Health inspection·April 4, 2024

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few lightly biting on her fingers. CNA B was observed providing in room lunches to the residents who remained in their rooms. At 1:10 PM, CNA B retrieved a lunch tray from the cart and brought it over to Resident #7, who she sat down by. Resident #7 was observed to immediately start eating without the immediate aide of CNA B. CNA B did stay with Resident #7 and assisted her with her drink and diced up her food. Interview on 04/02/2024 at 2:06 PM, CNA B stated that she could have used an additional person to help deliver lunches today and knew that Resident #7 was the only person who did not get their lunch in the dining room. CNA B stated that she assists Resident #7 with her meals and had to assist another resident in his room that she was afraid would fall. CNA B stated that Resident #7 can eat with little to no assistance at times but can also become very shaky and does require assistance with her meals, which is why she was not served with the other residents. CNA B stated that on this date LVN A did assist her but that she could have used an additional aide. CNA B stated that failure to serve Resident #7 with her lunch when others were served posed an issue with her dignity. Interview on 04/04/2024 at 11:55 AM, the ADON stated that all residents should be served at the same time or as close as possible. The ADON stated that Resident #7 waiting for ten minutes for her lunch after the other residents in the dining room were served was unacceptable and could lead to emotional distress for the resident. The ADON stated that Resident #7 does require assistance with meals but should not have waited as long as she did. The ADON stated that when Resident #7 becomes anxious she will place her hand in her mouth. Observation on 04/04/2024 at 12:20 PM, Resident #7 was now at a table with other residents and was served at the same times as those at the table. Interview on 04/04/2024 at 1:45 PM, LVN A stated that they should attempt to serve everyone in the dining room at the same time for dignity reasons. LVN A stated that on 04/02/2024 CNA B waited to serve Resident #7 because she shakes and requires assistance with her meals. Interview on 04/04/2024 at 2:42 PM, the DON stated that Resident #7 should not have had to wait for her lunch while others ate and that it could result in anxiety issue for the residents. Interview on 04/04/2024 at 2:54 PM, the ADM stated that residents should be served table by table but added that if they need assistance it could play a role in when they receive their meal. The ADM stated that failure to serve all residents as closely to each other as possible cold pose a dignity issue and was not fair for one resident to have to sit and watch another resident eating while they wait. Review of In-Service Training Report from 10/4/23 with Topic: Meal Service revealed, Residents at same table must be served at same time. Review of the facility's Dignity policy dated 02/2021 revealed, Policy Statement - Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. Policy Interpretation and Implementation, 1. Residents are treated with dignity and respect at all times. Review of the facility's Resident Rights policy dated 02/2021 revealed, Policy Statement - Employees shall treat all residents with kindness, respect, and dignity. Policy Interpretation and Implementation, 1. Federal and state laws guarantee certain basic rights to all residents of this facility. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676089 If continuation sheet Page 2 of 21 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 04/04/2024 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 0550 These rights include the resident's right to: a. a dignified existence; b. be treated with respect, kindness, and dignity. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676089 If continuation sheet Page 3 of 21 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 04/04/2024 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to provide maintenance services necessary to maintain a safe, sanitary, orderly, and comfortable interior for four (room [ROOM NUMBER], 406, 411, and 412) of eleven rooms reviewed for environmental conditions. The facility failed to cut down and cap the two mounting bolts that secure the toilet's base to the floor, which ensures that the toilet does not move or leak in room [ROOM NUMBER], 406, 411, and 412. The facility failed to ensure that room [ROOM NUMBER]'s heat lamp control panel was covered and had a knob to activate the heat lamp and adjust the time of use. These failures could place residents at risk of living in an unsafe, unhomelike, and uncomfortable environment. Findings included: Observation on 04/02/2024 at 10:56 AM, room [ROOM NUMBER]'s bathroom toilet had the two base mounting bolts exposed and not capped. The bathroom had an electric control box present under the light switch that had no cover (faceplate) or knob to identify the intent use or ability to utilize it. The electric control box did not have any exposed wires present. Observation on 04/02/2024 at 11:20 AM, room [ROOM NUMBER]'s bathroom toilet had the two base mounting bolts exposed with some rust present and were not capped. Observation on 04/02/2024 at 11:33 AM, room [ROOM NUMBER]'s bathroom toilet had the two base mounting bolts exposed with some rust present and were not capped. Observation on 04/02/2024 at 1:57 PM, room [ROOM NUMBER]'s bathroom toilet had the two base mounting bolts exposed and were not capped. Observation on 04/04/2024 at 8:38 AM, room [ROOM NUMBER]'s bathroom toilet had the two base mounting bolts exposed and were not capped. The electronic control box now had a cover (faceplate) on it that indicated it was for the bathroom's heat lamp timer. The control box did not have a knob on it to control the timer. Observation on 04/04/2024 from 8:41 AM through 8:51 AM revealed that room [ROOM NUMBER], 411, and 412's toilet bowl