Health inspection·May 31, 2024

F 0580 Level of Harm - Immediate jeopardy to resident health or safety Intervention: Keep resident's, routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion. Resident #1 was prone to skin tears and bruising related to fragile skin. Intervention: all injuries will be monitored until they are resolved. Notify charge nurse of any new bruising or skin tears. She was high risk for falls related to unsteady balance, incontinence, poor safety awareness and being forgetful. Interventions: educate the resident/ family and care givers about safety reminders and what to do if a fall occurs. Anticipate and meet the resident's needs. Follow facility protocol. Residents Affected - Few Record review of Resident #1's electronic medical records reflected Resident #1 did not have any nursing note entries on 05/03/2024. Record review of Resident #1's electronic medical records reflected Resident #1 did not have a pain assessment or incident/accident report on 05/03/2024. There was one entry at 10:38 AM B/P was 129/79 mmHg. Record review of Resident #1's Nurses notes, at 1:13 PM on 05/04/2024, reflected Resident #1 continued to decline with a B/P of 96/55 and pulse of 55 within an hour of having elevated blood pressure earlier in AM. Resident #1 had a glazed (expression is dull, usually because a person is tired or had difficulty concentrating on something) look to her eyes and small pinpoint pupils. Her 02 sats dropped from 94 % R/A to 86 % R/A. O2 per nasal cannula put on Resident #1 to aid in oxygen saturation. O2/3L/NC 93%. NP was notified and new order to send Resident #1 to the emergency room for evaluation and treatment. Resident #1 was transported by EMS to the emergency room at 11:44 AM. Family and ADON was notified of Resident #1 being transported to the Emergency Room. Written by RN C. Record review of Resident #1's Nurses Notes, at 1:49 PM on 05/04/2024, reflected Resident #1 was hospitalized . Record review of Resident #1's Hospital Records dated 05/04/2024 reflected minimally displaced left sub capital femoral neck fracture (these fractures occur in the neck of the thighbone). There were no other injuries according to the x-ray report. Observation and interview on 05/30/2024 at 9:00 AM, Resident #1 were sitting in the common area beside another resident. She smiled and she did not respond to questions. Resident #1 did not show any signs or symptoms of any distress. She was relaxed and watching people. In an interview on 05/30/2024 at 9:12 AM, CNA B stated on 05/03/2024 CMA A came to her after lunch when she was giving Resident #2 a shower and requested if she had time to assist her in transferring Resident #1 from the floor to the wheelchair. She stated CMA A explained she found Resident #1 lying on the floor. CNA B stated she asked CMA A to find CNA D she was unable to leave the shower. CNA B stated she was assigned to Resident #1 on 05/03/2024. She stated she went to the nurse's desk after giving Resident #2 a shower and assisted Resident #2 to her room. CNA B also stated she observed Resident #1 sitting in her wheelchair and she was her normal self. She stated she would stand and walked from chair to chair. She stated this was her usual routine when sitting in the common area near nurses' desk. She stated she received a verbal report from LVN E and she stated she believed Resident #1 slid out of her wheelchair. She also stated she had been in-serviced on what to do if a resident fell or was found on the floor. CNA B stated only nurses was allowed to touch the resident and complete a skin assessment, pain assessment and if there was an injury to call the physician and the non-nursing staff including CMAs was expected to wait and follow the nurses' directions on what to do with the resident and when to move the resident. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676089 If continuation sheet Page 2 of 31 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 05/31/2024 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 0580 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Interview on 05/30/2024 at 10:03 AM, LVN F stated he was coming on duty for the night shift on 05/03/2024 and LVN E was giving him verbal report of what occurred on the day shift on 05/03/2024. He stated during the verbal report LVN E informed him Resident #1 had a fall and she did not report anything else about Resident #1. He stated he monitored her on the night shift for any changes in her mental or physical condition. LVN F stated Resident # 1 never complained of pain and was at her baseline physically and mentally on his shift (from 6:00 PM on 05/03/2024 to 6:00 AM on 05/04/2024). He stated he had been in-serviced on fall protocol. He stated only nurses are allowed to complete range of motion, neuro checks, pain assessment and completed incident/ accident report. LVN F stated the physician, DON, and family was expected to be notified. He also stated he would follow the physician directions of what treatment he believed the resident needed. Interview on 05/30/2024 at 10:15 AM, CMA A stated she was walking by the activity area near the nurse's desk and observed Resident #1 on the floor in front of the television. She stated Resident #1's wheelchair was a few feet away from her by a table. She stated Resident #1 was not a good historian and unable to give any information of the incident of her lying on the floor. CMA A stated Resident #1 was lying on her back. She also stated she went to get assistance from CNA B. She stated CNA B was giving another resident a shower and was unable to assist her with transferring Resident #1 from the floor to her wheelchair. She stated she found LVN E. She stated LVN E was busy with a new admission and was unable to assist her with Resident #1. CMA A stated there were other nurses in the facility and did not think about going to find another nurse. CMA A stated she did not want Resident #1 laying on the floor any longer and she had observed nurses perform range of motion on residents after they had fall and she decided she would perform range of motion and she asked a CNA to assist her in transferring Resident #1 to the wheelchair. She stated she put the vital signs on a piece of paper and laid it on the desk and she does not know if the Nurse completed an assessment on Resident #1. She stated she did not follow up on the incident. CMA A stated she had been in-service on fall protocol. She stated she was instructed during the in-service the nurses was the only staff was allowed to assess a resident found on the floor and complete range of motion. She stated she was not to assess Resident #1 or complete range of motion. She stated she was wrong, and she knows she did everything wrong in the situation of finding Resident #1 on the floor. She stated it was a busy day and she did not think to go and report it to DON or Administrator. She stated she could have asked another nurse but she was wanting to assist resident off the floor as soon as possible. In an interview via phone on 05/30/2024 at 10:38 AM, LVN E stated 05/03/2024 was her last day to work at this facility. She stated it was a very busy day. LVN E stated she did not recall anyone come to her and report anyone on the floor. She stated she was busy with a new admit all day and if anyone fell it would have been when LVN G worked on 05/02/2024. LVN E stated to contact LVN G and ask her about anyone falling. She stated I think Resident #1 fell on LVN G's shift on 05/02/2024. She stated she was at work and needed to go back to work. LVN E stated she did not have anything else to say about Resident #1. In an interview on 05/30/2024 at 10:50 AM, LVN G stated she did work on 05/02/2024. She stated no one fell on her shift. LVN G stated Resident #1 did not fall or was found on the floor the date of 05/02/2024. LVN G stated when she came back to work on 05/06/2024 it was reported to her Resident #1 was in the hospital with a hip fracture during the morning meeting. LVN G stated it was not mentioned she was found on the floor or had a on 05/03/2024. She stated it was unknown how she fractured her hip. She stated she had been in-serviced on falls assessments and what to do if a resident fell. LVN G stated if a resident was found on the floor or witnessed a fall only the nurses was allowed to assess the residents and do range of motion. She