed Resident #17 was a [AGE] year old male admitted to the facility on [DATE] with a diagnoses respiratory failure, atrial fibrillation (abnormal heart rhythm), chronic kidney disease, high blood pressure, congestive heart failure (weakening of the heart muscle), depression and edema (excess fluid collection in tissues related to congestive heart failure). Review of Resident #17's in progress quarterly MDS assessment dated [DATE] revealed Resident #17 had a BIMS score of 11 to indicate moderately impaired cognition. Resident #17 was noted to receive a therapeutic diet with no recent weight loss. Review of Resident #17 care plan dated 04/12/2019 revealed Resident #17 received a No Salt on Tray Diet, regular consistency with interventions to include provide, serve diet as ordered. Monitor intake and record each meal . RD to evaluate and make diet change recommendation as needed .Weigh per facility protocol. In an interview on 02/14/2023 at 11:20 AM, Resident #17 stated he did not care for the food sometimes. He said the food had no seasoning or flavor most of the time and he did not like it. When asked if he was offered different food as a substitute, he said no. When asked if he was offered a health shake or other alternative when he did not eat the meal, he said no. He said he did not know he could ask for a substitute or alternative. In an observation on 02/14/2023 at 1:10 PM, Resident #17's plate had mashed potatoes, okra and tomato mix, chocolate and banana pudding dessert remaining on the tray. In a follow-up interview on 02/14/2023 at 1:12 PM, Resident #17 stated he only ate the pork chop at the meal and the roll. He did not like the rest of the food. When asked if he was offered a substitute or alternative meal, he said no. When asked if he would drink a health shake, he said no but he would eat ice cream. In an interview on 02/14/2023 at 1:20 PM, the DON stated Resident #17 should have been offered the substitute meal or an alternative like health shake to increase his intake. She said if residents do not eat well, staff should offer the alternative meal, sandwich, health shake or other alternative (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676089 If continuation sheet Page 15 of 16 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 676089 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Winnie L Nursing & Rehabilitation 2104 N Karnes Cameron, TX 76520 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 0806 with respect to their preferences. Level of Harm - Minimal harm or potential for actual harm In an interview on 02/15/2023 at 3:35 PM, CNA M stated if a resident did not eat well staff were to offer the substituted meal or an alternative like a sandwich. She stated Resident #17 did not like the food at times and would say no to the substitute meal. She stated she had not offered a health shake or ice cream to him in the past because she did not know that was an option. Residents Affected - Few In an interview on 02/16/2023 at 9:05 AM, LVN K stated if a resident at less than 50% staff were to offer the substitute meal, an alternative like sandwich or a health shake. She stated if it was resident's preference to have ice cream, she stated they could offer ice cream. She stated she was not sure why staff did not offer ice cream to Resident #17 when he did not eat well. She stated inadequate oral intake could result in weight loss, malnutrition and decline in a resident's function. In an interview on 02/16/2023 at 12:13 PM, the RD stated residents who eat less than 50% of their meal should be offered additional food according to their preferences. Staff could offer the alternative meal, sandwich, snack or health shake. She stated the routine staff at the facility know to offer a variety of alternatives but agency staff may not know to offer a choice of alternatives. She stated Resident #17's weight was stable but to prevent weight loss, he should have been offered a choice of alternatives to prevent weight loss. She stated decreased oral intake could result in weight loss, malnutrition and the complications that come with weight loss like skin breakdown. Review of Alternate Food Choices and Substitutions Policy dated 12/01/2011 revealed the consultant dietitian will ensure that a minimum of one alternate entrée and vegetable is offered at each meal. Other substitutions should also be available in the event a resident does not choose the main meal or entrée. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676089 If continuation sheet Page 16 of 16