mounting bolts remained uncut and not capped. Interview and observation on 04/04/2024 at 11:25 AM, the AD stated that he was the facilities maintenance person until recently when he became the AD. The AD stated that he assisted with maintenance issues but that the ADM handles the responsibility. The AD stated that the facility must be maintained because this is the residents' home, and it should be kept that way. The AD stated that if something is broken it needs to be fixed because that is what he would want in his home. At 11:28 AM, the AD entered the bathroom of room [ROOM NUMBER] and stated that he did not put the cover (faceplate) on the electric control box but stated that it should have a knob. The AD stated that the mounting (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676089 If continuation sheet Page 4 of 21 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 04/04/2024 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some bolts for the toilet base should be cut down and capped. The AD stated that the bolts needed to be cut and capped to prevent a resident from contacting them and possibly injuring themselves. The AD stated that the bolt caps also make the toilet look better and would be standard for a toilet install. Interview and observation on 04/04/2024 at 11:35 AM, the ADM stated that he currently is responsible for maintenance of the facility. The ADM stated that it is his goal for the facility and the resident rooms to be just like home. At 11:37 AM, the ADM entered the bathroom of room [ROOM NUMBER] and stated he put the cover (faceplate) on the electric control box on 04/02/24 or 04/03/2024 and should have installed a knob on it as well. The ADM was shown the exposed toilet base bolts and stated they are there to hold the toilet in place. The ADM stated that the bolts should have been cut down and when asked if they should be capped he stated that they could be. Surveyor demonstrated a resident stepping towards the toilet and placed a foot by one of the bolts. The ADM stated that now he could see the issue and did not want a resident to injure themselves. The ADM stated that he was going to ensure that all bolts were cut and capped. Review of the facility's Maintenance Service policy dated 12/2009 revealed, Policy Statement Maintenance service shall be provided to all area of the building, grounds, and equipment. Policy Interpretation and Implementation, 1. The Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. 2. Functions of maintenance personnel include, but are not limited to: b. Maintaining the building in good repair and free from hazards. D. Maintaining the heat/cooling system, plumbing fixtures, wiring, etc., in good working order. Review of how-to install a toilet through https://www.[NAME].com/n/how-to/replace-a-toilet revealed, make sure the nuts are firm but don't tighten them too much; the bowl could crack. Then use a [NAME] saw to cut off the excess bolt. Snap on the caps. Further review revealed, toilet bolt caps cover up rusted or protruding toilet floor bolts, which will help update the look of the bathroom and secure safety of your family. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676089 If continuation sheet Page 5 of 21 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 04/04/2024 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop a comprehensive care plan consistent with residents rights and include the services to be furnished for one (Resident #3) of eight residents care plan reviewed for DNR and hospice. The facility failed to develop a comprehensive care plan consistent with resident rights because Resident#3's care plan indicated full code resulting in an inaccurate care plan. The facility failed to ensure that Resident #3's care plan reflected their choice of DNR (Do Not Resuscitate). The facility failed to ensure that Resident #3's care plan reflected that they were under Hospice Care. These failures could place residents at risk of not having their medical, physical, and psychosocial needs meet. Findings included: Review of Resident #3's Face Sheet dated [DATE] reflected a [AGE] year-old female admitted to the facility on [DATE] with the following diagnosis: Dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), Chronic Pulmonary Edema (condition in which too much fluid accumulates in the lungs, interfering with a person's ability to breathe normally), and Congestive Heart Failure (serious condition in which the heart does not pump blood as efficiently as it should). Resident #3's Face Sheet further reflected under Advance Directive DNR DO NOT RESUSCITATE but had no documentation in reference to Hospice Care. Review of Resident #3's Optional State MDS Assessment, dated [DATE] revealed Resident #3 had a BIMS Score of 04 indicating severe cognitive impairment. Review of Resident #3's Comprehensive Care Plan reflected, Focus * Full code CPR order in place, Dated Initiated: [DATE], Revision on: [DATE], Interventions/Tasks *Call 911 and innate CPR. Further review reflected no documentation of Resident #3 being under Hospice Care. Review of Resident #3's Consolidated Orders obtained on [DATE] reflected an active order from [DATE] for DNR DO NOT RESUSCITATE. Further review of Resident #3's Consolidated Orders did not reflect a current or past order for Hospice Care. Review of the facility's computerized resident record system revealed an OUT-OF-HOSPITAL DO-NOT RESUSCITATE (OOH-DNR) ORDER for Resident #3, which was formatted and signed off on by two physicians on [DATE]. Interview on [DATE] at 8:50 PM, Resident #3's RP was asked if Resident #3 was under Hospice Care due to her being 100 years-of-age. Resident #3's RP stated that she believed Resident #3 was placed on it today but due to her own medical issues had not been recently to the facility to confirm. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676089 If continuation sheet Page 6 of 21 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 04/04/2024 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on [DATE] at 10:57 AM, MDS Coordinator stated that she is responsible for MDS and Care Plans. MDS Coordinator stated that care plans are to be updated for issues such as weight change, falls, behavior, pressure ulcers, and when questioned stated DNR and Hospice as well. MDS Coordinator stated that information is usually obtained from staff during the morning meetings and then she will update the care plan of the resident involved. MDS Coordinator stated that it is important to update care plans to ensure proper care and individualized care. MDS Coordinator stated that when a resident wishes to change from full code to DNR their plan needs to be updated. MDS Coordinator stated that when placed on Hospice the Charge Nurse on the day it takes place would need to notify her for care plan purposes. MDS Coordinator stated that she knew that Resident #3 was placed under Hospice Care on Monday, [DATE] with [HOSPICE PROVIDER]. MDS Coordinator retrieved the current care plan for Resident #3 and stated that she had failed to revise it to include Resident #3's DNR and Hospice status. MDS Coordinator stated that she was aware and was probably overwhelmed and just forgot. Interview on [DATE] at 11:55 AM, the ADON stated that she knew Resident #3 was placed on Hospice Care on Monday, [DATE] through [HOSPICE COMPANY]. The ADON stated that it is important to care plan DNR to ensure CPR is not preformed and that the Resident or their Responsible Party's wishes are honored. The ADON stated that LVN A was on duty Monday and would have taken care of Resident #3 and Hospice. The ADON stated that the MDS Coordinator is responsible for Care Plans. Interview on [DATE] at 1:45 PM, LVN B stated that he was present on Monday, [DATE] and took care of Resident #3 and the Hospice Provider. LVN B stated that normally there is an order for Hospice that is put in but that he could have done so on Monday, when it was started. LVN B stated that he failed to record Resident #3's Hospice on her progress report and should have done so. LVN B stated that Hospice Care should be placed on the care plan to let staff know who they are to report medical issues to and for care purposes. LVN B stated that care planning and knowledge of Hospice Care is also important due to possible medication changes and knowledge of staff coming to see Resident #3. LVN B stated that DNR should also be immediately care planned to ensure a resident's wishes are honored and that CPR is not performed on a DNR resident. Interview on [DATE] at 2:42 PM, the DON stated that DNR and Hospice Care needed to be placed on a resident's care plan immediately because staff are to utilize them to ensure proper care for the residents. The DON stated that failure to properly care plan could result in a resident's wishes not being honored and CPR being performed on a DNR resident. Review of the facility's Using the Care Plan policy dated 08/2006 revealed, Policy Statement - The care plan shall be used in developing the resident's daily care routines and will be available to staff personnel who have responsibility for providing care or services to the resident. Policy Interpretation and Implementation 4. Other facility staff noting a change in the resident's condition must also report those changes to the Nurse Supervisor and/or MDS Assessment Coordinator. 5. Changes in the resident's condition must be reported to the MDS Assessment Coordinator so that a review of the resident's assessment and care plan can be made. 6. Documentation must be consistent with the resident's care plan. Review of [HOSPICE PROVIDER] written coordination of care note, which was at the facility's nurse's station reflected, [DATE] 0945 Admit to [HOSPICE PROVIDER] Primary Dx: Alzheimer's Disease and was signed by the Hospice RN . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676089 If continuation sheet Page 7 of 21 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 04/04/2024 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 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming and personal and oral hygiene for 2 of 15 residents (Residents #95 and #23) reviewed for ADLS. Residents Affected - Few A. Resident #95's adult pull-up was soiled with feces, and she stated she had not been changed since the previous evening. B. Resident #23's top sheet had feces on it and his adult brief and under pad were soiled with feces. His left hand was contractured with long fingernails. These failures could place residents at risk of skin breakdown, pain, infection, and loss of self-esteem. Findings included: A. Record review of the undated Face Sheet for Resident #95 reflected she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of Pneumonia (infection that inflames air sacs in one or both lungs which may fill with fluid), Acute Respiratory Failure with Hypoxia (lack of enough oxygen in blood which can cause shortness of breath, confusion, and a bluish tint in the lips) and Type 2 Diabetes Mellitus (a long term condition in which the body has trouble controlling blood sugar and using it for energy) and autonomic polyneuropathy (damage to the nerves that control automatic body functions). Record review of the MDS section in Resident #95's chart reflected her initial one was in progress. Record review of Resident #95's Care Plan dated 04/02/2024 reflected she had an ADL self-care deficit and required staff participation to use the toilet. In an interview on 04/02/2024 at 9:00 AM Resident #95 stated her diaper had not been changed since last night and it was soiled. Observation on 04/02/2024 at 9:30 AM of Resident #95's adult pull-up brief revealed it was soaked with urine and a loose bowel movement. There was a dressing on her sacral area dated 03/26/2024 with feces under the bottom edge of it. In an interview on 04/02/2024 at 4:14 PM CNA C stated he had cleaned Resident #95 that morning at approxiamtely 9:30 AM after caring for another resident and the ADON had removed the soiled