stated the nurse would complete head to toe skin assessment, neuro checks, vitals (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676089 If continuation sheet Page 3 of 31 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 05/31/2024 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 0580 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few and call the physician immediately if there was an injury. LVN G also stated she would follow the physician directions and would also contact the DON and the responsible party of the resident. She stated a nurse's note was required to be completed after any incident of a resident. In an interview on 05/30/2024 at 11:20 AM, CNA D stated No when asked if he was aware of anything happening to Resident #1 on 5/3/2024. CNA D would only answer yes/no type questions. He would not respond to any questions that required detailed information. In an interview on 05/30/2024 at 11:55 AM, CMA H stated he did work with LVN G on 05/02/2024. He stated if there were any changes with a resident including finding a resident on the floor or witnessing a fall, they reported to each other. He stated he was not aware of Resident #1 falling on 05/02/2024. CMA H stated he would definitely know if anyone fell when he is working in the facility. He stated he had been in-serviced on fall protocol. CMA H also stated only nurses was allowed to assess a resident if a resident was found on the floor or if it was a witnessed fall. He stated no one but the nurse was complete entire assessment such as neuro checks, pain assessment, incident/ accident report or do range of motion on a resident. CMA H stated other staff was allowed to assist resident with transfer only after the nurse completed assessments and gave instructions to other staff it was safe to transfer the resident. He stated if he found someone on the floor and the nurse supervisor for that particular resident was not available, he would find another nurse and would not touch the resident until the nurse did their assessment. In an interview on 05/30/2024 at 1:30 PM, the DON stated she was working on 05/03/2024 and no one reported to her of Resident #1 being found on the floor or any incident with Resident #1. She stated there were two nurse supervisors, MDS Nurse and she was in the facility on 05/03/2024. She stated only a LVN or RN was allowed to complete pain assessments, head to toe skin assessments, neuro checks, incident/ accident reports. She stated if a resident was injured the nurse would contact the physician and follow the physician orders. She also stated if a resident was not injured, she expected the physician to be contacted. The DON also stated the responsible party of the resident was also expected to be contacted. She stated the nurse would direct other staff what to do after she had assessed the resident and contacted the physician. She also stated CMA was not qualified to do range of motion on a resident or to do any type of pain assessments or neuro checks. She stated if the nurse responsible for Resident #1 was not available CMA A was expected to find another nurse to assess Resident #1. The DON also stated the nurse was expected to complete incident/ accident report, pain assessment, and a nurses note. She also stated the CMA or LVN E was expected to notify DON or ADON when there is a fall or a resident found on the floor. She stated she was not aware of Resident #1 was found on the floor. The DON stated there was not incident report, pain assessment, nurses note or any documentation in the electronic medical record about Resident #1 found on the floor. In an interview on 05/30/2024 at 2:15 PM, the ADON stated she reviewed Resident #1's electronic medical record and there was not any documentation of any type of incident on 05/03/2024 of Resident #1 being found on the floor. She stated CMA A or any CMA was not qualified to do range of motion, skin assessments, neuro checks or determine if a resident was injured. She stated if CMA A reported to a nurse and the nurse was busy it was expected for any staff including CMA A to find another nurse in the facility to assess Resident #1. She also stated Resident #1 was required to be assessed by a nurse before anyone transferred her from the floor to the wheelchair. She stated CMA A was not qualified to determine if it was safe to transfer Resident #1. The ADON stated she was not working on 05/03/2024, however, there were 2 nurse supervisors, DON, and MDS nurse in the facility. She stated CMA A (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676089 If continuation sheet Page 4 of 31 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 05/31/2024 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 0580 did not follow the facilities fall protocol. Level of Harm - Immediate jeopardy to resident health or safety In an interview on 05/30/2024 at 3:10 PM, the Administrator stated he was not notified of Resident #1 being found on the floor. He stated his expectations was for a nurse to assess a resident anytime a resident is found on the floor or any type of incident. The Administrator stated CMA A was not qualified to do range of motion, complete pain assessments or incident /accident reports. He stated if a nurse was busy, he expected the staff to find another nurse in the facility and have them to assess a resident or give care to a resident in an emergency. He stated this was not the correct protocol for this facility for a non- licensed nurse to do any type of nursing treatment on a resident. CMA A was given written disciplinary action. Residents Affected - Few In an interview on 05/30/2024 at 3:40 PM, the Physician stated he was not notified of any incident in May of Resident #1 except when the Administrator did contact him about her fracture and being in the hospital. He stated he was not notified of Resident #1 being found on the floor. The Physician stated the Administrator, DON, ADON or a nurse always contacted him if there was a fall or any change of condition with a resident. He stated the Administrator would always contact him about any incident with a resident when he was notified. He also stated the nurses always notified him but the Administrator would contact him also. The Physician stated Resident #1 could have broken any bone without falling. He stated she does have brittle bones and it would be difficult for him to determine if Resident #1 may have broken a bone without knowing if she actually fell or laid on the floor. Record review of Inservice on Falls, dated 04/14/2024 reflected the following was discussed during the in-service: 1. When a resident falls all non- licensed nursing staff will notify the nurse. Once the Nurse assess the resident such as: vitals, does a resident have an injury, change of condition then the nurse will make decision of whether to transfer resident back to bed or wheelchair or does the resident require to be transferred to the hospital. All unwitnessed falls must have neuros. 2. Nurse will notify the Administrator, Director of Nurses, Responsible Party, and the Physician. Incident report completed by the nurse and sign/ date the report. (the in-service was signed by CMA A). Record review of Facility Policy on Falls- Clinical Protocol, revised March 2018, reflected the nurse shall assess and document the following: a. Vital signs. b. Recent injury, especially fracture or head injury. c. Musculoskeletal function, observing for change in normal range of motion, weight bearing, etc. d. Change in condition or level of consciousness. e. Neurological status. f. Pain g. Frequency and number of falls since last physician visit. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676089 If continuation sheet Page 5 of 31 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 05/31/2024 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 0580 h. Precipitating factors, details on how falls occurred. Level of Harm - Immediate jeopardy to resident health or safety i. All current medications, especially those associated with dizziness or lethargy. Residents Affected - Few The Administrator was notified on 05/30/2024 at 6:19 PM,that an Immediate Jeopardy had been identified due to the above failures and an IJ template was provided. j. All active diagnoses. The following POR was accepted on 05/31/2024 at 1:44 PM: Date 05/31/2024 On 05/30/2024 a facility self-reportable investigation was initiated at the facility. 