dressing on her sacrum. He stated there was nothing under there. He stated she was getting cream applied to her perineal area. B. Record review of Resident #23's undated Face Sheet reflected he was a [AGE] year-old male admitted (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676089 If continuation sheet Page 8 of 21 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 04/04/2024 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 - Few to the facility on [DATE] and readmitted on [DATE] with diagnoses of Cerebral Infarction (brain stroke) and need for assistance with personal care. Record review of the Quarterly MDS for Resident #23 dated 02/17/2024 reflected he had a BIMS score of 6 indicating severe cognitive impairment. His functional abilities and goals reflected he was dependent for toileting hygiene. His bowel assessment indicated he was always incontinent of bowel. Record review of the Care Plan for Resident #23 dated 04/02/2018 and revised on 09/11/2019 reflected he had an ADL self-care deficit. Toilet use: The resident requires extensive assistance of 1-2 staff participation to use toilet. Personal hygiene requires 1-2 staff participation with personal hygiene. Observation and interview on 04/02/2024 at 9:05 AM of Resident #23 who had feces on his top sheet that he was holding up to his face and feces on his under pad. His left hand was contractured and when he was asked to open his left hand, all of his fingernails were ½ to ¾ inch long past his fingertips. His left palm was reddened but there was no open skin. He stated no when asked if he had been changed that morning. CNA C came into the room and stated he had worked at the facility three years in June of 2023. He stated he had been late to work that morning and was trying to catch up on caring for the residents. He was observed changing Resident #23 whose brief was full of overflowing, loose feces. In an observation and interview on 04/02/2024 at 10:15 AM LVN E opened Resident #23's left hand and noted he had long fingernails and redness to his palm but no open areas. She stated he was a diabetic and she and other nurses were responsible for cutting his nails. She had no explanation as to why his nails had not been trimmed. In an interview on 04/04/2024 at 11:50 AM the ADON stated the 200-hall aide was late to work on the 04/02/2024, but they should have had someone working on the hall. She stated she did the scheduling, but the charge nurse could have called her. She further stated by the time she could have gotten a replacement staff the other staff would have shown up. She stated the charge nurse could have made rounds and ensured the residents were clean and dry. She stated there were nurses and an MA on duty as well who could have helped on that hall. She stated her expectation was the nurses would assist with resident care. She stated the potential risk to the resident of laying in feces was they could ingest it, could get bedsores, or get UTIs. In an interview on 04/04/2024 at 12:12 PM the DON stated the aides should be doing rounds every 2 hours and the nurses can change residents as well. The issue with not changing can be MASD and UTIs. She stated it was an infection control issue. In an interview on 04/04/2024 at 12:15 PM the Regional RN stated aides were supposed to make rounds after breakfast and change the residents as needed. She further stated Resident #23 could get an injury, infections, or skin breakdown by having long fingernails and a contractured hand. In an interview on 04/04/2024 at 2:24 PM the ADM stated staff should be doing rounds on the residents every 2 hours and prn to check and change them. He stated the potential risk of not doing that was a loss of dignity and infections. He stated the nurses should be trimming the diabetic residents' nails. He stated long nails could be a danger to themselves or others. Record review of a facility policy and procedure titled Activities of Daily Living dated 2001 and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676089 If continuation sheet Page 9 of 21 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 04/04/2024 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 - Few revised March 2018 reflected Residents will be provided with car, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLS). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. 2. Appropriate care and services will be provided for residents who are unable to carry out ADLS independently with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. Hygiene (bathing, dressing, grooming and oral care). c. Elimination (toileting). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676089 If continuation sheet Page 10 of 21 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 04/04/2024 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 - Few 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 1 of 5 resident (Resident #31) reviewed for fall mats. The facility failed to ensure Resident #31 had a fall mat in place beside her bed. This failure could place residents at risk of falls, injuries, pain, and hospitalization. Findings included: Record review of Resident 31's undated Face Sheet reflected she was a [AGE] year-old female admitted to the facility on [DATE] and readmitted on 01/03 /2024 with a diagnosis of Cognitive Communication Deficit (difficulty with thinking and how someone uses language) and repeated falls. Record review of Resident #31's Comprehensive MDS dated [DATE] reflected she had a BIMS score of 99 indicating she was unable to complete the interview. Her functional abilities and goals indicated she was dependent on staff for chair/bed-to-chair transfer. Her additional active diagnoses included fall from or off toilet with strike. Record review of the Care Plan for Resident #31 dated 01/17/2023 and revised on 05/05/2023 reflected she had frequent falls prior to and after admission. Actual falls: 02/07/2023 in room next to bed, 02/15/2023 sitting on floor in room, 02/21/2023 attempting self-transfer in common area, witnessed, 03/04/2023 witnessed self-transfer in common area, 04/15/2023 unwitnessed fall, no injury, sitting on mat beside low bed, 04/18/2023 unwitnessed fall, no injury, sitting on mat beside bed. On 02/15/2023 an intervention was floor mats on floor beside bed while resident is in the bed. Observation on 04/02/2024 at 12:47 PM in Resident #31's room revealed she was in her bed and her fall mat was not beside her bed. In an interview on 04/04/2024 at 12:02 PM the ADON stated Resident #31 was a fall risk and anyone who worked with her should know she had a history of falls. She stated her fall mat should always have been put back in place beside her bed. In an interview on 04/04/2024 at 12:21 PM the DON stated fall mats should be in place, flushed against the bed to prevent fall injuries including head injuries and brain bleeds. In an interview on 04/04/2024 at 12:28 PM the Regional RN stated not using the fall mats properly could result in an injury to the residents. In an interview on 04/04/2024 at 2:29 PM the ADM stated Resident #31 had falls due to confusion and she thought there was something on the floor she needed to pick up. He stated Resident #31 had an order for a fall mat to minimize the severity of a fall. Record review of a facility policy and procedure titled Falls and Fall Risk, Managing dated 2001 and revised March 2018 reflected Based on previous evaluations and current data, the staff will (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676089 If continuation sheet Page 11 of 21 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 04/04/2024 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 identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. 2. Resident conditions that may contribute to the risk of falls include: c. delirium and other cognitive impairments. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676089 If continuation sheet Page 12 of 21 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 04/04/2024 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that a resident who needs respiratory care, is provided such care, consistent with professional standards of practice for 1 (Resident #3) of 5 residents reviewed for respiratory care. Residents Affected - Few The facility failed to ensure that Resident #3's Nebulizer tubing and mask, which includes the nebulizing chamber (unit into which liquid medicine is converted into aerosol or mist by the pressurized air pumped through the tubing) was dated. The facility failed to ensure that Resident #3's Nebulizer mask was properly bagged when not in use. These failures could place residents at risk for respiratory compromise and infection. Findings included: Review of Resident #3's Face Sheet dated 03/03/2024 reflected a [AGE] year-old female admitted to the facility on [DATE] with the following diagnosis: Dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), Chronic Pulmonary Edema (condition in which too much fluid accumulates in the lungs, interfering with a person's ability to breathe normally), and Congestive Heart Failure (serious condition in which the heart does not pump blood as efficiently as it should). Review of Resident #3's Optional State MDS Assessment, dated 01/26/2024 revealed Resident #3 had a BIMS Score of 04 indicating severe cognitive impairment. Review of Resident #3's Comprehensive Care Plan revealed a focus area dated 02/01/2024, [Resident #3] has Asthma r/t Dx , Unsp ASTHMA (condition in which airways narrow or swell and may produce extra mucus, which can make breathing difficult), uncomplicated. Intervention with a revision date of 02/01/2024 indicated, Give nebulizer treatments and oxygen therapy as ordered. Review of Resident #3's Consolidated Physician Orders reflected an order dated 03/14/2024, Ipratropium-Albuterol Inhalation Solution .05-2.5 (3) MG/3ML), Directions - 1 application inhale orally three times a day for congestion. There was no order for the care of Resident #3's Nebulizer mask, chamber, or tubing. Observation on 04/02/2024 at 2:19 PM, Resident #3 was asleep in her bed and was under droplet precaution for COVID (highly contagious respiratory disease). Resident #3 had a nebulizer on her nightstand with tubing, nebulizing chamber, and mask. Resident #3's mask had dried moisture spots on the inside of it. Resident #3's nebulizer mask and chamber were in a plastic bag, but the bag had an approximate two-inch by two-inch whole in it that allowed air and particles into it. Resident #3's nebulizer tubing, mask, and chamber did not display a date on any of them. Observation on 04/03/2024 at 10:23 AM, Resident #3's moisture spotted mask and chamber were still present in the plastic bag with a hole in it. The tubing now had a pink tag on it where it came out of the nebulizer that displayed a date of 4/3/24. There was a sealed bag containing a handheld nebulizer mouthpiece with chamber on the nightstand. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676089 If continuation sheet Page 13 of 21 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 04/04/2024 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview and observation on 04/03/2024 at 11:01 AM, ADON A was taken in the room of Resident #3 to view her nebulizer. ADON A stated that she did not place the pink sticker and date on the tubing. ADON A stated that the date the mask was changed out should be on the nebulizer chamber and that the bag it is stored in should not have a hole in it. ADON A stated that she did not understand why the sealed nebulizer handheld mouthpiece was present because Resident #3 uses a mask nebulizer. ADON A stated that all nebulizer tubing and mask are to be dated and changed out weekly and that they are to be bagged when not in use. ADON A stated that failure to properly change, date, and bag nebulizer equipment could result in respiratory infection. Interview on 04/04/2024 at 10:15 AM, the ADM stated that per their policy oxygen / nebulizer tubing and mask should be dated and changed out weekly. The ADM stated that mask should always be bagged when not in use and that use of a bag with a hole in it was unacceptable. The ADM stated their policies should be followed and that they are in place to prevent Upper Respiratory Infection . Review of facility's In-service records for the past six months revealed no training in reference to Oxygen / Nebulizer care. Record Review of facility Administration of Oxygen and Maintenance of Tubing and Equipment Policy dated 10/2017 revealed, Maintenance of Tubing and Equipment 1) Tubing will be kept in a bag when not in use. 2) Tubing will be dated, and will be changed weekly. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676089 If continuation sheet Page 14 of 21 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 04/04/2024 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 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. Based on interview and record review, the facility failed to use the services of a Registered Nurse for at least 8 consecutive hours a day, 7 days a week on 22 out of 22 weekends reviewed for RN coverage. Residents Affected - Many The facility did not have an RN in the facility for 8 hours on every weekend from 11/4/2023 through 03/31/2024. This failure could place residents at risk for lack of continuity of care and the level of care provided by the oversight of an RN. Findings included: Record review of RN Weekend Coverage and time sheets reflected the facility did not have a Registered Nurse working 8 consecutive hours every weekend from 11/4/2023 through 03/31/2024. In an interview on 04/04/2024 at 11:59 AM the ADON stated they had an ad in a popular website dedicated to hiring professional staff for a weekend RN position. In an interview on 04/04/2024 at 12:16 PM the Regional RN stated they had hired a weekend RN, but she only worked one day and then said it was too much work as they expected them to work as a floor nurse. She stated they had advertised and offered bonuses to get agency RNs to fill the position with no luck. She stated the potential risk to residents was the quality of care and a lack of oversight. She stated they had a telehealth contract for medical professionals including RNs that could be contacted. In an interview on 04/04/2024 at 2:25 PM the ADM stated they had not requested a nursing waiver for the weekend RN position; they had been looking hard for a weekend RN and used a headhunter who did the hiring. He stated they placed ads on a website for professional staff. He further stated the risk to the residents was LVNs can follow orders, but RNs have extra training and need to supervise them. Record review of an undated facility policy and procedure titled Staffing reflected Our facility provides sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with resident care plans and the facility assessment. Policy Interpretation and Implementation. An RN is available for coverage 8 hours a day, 7 days a week. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676089 If continuation sheet Page 15 of 21 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 04/04/2024 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 Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on interview and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident, for 2 of 2 halls narcotic logbooks (Halls 200 and 500) reviewed for drug administration. The facility failed to ensure nurses signed the narcotic logbook counts on two medication carts. This failure could have resulted in drug diversions and the inability of residents/staff to determine the time frame of the potential drug diversion. Findings included: Record review of 200 hall and 500 hall narcotic logbooks on 04/03/2024 at 11:45 AM reflected omissions of signatures verifying counts of narcotics. On the 200 hall, omissions included 04/01/2024 the 6:00 PM to 6:00 AM shift and 04/02/2024 the 6:00 AM to 6:00 PM shift. On the 500 hall, omissions included 03/14/2024 the 6:00 PM to 6:00 AM shift, 03/15/2024 the 6:00 PM to 6:00 AM shift, 03/19/2024 the 6:00 PM to 6:00 PM shift and 04/02/2024 the 6:00 AM to 6:00 PM shift. In an interview on 04/03/2024 at 11:50 AM MA D of 200 hall stated he told the staff all the time that they needed to be signing off on the narcotics logs. In an interview on 04/03/2024 at 11:55 AM the Regional RN stated there were two shifts and the nurses must have just missed signing off on the narcotics logs. In an interview on 04/03/2023 at 1:49 PM the ADON stated that moving forward the narcotic logbooks would be checked daily by herself and the DON. She stated all nurses and MAs are instructed to have two staff sign off and count narcotics each oncoming and off going shift upon hire, and it should be common knowledge. She further stated the potential risk of not counting or signing off on narcotics was drug diversion. In an interview on 04/04/2024 at 12:10 PM the ADON stated she was responsible for checking the narcotic log and she had overlooked that task. She stated the log showed the narcotics had been counted and if not completed there could potentially be a drug diversion. In an interview on 04/04/2024 at 12:18 PM the DON stated she was responsible for ensuring the narcotic inventory log was signed by two nurses and she would start making rounds to make sure it was completed. She stated the drug count could be off and there could be drug diversion. She stated she had given an in-service but would be in-servicing staff again. In an interview on 04/04/2024 at 12:27 PM the Regional RN stated the nurses should be counting the narcotics and signing their name every shift. She stated the DON and ADON were responsible for ensuring the nurses were completing that task and if not done it could result in a drug diversion. In an interview on 04/04/2024 at 2:27 PM the ADM stated there would be a POC in place with the DON to ensure the narcotics were being counted and one nurse needs to check on another. He stated the ADON, or a designee needed to be checking the log for signatures and the potential risk of not doing (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676089 If continuation sheet Page 16 of 21 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 04/04/2024 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 that task was drug diversion. Level of Harm - Minimal harm or potential for actual harm Record review of a facility policy and procedure titled Controlled Substances and dated 2001 and revised April 2019 reflected The facility complies with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled substances. 