05/30/2024 the surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an Immediate Jeopardy to resident health and safety. The notification of Immediate Jeopardy states as follows: The facility failed to ensure care was provided by qualified persons in accordance with professional standards of practice. Interventions: 1. On 5/30/24 safe surveys with all oriented residents were completed by administrative staff to ensure no other falls/incidents have not been reported or addressed. 2. On 5/30/24 pain assessments on all residents were started by nursing administration to ensure all pain needs were addressed with interventions in place. 3. On 5/30/24 disciplinary action was begun for CMA A and CNA B by the DON/ Administrator for practicing outside their practice by moving and assessing resident #1, and not reporting incident to the Administrator or DON. 4. Nurse in question no longer works at facility. 5. Administrator/DON initiated an in-service for all staff on 5/30/24 on incident/accident policy, incident communication between staff and administration, abuse neglect exploitation, assessments post fall/incident to be completed by licensed nurse only, and scope of practice by position. A post-test will be performed with staff over information in-serviced on by administration, and a score of 100% (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676089 If continuation sheet Page 6 of 31 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 05/31/2024 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 0580 must be achieved. If less than 100%, staff will be reeducated and retest until 100% is achieved. Level of Harm - Immediate jeopardy to resident health or safety 6. Residents Affected - Few Administrator/DON initiated an in-service for nursing staff on 5/30/24 on physician and family notification of incidents or change in status, neuro protocol for unwitnessed falls or falls with head injury, completing a new fall risk assessment after fall, and assessing residents after a fall/incident by licensed nurse only. A post-test will be performed with staff over information in-serviced on by administration, and a score of 100% must be achieved. If less than 100%, staff will be reeducated and retest until 100% is achieved. 7. Administrator/DON initiated an in-service for CMA A and CNA B a one-on-one in-service about notification of administrator/DON of a fall/incident, and to stay within scope of practice for their position. A post-test will be performed with staff over information in-serviced on by administration, and a score of 100% must be achieved. If less than 100%, staff will be reeducated and retest until 100% is achieved. 8. Administrator and DON were in-serviced on 5/31/24 by Regional Director of Operations on all the policies mentioned above, and to notify regional/corporate staff of ALL falls/incidents and are to notify regional/corporate staff of any discrepancies. Regional/corporate staff will follow-up on each fall/incident in question and direct with appropriate interventions. If staff are unable to attend any of the in-services, they will be required to complete the in-service before starting their assigned shift. Any agency will be in-serviced prior to the beginning of their shift. Any new hires will be in-serviced on hire, prior to working a shift. The Medical Director was made aware of the Immediate Jeopardy 5/30/24 at 9:00 PM and has been involved in developing the Plan of Removal. These conversations are considered part of the QA process. A QAPI meeting was held on 5/30/24 with attendance of Administrator, Director of Nursing, Assistant Director of Nursing, MDS Coordinator, Regional Director of Clinical Services, and Regional Director of Operations. This plan was initially implemented 5/30/24 and will be monitored through completion by corporate and regional staff. Plan of Removal completion date is 5/31/24 by 5:00 PM with continuation of oncoming staff and follow-up. The Surveyor monitored the POR on 05/31/2024 as followed: 1. Review of the facility's safe surveys with all the oriented residents reflected it was completed and conducted by the Director of Nurses on 05/31/2024. The safe surveys revealed any additional falls/ incidents had not been reported. 2. Review of the facility's pain assessments on all residents were completed on 05/31/2024 by the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676089 If continuation sheet Page 7 of 31 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 05/31/2024 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 0580 Director of Nurses, LVN I and LVN J. Level of Harm - Immediate jeopardy to resident health or safety 3. Review of the facility's disciplinary action for CMA A and CNA B for performance and safety. Violated policy performance expectations, inefficient, intentional, careless or any poor / substandard performance of duties, conducting endangering life, safety or health of others and failure to comply with business rules, regulations, and policies/ procedures. Residents Affected - Few 4. Verified LVN E no longer is an employee at the facility. Reviewed LVN E personnel record. LVN E resigned from the facility. LVN E resigned on 05/05/2024. 5. Review of the following in-service conducted on 05/30/2024 for nursing staff and other disciplines: a. Accidents and Incidents- Accidents and incidents should be reported immediately to the nurse on duty. The nurse to intervene immediately. All accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated and reported to the administrator. The nurse supervisor/ charge nurse/or the department or supervisor shall complete a Report of Incident/ Accident form and submit the original to the Director of Nurses within 24 hours of the incident or accident. b. Disciplinary action for all staff involved with communication failure. It is expected for all staff to communicate as a team. Failure to communicate or report a change of condition, a fall, etc. could result in discipline up to termination. If a staff member does not take appropriate action after staff has communicated an issue, please contact the Administrator or Director of Nurses immediately. c. Abuse and Neglect- All residents have the right to be free from any abuse, neglect or exploitation. Staff is expected to report any abuse or neglect to the nurse on duty then immediately to the administrator for immediate intervention. d. Falls - If a resident falls, the nurse must be notified immediately. If your nurse is unavailable, someone will need to send an aide to the other hall so that the nurse from the other unit can come and assess the resident. The Director of Nurses, Assistant Director of Nurses, and MDS nurse are also available to do assessments for falls as well. No one other that the nurse should assess or move the resident. When a resident falls, no matter your title, please let the Administrator, Director of Nurses and Assistance Director of Nurses know so that the fall will be followed up as soon as possible. e. Scope of Practice and Duties- All staff have job duties and are expected to complete them. Any job no completed or doing a job or duties that is beyond your training or scope of practice is not allowed. Discipline will follow. Only nurses can assess a resident and do range of motion. (job duties for all disciplines were reviewed). f. Post Test- reviewed the post tests given to staff after the in-services. There were 32 staff had taken the post test and made 100 on the test. g. Physician and responsible party notification- NP/ Physician must be notified and documented for all incidents including falls and behaviors and document/complete all incidents neuros, and pertinent information. Family, responsible party and/ or resident needs to be notified in the event of a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676089 If continuation sheet Page 8 of 31 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 05/31/2024 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 0580 fall or change of condition. Level of Harm - Immediate jeopardy to resident health or safety h. Neuro checks protocol for unwitnessed falls or falls with head injury. Fall assessment to be completed after each fall and quarterly. Neuro checks must follow any unwitnessed fall or evidence of head trauma. Incident reports are completed fore each fall. Documentation of incidents must be charted in the progress note, and must contain investigation of cause of fall, interventions to prevent further falls, assessment summary including injuries, vital signs, and initiation neuros indicated. Residents Affected - Few i. Filling out Risk Assessment after fall - Everything must be addressed and completed. Must have vital signs included in the report. Must have an intervention. Include all notified example: Director of Nurses, Administrator, Doctor, and Responsible Party. Do progress note from this report. Be sure to sign report under signature. j. Incident communications- Charge nurses will communicate all incidents on shift change with oncoming nurses and on the hall and specify any adverse findings and document appropriately in resident's record and notify all parties such as: responsible party, Physician, Administrator and the Director of Nurses. Inservice one-on-one on 05/31/2024 with CMA A: if a resident falls the nurse must be notified immediately. If your nurse is unavailable, someone will need to send an aide to the other hall so that the nurse from the other unit can come assess the resident. The Director of Nurses, Assistant Director of Nurses and the MDS Nurse are also available to do assessments for falls. No one other than the nurse should assess or move the resident. When a resident falls, no matter your title, please let the Administrator, Director of Nurses and the Assistant Director of Nurses know about the fall. Inservice one-on-one on 05/31/2024with CNA B: If a resident is found on the floor, a nurse must immediately assess the resident before moving the resident. If one (nurse) is not available one from another hall must be summons. Resident is not to be moved or assessed by a non-nurse. After every fall, please notify the Administrator. The Director of Nurses or the Assistant Director of Nurses will go follow up with nursing to ensure documentation has been completed and the family and physician has been notified. The Administrator and Director of Nurses was in-serviced by the Regional Director of Operations on 05/31/2024 on the following topics: a. Incident/ Accident policy b. Incident communication between staff and Administrator c. Abuse, neglect, and exploitation d. Assessment post fall e. Incident report to be completed by licensed nurse only. f. Scope of practice by position g. Physician and family notification of residents or change in status. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676089 If continuation sheet Page 9 of 31 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 05/31/2024 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 0580 h. Neuro protocol for unwitnessed falls or falls with head injuries. Level of Harm - Immediate jeopardy to resident health or safety i. Completing a new fall risk assessment after a fall. Residents Affected - Few Review of the QAPI Meeting Report dated 05/30/2024 reflected the following were in attendance: Administrator, Director of Nurses, Assistant Director of Nurses, MDS Coordinator, Regional Director of Clinical Services, and Regional Director of Operations. The Medical Director was made aware of the Immediate Jeopardy on 05/30/2024 at 9:00 PM and was involved with the Plan of Removal. j. All staff will be required to complete all required in-services prior to the beginning of their first shift. Observation on 05/30/2024 at 5:45 PM- 6:05 PM the ADON and the DON was conducting in-services and the post test before the 6:00 PM - 6:00 AM staff could give care to the residents. This was ongoing on 05/30/2024. In an interview on 05/31/2024 at 2:10 PM, Laundry Aide K stated she had been in-service on Incident/ Accidents- if she saw a resident fall, she was to find a nurse immediately. She stated she was not to touch the resident and report what happened to the nurse. She stated she was in-service on abuse and neglect. She stated abuse was if a staff yelled at a resident or hit a resident. She stated neglect was when a staff refused to give resident a drink of water or food. She stated she did take a test and made 100 on it. She also stated only the nurse was allowed to touch the resident until she assessed the resident. In an interview on 05/31/2024 at 2:15 PM, LVN F stated he had been in-service on incident and accidents policy/protocol. He stated only nurses was allowed to assess a resident after a fall, or if found on floor and/or any type of incident/accident. LVN F stated the nurse completed neuro checks, completed head to toe skin assessment, vital signs and if there was an injury the physician was called immediately and follow the orders from the Physician. He stated he was also not to move the resident if there was an injury until EMR transported the resident to hospital. LVN F stated the family, DON and Administrator was also to be notified immediately if there were any change of condition with a resident. He stated if the nurse assigned to the resident who was found on the floor and that nurse was busy it was expected any nurse can assess the resident. He stated he was inserviced on abuse and neglect. LVN F stated abuse was when a staff or another resident slapped a resident, cussed a resident and neglect was when staff refused to give resident their scheduled medication or refused to assist resident to the bathroom. He stated job duties was discussed and to follow your job duties. He stated only nurses are allowed to complete the nursing documentation of incident/ accident reports, nurses notes, skin assessments, etc. He stated if it is a new fall it is required to complete a new fall risk assessment. LVN F also stated after any incident / accident the physician, family and the DON/ Administrator was to be contacted immediately. He stated he did take a posttest and made 100 on the test. In an interview on 05/31/2024 at 2:26 PM, Dietary Aide/CNA L stated she worked as a CNA and some days in the kitchen. She stated she was in-service on 5/31/2024 on the following: 1. Abuse and neglect 2. Not to move a resident or touch a resident until nurse assess the resident if they had fallen. The nurse was to give directions of what to do after she completed all her assessments. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676089 If continuation sheet Page 10 of 31 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 05/31/2024 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 0580 3. Report any falls or accidents immediately to the nurse. If nurse super[TRUNCATED] Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676089 If continuation sheet Page 11 of 31 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 05/31/2024 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 0659 Provide care by qualified persons according to each resident's written plan of care. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure services provided or arranged by the facility, as outlined by the comprehensive care plan were provided by qualified persons in accordance with each residents written plan of care for one (Resident #1) of four residents reviewed for qualified persons. Residents Affected - Few The facility failed to ensure Resident #1 received assessment after an unwitnessed fall by a qualified staff member on 05/03/2024 when CMA A stated she conducted range of motion assessment, transferred the resident from the floor to the wheelchair and did not inform administrative staff. An Immediate Jeopardy (IJ) situation was identified on 05/30/2024 at 6:05 PM. While the IJ was removed on 05/31/2024 at 7:05 PM, the facility remained out of compliance at a scope of isolated with potential for more than minimal harm that is not immediate jeopardy because all staff had not be trained on falls. These failures placed residents at risk for not receiving appropriate care and treatment by qualified staff. Findings included: Record review of Resident #1's face sheet dated 05/30/2024 reflected an [AGE] year-old female admitted on [DATE] and readmitted on [DATE] with diagnoses of fracture of unspecified part of neck of left femur, subsequent encounter for closed fracture with routine healing (breaks or rupture in bone situated between the hip and the knee), difficulty with walking ( problems with bones or pain can make it difficult to walk properly), abnormalities in gait and mobility ( an injury or underlying medical condition can cause an abnormal gait), Alzheimer's disease ( a brain disease that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks), unspecified lack of coordination ( muscle control problem that causes an inability to coordinate movements. It leads to jerky, unsteady, to and from motion of the middle of the body and an unsteady walking style), and unspecified fall (finding of sudden movement downward, usually resulting in injury). Record review of Resident #1's Annual MDS Assessment, dated 04/11/2024, reflected Resident #1 had a BIMS score of 0 indicated severe cognitive impairment. She was assessed to have poor short- and long-term memory recall. Her decision-making ability was severely impaired. Resident #1 was assessed to require assistance with ADLs including the following: transfers, eating, personal hygiene, showers, and dressing. Record review of Resident #1's Comprehensive Care Plan revised on 05/31/2024 reflected Resident #1 had impaired cognitive function or impaired thought process related to Alzheimer's Disease. Intervention: Keep resident's, routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion. Resident #1 was prone to skin tears and bruising related to fragile skin. Intervention: all injuries will be monitored until they are resolved. Notify charge nurse of any new bruising or skin tears. She was high risk for falls related to unsteady balance, incontinence, poor safety awareness and being forgetful. Interventions: educate the resident/ family and care givers about safety reminders and what to do if a fall occurs. Anticipate and meet the resident's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676089 If continuation sheet Page 12 of 31 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 05/31/2024 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 0659 needs. Follow facility protocol. Level of Harm - Immediate jeopardy to resident health or safety Record review of Resident #1's electronic medical records reflected Resident #1 did not have any nursing note entries on 05/03/2024. Residents Affected - Few Record review of Resident #1's electronic medical records reflected Resident #1 did not have a pain assessment or incident/accident report on 05/03/2024. There was one entry at 10:38 AM B/P was 129/79 mmHg. Record review of Resident #1's Nurses notes, at 1:13 PM on 05/04/2024, reflected Resident #1 continued to decline with a B/P of 96/55 and pulse of 55 within an hour of having elevated blood pressure earlier in AM. Resident #1 had a glazed (expression is dull, usually because a person is tired or had difficulty concentrating on something) look to her eyes and small pinpoint pupils. Her 02 sats dropped from 94 % R/A to 86 % R/A. O2 per nasal cannula put on Resident #1 to aid in oxygen saturation. O2/3L/NC 93%. NP was notified and new order to send Resident #1 to the emergency room for evaluation and treatment. Resident #1 was transported by EMS to the emergency room at 11:44 AM. Family and ADON was notified of Resident #1 being transported to the Emergency Room. Written by RN C. Record review of Resident #1's Nurses Notes, at 1:49 PM on 05/04/2024, reflected Resident #1 was hospitalized . Record review of Resident #1's Hospital Records dated 05/04/2024 reflected minimally displaced left sub capital femoral neck fracture (these fractures occur in the neck of the thighbone). There were no other injuries according to the x-ray report. Observation and interview on 05/30/2024 at 9:00 AM, Resident #1 were sitting in the common area beside another resident. She smiled and she did not respond to questions. Resident #1 did not show any signs or symptoms of any distress. She was relaxed and watching people. In an interview on 05/30/2024 at 9:12 AM, CNA B stated on 05/03/2024 CMA A came to her after lunch when she was giving Resident #2 a shower and requested if she had time to assist her in transferring Resident #1 from the floor to the wheelchair. She stated CMA A explained she found Resident #1 lying on the floor. CNA B stated she asked CMA A to find CNA D she was unable to leave the shower. CNA B stated she was assigned to Resident #1 on 05/03/2024. She stated she went to the nurse's desk after giving Resident #2 a shower and assisted Resident #2 to her room. CNA B also stated she observed Resident #1 sitting in her wheelchair and she was her normal self. She stated she would stand and walked from chair to chair. She stated this was her usual routine when sitting in the common area near nurses' desk. She stated she received a verbal report from LVN E and she stated she believed Resident #1 slid out of her wheelchair. She also stated she had been in-serviced on what to do if a resident fell or was found on the floor. CNA B stated only nurses was allowed to touch the resident and complete a skin assessment, pain assessment and if there was an injury to call the physician and the non-nursing staff including CMAs was expected to wait and follow the nurses' directions on what to do with the resident and when to move the resident. Interview on 05/30/2024 at 10:03 AM, LVN F stated he was coming on duty for the night shift on 05/03/2024 and LVN E was giving him verbal report of what occurred on the day shift on 05/03/2024. He stated during the verbal report LVN E informed him Resident #1 had a fall and she did not report anything else about Resident #1. He stated he monitored her on the night shift for any changes in her mental or physical condition. LVN F stated Resident # 1 never complained of pain and was at her (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676089 If continuation sheet Page 13 of 31 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 05/31/2024 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 0659 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few baseline physically and mentally on his shift (from 6:00 PM on 05/03/2024 to 6:00 AM on 05/04/2024). He stated he had been in-serviced on fall protocol. He stated only nurses are allowed to complete range of motion, neuro checks, pain assessment and completed incident/ accident report. LVN F stated the physician, DON, and family was expected to be notified. He also stated he would follow the physician directions of what treatment he believed the resident needed. Interview on 05/30/2024 at 10:15 AM, CMA A stated she was walking by the activity area near the nurse's desk and observed Resident #1 on the floor in front of the television. She stated Resident #1's wheelchair was a few feet away from her by a table. She stated Resident #1 was not a good historian and unable to give any information of the incident of her lying on the floor. CMA A stated Resident #1 was lying on her back. She also stated she went to get assistance from CNA B. She stated CNA B was giving another resident a shower and was unable to assist her with transferring Resident #1 from the floor to her wheelchair. She stated she found LVN E. She stated LVN E was busy with a new admission and was unable to assist her with Resident #1. CMA A stated there were other nurses in the facility and did not think about going to find another nurse. CMA A stated she did not want Resident #1 laying on the floor any longer and she had observed nurses perform range of motion on residents after they had fall and she decided she would perform range of motion and she asked a CNA to assist her in transferring Resident #1 to the wheelchair. She stated she put the vital signs on a piece of paper and laid it on the desk and she does not know if the Nurse completed an assessment on Resident #1. She stated she did not follow up on the incident. CMA A stated she had been in-service on fall protocol. She stated she was instructed during the in-service the nurses was the only staff was allowed to assess a resident found on the floor and complete range of motion. She stated she was not to assess Resident #1 or complete range of motion. She stated she was wrong, and she knows she did everything wrong in the situation of finding Resident #1 on the floor. She stated it was a busy day and she did not think to go and report it to DON or Administrator. She stated she could have asked another nurse but she was wanting to assist resident off the floor as soon as possible. In an interview via phone on 05/30/2024 at 10:38 AM, LVN E stated 05/03/2024 was her last day