8. Controlled substances are reconciled upon receipt, administration, dispositions and at the end of each shift. 12. At the end of each shift: a. Controlled medications are counted at the end of each shift. The nurse coming on duty and the nurse going off duty determine the count together. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676089 If continuation sheet Page 17 of 21 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 04/04/2024 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview and record review the facility failed to ensure medications and biologicals were stored in locked compartments for 1 of 1 treatment carts reviewed for medication storage. The facility failed to ensure nursing staff locked a treatment cart for 50 minutes while it was located at the nurse's station and facing hall 500. This failure could have resulted in harm due to unauthorized access to medications, biologicals, and needles. Findings included: Observation on 04/03/2024 at 7:10 AM revealed a treatment cart was left unlocked next to the nurse's station and facing 500 hall. Observation on 04/03/2024 at 8:00 AM of the unlocked treatment cart facing hall 500. Contents included: Hydrophilic (substance that absorbs water) wound dressing, hypodermic (relating to the region beneath the skin) needles 22 G, infection control cleanser, no rinse for body and perineal area. Warning: external use only in case of eye contact, flush eyes with water, Hydrocortisone (steroid) cream, 1%, medicated corn removers, salicylic acid 40% (helps skin shed dead skin cells from the top layer). If swallowed get medical help or contact poison control center right away. Povidone iodine swab stick, antiseptic (prevents growth of disease-causing germs) germicide (kills germs). Do not use in the eyes or over large areas of the body. Keep out of reach of children, if swallowed get medical help or call poison control right away. 1/2 strength Sodium Hypochlorite (bleach) solution for wound care, Keep out of reach of children if swallowed get medical help or contact poison control center. In an interview on 04/03/2024 at 8:25 AM LVN E stated she had worked at the facility for over a year. She stated it was her treatment cart, but she had not performed any treatments that morning. She stated she should have checked the cart to see if it was locked. She stated a resident could have ingested one of the items and been injured or could have had an allergic reaction and required hospitalization. She stated a resident could have stabbed themselves or other residents with the needles. She stated she had received initial training on locking carts when she hired on. She further stated she would start checking both carts (medication and treatment) when she arrived at the facility. In an interview on 04/04/2024 at 11:42 AM the ADON stated the treatment cart should be locked up at all times. She stated nurses are trained on that and they had started a re-education on locking the carts. She stated the potential risk of leaving the treatment cart open was a resident could have obtained a needle and stuck themselves or they could have ingested something and caused an adverse reaction. She further stated the residents could have placed one of the items in the cart in their eyes and caused burning or an adverse reaction. In an interview on 04/04/2024 at 12:10 PM the DON stated nurses should lock the treatment cart before they walk away. She stated the risk to a resident was they could ingest a substance, rub it in their eyes or poke themselves with the needles. She further stated they could have an allergic reaction. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676089 If continuation sheet Page 18 of 21 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 04/04/2024 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 0761 Level of Harm - Minimal harm or potential for actual harm In an interview on 04/04/2024 at 12:15 PM the Regional Nurse stated the treatment cart should be locked at all times when not in use. She stated the resident could have obtained one of the needles and received a needle stick. She stated the needles may have been left on there from when they gave flu shots. She further stated the resident could get a skin burn or ingestion of one of the substances could make them sick. Residents Affected - Some In an interview on 04/04/2024 at 2:21 PM the ADM stated the treatment cart should be locked for the resident's safety. He stated a resident could have been stuck by one of the needles, someone could steal items, or a resident could have ingested the substances or placed them in their eyes causing illness. Record review of a facility policy and procedure titled Storage of Medication dated 2001 and revised November 2020 reflected The facility stores all drugs and biologicals in a safe, secure, and orderly manner. 6. Compartments (including, but not limited to drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals are locked when not in use. Unlocked medications are not left unattended. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676089 If continuation sheet Page 19 of 21 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 04/04/2024 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 0812 Level of Harm - Minimal harm or potential for actual harm 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 under sanitary conditions in the facility's only kitchen reviewed for sanitation. Residents Affected - Many The facility failed to label and date meat products stored in the facility's walk-in freezer. The facility failed to ensure that food products were not stored on the floor in the walk-in freezer. The facility failed to remove dented cans from the dry storage area to prevent service to residents. The facility failed to clean the industrial can opener. The facility failed to maintain cleanliness of the dining plate storage cart. These failures could place residents at risk of cross contamination, loss of nutritional value, weight loss, and foodborne illness. Findings included: Observation on 04/02/2024 at 9:09 AM of the facility's walk-in freezer revealed: Sealed box of cauliflower florets (flower-shaped pieces that make up the head of the cauliflower and are connected together) consisting of 12 - two pounds packs which was on the floor, a wrapped frozen turkey on the floor, and a tied plastic bag of chicken breast on the floor. On the bottom shelf in the freezer were unlabeled and undated meat products. Observation on 04/02/2024 at 9:16 AM of the facility rolling can holder in the dry storage area revealed: 1 six pound can of blackeye peas dated 9/29 with two dents in the side of the can near the bottom, and 1 - six pound can of whole kernel corn dated 3/29/24 with a dent near the top and partially affecting the top ring of the can. Observation on 04/02/2024 at 9:31 AM of the facility's industrial can opener revealed that it was sticky to the touch and had a dried and wet black substance on and around the cutting blade. Observation on 04/02/2024 at 9:33 AM of the facility's dining plate storage cart revealed that it had dirt and dried food particles on it in the immediately area of the plates. Interview on 04/02/2024 at 9:34 AM, the DM stated that their can opener should be cleaned weekly and stated upon inspection that it had not been. The DM stated that the failure to properly clean the can opener could result in cross contamination. The DM upon inspection of the dining plate cart stated that it was not sanitary and could lead to cross contamination. The DM upon inspection of the two dented cans stated it could result in issues of rust and cross contamination and should not have been placed on the rolling cart for service. The DM stated that all items are to be labeled when they are delivered and when they are opened. The DM stated that all items should be clearly labeled if they are not in a container that identifies the contents. The DM stated that it was important to date and label products to know how long they have been in the refrigerator or freezer and to ensure the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676089 If continuation sheet Page 20 of 21 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 04/04/2024 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many proper product is being cooked. At 9:42 AM, the DM entered the freezer and stated that nothing should be stored on the floor. The DM stated that all meat products stored on the shelf in the freezer should have been labeled and dated. The DM verbally identified and removed the following unlabeled and undated items from the freezer: 14 plastic bags of chicken breast, 5 packages of beef tips, 4 plastic bags of hamburger patties, and 3 packages of diced chicken breast. The DM stated that the way the items were stored and frozen could result in a loss of nutritional value, freezer burn, loss in taste, and food borne illnesses. Interview on 04/03/2024 at 10:45 AM, Dietary Aide stated that all products should be dated the day they are received. Dietary Aide stated all products in the refrigerator and freezer should be labeled and dated. Dietary Aide stated that failure to do so could result in freezer burn, could affect task, loss of nutritional value, and could make someone sick if spoiled. Dietary Aide stated that dented cans are not to be served and should be placed in the DM's office because the damage could result in contamination. Dietary aide stated that the industrial can opener is to be cleaned daily and that failure to do so could result in contamination of food products. Interview on 04/04/2024 at 2:54 PM, the ADM stated that all food products should be dated to ensure freshness. The ADM stated that no dented cans should be accepted and if they are they should not be placed on the shelf and should be returned because they could be contaminated. The ADM stated that failure to follow their labeling and storage policies could result in food borne illnesses. Record review of facility's in-service revealed training by the DM on 1/16/2024 for, Topic: Storage & Labeling, Contents and Summary of In-Service/Training Session: How long to keep open items, Dating & Labeling open bags, open dates on containers that aren ' t used all at once, sealing all open bags. Record review of the facility's Food Receiving and Storage Policy, revised in October of 2017 revealed, Policy Statement - Foods shall be received and stored in a manner that complies with safe food handling practices. Policy Interpretation and Implementation 2. When food is delivered to the facility it will be inspected for safe transport and quality before being accepted. 8. All foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date). Review of the Food and Drug Administration Food Code, dated 2022, reflected, .3-302.12 Food Storage Containers, Identified with Common Name of Food. Except for containers holding food that can be readily and unmistakably recognized such as dry pasta, working containers holding food, or food ingredients that are removed from their original packages for use in the food establishment, such as cooking oils, flour, herbs, potato flakes, salt, spices, and sugar shall be identified with the common name of the food 3-305.11 Food Storage.(B) .refrigerated, ready-to eat time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676089 If continuation sheet Page 21 of 21