to work at this facility. She stated it was a very busy day. LVN E stated she did not recall anyone come to her and report anyone on the floor. She stated she was busy with a new admit all day and if anyone fell it would have been when LVN G worked on 05/02/2024. LVN E stated to contact LVN G and ask her about anyone falling. She stated I think Resident #1 fell on LVN G's shift on 05/02/2024. She stated she was at work and needed to go back to work. LVN E stated she did not have anything else to say about Resident #1. In an interview on 05/30/2024 at 10:50 AM, LVN G stated she did work on 05/02/2024. She stated no one fell on her shift. LVN G stated Resident #1 did not fall or was found on the floor the date of 05/02/2024. LVN G stated when she came back to work on 05/06/2024 it was reported to her Resident #1 was in the hospital with a hip fracture during the morning meeting. LVN G stated it was not mentioned she was found on the floor or had a on 05/03/2024. She stated it was unknown how she fractured her hip. She stated she had been in-serviced on falls assessments and what to do if a resident fell. LVN G stated if a resident was found on the floor or witnessed a fall only the nurses was allowed to assess the residents and do range of motion. She stated the nurse would complete head to toe skin assessment, neuro checks, vitals and call the physician immediately if there was an injury. LVN G also stated she would follow the physician directions and would also contact the DON and the responsible party of the resident. She stated a nurse's note was required to be completed after any incident of a resident. In an interview on 05/30/2024 at 11:20 AM, CNA D stated No when asked if he was aware of anything (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676089 If continuation sheet Page 14 of 31 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 05/31/2024 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 0659 Level of Harm - Immediate jeopardy to resident health or safety happening to Resident #1 on 5/3/2024. CNA D would only answer yes/no type questions. He would not respond to any questions that required detailed information. In an interview on 05/30/2024 at 11:55 AM, CMA H stated he did work with LVN G on 05/02/2024. He stated if there were any changes with a resident including finding a resident on the floor or witnessing a fall, they reported to each other. Residents Affected - Few He stated he was not aware of Resident #1 falling on 05/02/2024. CMA H stated he would definitely know if anyone fell when he is working in the facility. He stated he had been in-serviced on fall protocol. CMA H also stated only nurses was allowed to assess a resident if a resident was found on the floor or if it was a witnessed fall. He stated no one but the nurse was complete entire assessment such as neuro checks, pain assessment, incident/ accident report or do range of motion on a resident. CMA H stated other staff was allowed to assist resident with transfer only after the nurse completed assessments and gave instructions to other staff it was safe to transfer the resident. He stated if he found someone on the floor and the nurse supervisor for that particular resident was not available, he would find another nurse and would not touch the resident until the nurse did their assessment. In an interview on 05/30/2024 at 1:30 PM, the DON stated she was working on 05/03/2024 and no one reported to her of Resident #1 being found on the floor or any incident with Resident #1. She stated there were two nurse supervisors, MDS Nurse and she was in the facility on 05/03/2024. She stated only a LVN or RN was allowed to complete pain assessments, head to toe skin assessments, neuro checks, incident/ accident reports. She stated if a resident was injured the nurse would contact the physician and follow the physician orders. She also stated if a resident was not injured, she expected the physician to be contacted. The DON also stated the responsible party of the resident was also expected to be contacted. She stated the nurse would direct other staff what to do after she had assessed the resident and contacted the physician. She also stated CMA was not qualified to do range of motion on a resident or to do any type of pain assessments or neuro checks. She stated if the nurse responsible for Resident #1 was not available CMA A was expected to find another nurse to assess Resident #1. The DON also stated the nurse was expected to complete incident/ accident report, pain assessment, and a nurses note. She also stated the CMA or LVN E was expected to notify DON or ADON when there is a fall or a resident found on the floor. She stated she was not aware of Resident #1 was found on the floor. The DON stated there was not incident report, pain assessment, nurses note or any documentation in the electronic medical record about Resident #1 found on the floor. In an interview on 05/30/2024 at 2:15 PM, the ADON stated she reviewed Resident #1's electronic medical record and there was not any documentation of any type of incident on 05/03/2024 of Resident #1 being found on the floor. She stated CMA A or any CMA was not qualified to do range of motion, skin assessments, neuro checks or determine if a resident was injured. She stated if CMA A reported to a nurse and the nurse was busy it was expected for any staff including CMA A to find another nurse in the facility to assess Resident #1. She also stated Resident #1 was required to be assessed by a nurse before anyone transferred her from the floor to the wheelchair. She stated CMA A was not qualified to determine if it was safe to transfer Resident #1. The ADON stated she was not working on 05/03/2024, however, there were 2 nurse supervisors, DON, and MDS nurse in the facility. She stated CMA A did not follow the facilities fall protocol. In an interview on 05/30/2024 at 3:10 PM, the Administrator stated he was not notified of Resident #1 being found on the floor. He stated his expectations was for a nurse to assess a resident anytime a resident is found on the floor or any type of incident. The Administrator stated CMA A was not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676089 If continuation sheet Page 15 of 31 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 05/31/2024 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 0659 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few qualified to do range of motion, complete pain assessments or incident /accident reports. He stated if a nurse was busy, he expected the staff to find another nurse in the facility and have them to assess a resident or give care to a resident in an emergency. He stated this was not the correct protocol for this facility for a non- licensed nurse to do any type of nursing treatment on a resident. CMA A was given written disciplinary action. In an interview on 05/30/2024 at 3:40 PM, the Physician stated he was not notified of any incident in May of Resident #1 except when the Administrator did contact him about her fracture and being in the hospital. He stated he was not notified of Resident #1 being found on the floor. The Physician stated the Administrator, DON, ADON or a nurse always contacted him if there was a fall or any change of condition with a resident. He stated the Administrator would always contact him about any incident with a resident when he was notified. He also stated the nurses always notified him but the Administrator would contact him also. The Physician stated Resident #1 could have broken any bone without falling. He stated she does have brittle bones and it would be difficult for him to determine if Resident #1 may have broken a bone without knowing if she actually fell or laid on the floor. Record review of Inservice on Falls, dated 04/14/2024 reflected the following was discussed during the in-service: 1. When a resident falls all non- licensed nursing staff will notify the nurse. Once the Nurse assess the resident such as: vitals, does a resident have an injury, change of condition then the nurse will make decision of whether to transfer resident back to bed or wheelchair or does the resident require to be transferred to the hospital. All unwitnessed falls must have neuros. 2. Nurse will notify the Administrator, Director of Nurses, Responsible Party, and the Physician. Incident report completed by the nurse and sign/ date the report. (the in-service was signed by CMA A). Record review of Facility Policy on Falls- Clinical Protocol, revised March 2018, reflected the nurse shall assess and document the following: a. Vital signs. b. Recent injury, especially fracture or head injury. c. Musculoskeletal function, observing for change in normal range of motion, weight bearing, etc. d. Change in condition or level of consciousness. e. Neurological status. f. Pain g. Frequency and number of falls since last physician visit. h. Precipitating factors, details on how falls occurred. i. All current medications, especially those associated with dizziness or lethargy. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676089 If continuation sheet Page 16 of 31 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 05/31/2024 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 0659 j. All active diagnoses. Level of Harm - Immediate jeopardy to resident health or safety The Administrator was notified on 05/30/2024 at 6:19 PM,that an Immediate Jeopardy had been identified due to the above failures and an IJ template was provided. The following POR was accepted on 05/31/2024 at 1:44 PM: Residents Affected - Few Date 05/31/2024 On 05/30/2024 a facility self-reportable investigation was initiated at the facility. 05/30/2024 the surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an Immediate Jeopardy to resident health and safety. The notification of Immediate Jeopardy states as follows: The facility failed to ensure care was provided by qualified persons in accordance with professional standards of practice. Interventions: 1. On 5/30/24 safe surveys with all oriented residents were completed by administrative staff to ensure no other falls/incidents have not been reported or addressed. 2. On 5/30/24 pain assessments on all residents were started by nursing administration to ensure all pain needs were addressed with interventions in place. 3. On 5/30/24 disciplinary action was begun for CMA A and CNA B by the DON/ Administrator for practicing outside their practice by moving and assessing resident #1, and not reporting incident to the Administrator or DON. 4. Nurse in question no longer works at facility. 5. Administrator/DON initiated an in-service for all staff on 5/30/24 on incident/accident policy, incident communication between staff and administration, abuse neglect exploitation, assessments post fall/incident to be completed by licensed nurse only, and scope of practice by position. A post-test will be performed with staff over information in-serviced on by administration, and a score of 100% must be achieved. If less than 100%, staff will be reeducated and retest until 100% is achieved. 6. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676089 If continuation sheet Page 17 of 31 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 05/31/2024 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 0659 Level of Harm - Immediate jeopardy to resident health or safety Administrator/DON initiated an in-service for nursing staff on 5/30/24 on physician and family notification of incidents or change in status, neuro protocol for unwitnessed falls or falls with head injury, completing a new fall risk assessment after fall, and assessing residents after a fall/incident by licensed nurse only. A post-test will be performed with staff over information in-serviced on by administration, and a score of 100% must be achieved. If less than 100%, staff will be reeducated and retest until 100% is achieved. Residents Affected - Few 7. Administrator/DON initiated an in-service for CMA A and CNA B a one-on-one in-service about notification of administrator/DON of a fall/incident, and to stay within scope of practice for their position. A post-test will be performed with staff over information in-serviced on by administration, and a score of 100% must be achieved. If less than 100%, staff will be reeducated and retest until 100% is achieved. 8. Administrator and DON were in-serviced on 5/31/24 by Regional Director of Operations on all the policies mentioned above, and to notify regional/corporate staff of ALL falls/incidents and are to notify regional/corporate staff of any discrepancies. Regional/corporate staff will follow-up on each fall/incident in question and direct with appropriate interventions. If staff are unable to attend any of the in-services, they will be required to complete the in-service before starting their assigned shift. Any agency will be in-serviced prior to the beginning of their shift. Any new hires will be in-serviced on hire, prior to working a shift. The Medical Director was made aware of the Immediate Jeopardy 5/30/24 at 9:00 PM and has been involved in developing the Plan of Removal. These conversations are considered part of the QA process. A QAPI meeting was held on 5/30/24 with attendance of Administrator, Director of Nursing, Assistant Director of Nursing, MDS Coordinator, Regional Director of Clinical Services, and Regional Director of Operations. This plan was initially implemented 5/30/24 and will be monitored through completion by corporate and regional staff. Plan of Removal completion date is 5/31/24 by 5:00 PM with continuation of oncoming staff and follow-up. The Surveyor monitored the POR on 05/31/2024 as followed: 1. Review of the facility's safe surveys with all the oriented residents reflected it was completed and conducted by the Director of Nurses on 05/31/2024. The safe surveys revealed any additional falls/ incidents had not been reported. 2. Review of the facility's pain assessments on all residents were completed on 05/31/2024 by the Director of Nurses, LVN I and LVN J. 3. Review of the facility's disciplinary action for CMA A and CNA B for performance and safety. Violated policy performance expectations, inefficient, intentional, careless or any poor / substandard (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676089 If continuation sheet Page 18 of 31 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 05/31/2024 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 0659 performance of duties, conducting endangering life, safety or health of others and failure to comply with business rules, regulations, and policies/ procedures. Level of Harm - Immediate jeopardy to resident health or safety 4. Verified LVN E no longer is an employee at the facility. Reviewed LVN E personnel record. LVN E resigned from the facility. LVN E resigned on 05/05/2024. Residents Affected - Few 5. Review of the following in-service conducted on 05/30/2024 for nursing staff and other disciplines: a. Accidents and Incidents- Accidents and incidents should be reported immediately to the nurse on duty. The nurse to intervene immediately. All accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated and reported to the administrator. The nurse supervisor/ charge nurse/or the department or supervisor shall complete a Report of Incident/ Accident form and submit the original to the Director of Nurses within 24 hours of the incident or accident. b. Disciplinary action for all staff involved with communication failure. It is expected for all staff to communicate as a team. Failure to communicate or report a change of condition, a fall, etc. could result in discipline up to termination. If a staff member does not take appropriate action after staff has communicated an issue, please contact the Administrator or Director of Nurses immediately. c. Abuse and Neglect- All residents have the right to be free from any abuse, neglect or exploitation. Staff is expected to report any abuse or neglect to the nurse on duty then immediately to the administrator for immediate intervention. d. Falls - If a resident falls, the nurse must be notified immediately. If your nurse is unavailable, someone will need to send an aide to the other hall so that the nurse from the other unit can come and assess the resident. The Director of Nurses, Assistant Director of Nurses, and MDS nurse are also available to do assessments for falls as well. No one other that the nurse should assess or move the resident. When a resident falls, no matter your title, please let the Administrator, Director of Nurses and Assistance Director of Nurses know so that the fall will be followed up as soon as possible. e. Scope of Practice and Duties- All staff have job duties and are expected to complete them. Any job no completed or doing a job or duties that is beyond your training or scope of practice is not allowed. Discipline will follow. Only nurses can assess a resident and do range of motion. (job duties for all disciplines were reviewed). f. Post Test- reviewed the post tests given to staff after the in-services. There were 32 staff had taken the post test and made 100 on the test. g. Physician and responsible party notification- NP/ Physician must be notified and documented for all incidents including falls and behaviors and document/complete all incidents neuros, and pertinent information. Family, responsible party and/ or resident needs to be notified in the event of a fall or change of condition. h. Neuro checks protocol for unwitnessed falls or falls with head injury. Fall assessment to be completed after each fall and quarterly. Neuro checks must follow any unwitnessed fall or evidence of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676089 If continuation sheet Page 19 of 31 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 05/31/2024 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 0659 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few head trauma. Incident reports are completed fore each fall. Documentation of incidents must be charted in the progress note, and must contain investigation of cause of fall, interventions to prevent further falls, assessment summary including injuries, vital signs, and initiation neuros indicated. i. Filling out Risk Assessment after fall - Everything must be addressed and completed. Must have vital signs included in the report. Must have an intervention. Include all notified example: Director of Nurses, Administrator, Doctor, and Responsible Party. Do progress note from this report. Be sure to sign report under signature. j. Incident communications- Charge nurses will communicate all incidents on shift change with oncoming nurses and on the hall and specify any adverse findings and document appropriately in resident's record and notify all parties such as: responsible party, Physician, Administrator and the Director of Nurses. Inservice one-on-one on 05/31/2024 with CMA A: if a resident falls the nurse must be notified immediately. If your nurse is unavailable, someone will need to send an aide to the other hall so that the nurse from the other unit can come assess the resident. The Director of Nurses, Assistant Director of Nurses and the MDS Nurse are also available to do assessments for falls. No one other than the nurse should assess or move the resident. When a resident falls, no matter your title, please let the Administrator, Director of Nurses and the Assistant Director of Nurses know about the fall. Inservice one-on-one on 05/31/2024 with CNA B: If a resident is found on the floor, a nurse must immediately assess the resident before moving the resident. If one (nurse) is not available one from another hall must be summons. Resident is not to be moved or assessed by a non-nurse. After every fall, please notify the Administrator. The Director of Nurses or the Assistant Director of Nurses will go follow up with nursing to ensure documentation has been completed and the family and physician has been notified. The Administrator and Director of Nurses was in-serviced by the Regional Director of Operations on 05/31/2024 on the following topics: a. Incident/ Accident policy b. Incident communication between staff and Administrator c. Abuse, neglect, and exploitation d. Assessment post fall e. Incident report to be completed by licensed nurse only. f. Scope of practice by position g. Physician and family notification of residents or change in status. h. Neuro protocol for unwitnessed falls or falls with head injuries. i. Completing a new fall risk assessment after a fall. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676089 If continuation sheet Page 20 of 31 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 05/31/2024 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 0659 j. All staff will be required to complete all required in-services prior to the beginning of their first shift. Level of Harm - Immediate jeopardy to resident health or safety Review of the QAPI Meeting Report dated 05/30/2024 reflected the following were in attendance: Administrator, Director of Nurses, Assistant Director of Nurses, MDS Coordinator, Regional Director of Clinical Services, and Regional Director of Operations. The Medical Director was made aware of the Immediate Jeopardy on 05/30/2024 at 9:00 PM and was involved with the Plan of Removal. Residents Affected - Few Observation on 05/30/2024 at 5:45 PM- 6:05 PM the ADON and the DON was conducting in-services and the post test before the 6:00 PM - 6:00 AM staff could give care to the residents. This was ongoing on 05/30/2024. In an interview on 05/31/2024 at 2:10 PM, Laundry Aide K stated she had been in-service on Incident/ Accidents- if she saw a resident fall, she was to find a nurse immediately. She stated she was not to touch the resident and report what happened to the nurse. She stated she was in-service on abuse and neglect. She stated abuse was if a staff yelled at a resident or hit a resident. She stated neglect was when a staff refused to give resident a drink of water or food. She stated she did take a test and made 100 on it. She also stated only the nurse was allowed to touch the resident until she assessed the resident. In an interview on 05/31/2024 at 2:15 PM, LVN F stated he had been in-service on incident and accidents policy/protocol. He stated only nurses was allowed to assess a resident after a fall, or if found on floor and/or any type of incident/accident. LVN F stated the nurse completed neuro checks, completed head to toe skin assessment, vital signs and if there was an injury the physician was called immediately and follow the orders from the Physician. He stated he was also not to move the resident if there was an injury until EMR transported the resident to hospital. LVN F stated the family, DON and Administrator was also to be notified immediately if there were any change of condition with a resident. He stated if the nurse assigned to the resident who was found on the floor and that nurse was busy it was expected any nurse can assess the resident. He stated he was inserviced on abuse and neglect. LVN F stated abuse was when a staff or another resident slapped a resident, cussed a resident and neglect was when staff refused to give resident their scheduled medication or refused to assist resident to the bathroom. He stated job duties was discussed and to follow your job duties. He stated only nurses are allowed to complete the nursing documentation of incident/ accident reports, nurses notes, skin assessments, etc. He stated if it is a new fall it is required to complete a new fall risk assessment. LVN F also stated after any incident / accident the physician, family and the DON/ Administrator was to be contacted immediately. He stated he did take a posttest and made 100 on the test. In an interview on 05/31/2024 at 2:26 PM, Dietary Aide/CNA L stated she worked as a CNA and some days in the kitchen. She stated she was in-service on 5/31/2024 on the following: 1. Abuse and neglect 2. [TRUNCATED] FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676089 If continuation sheet Page 21 of 31 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 05/31/2024 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review , the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 (Resident #1) of 5 residents reviewed for quality of care. Residents Affected - Few The facility failed to ensure Resident #1, who was found on the floor by CMA A was properly assessed or monitored on 05/3/2024 until Resident #1 was transferred to the hospital on [DATE] at approximately 10:30 AM. An Immediate Jeopardy (IJ) situation was identified on 05/30/2024 at 6:05 PM. While the IJ was removed on 05/31/2024 at 7:05 PM, the facility remained out of compliance at a scope of isolated with potential for more than minimal harm that is not immediate jeopardy because all staff had not be trained on falls. These failures could place residents at risk of not receiving necessary medical care, harm, and death. Findings included: Record review of Resident #1's face sheet dated 05/30/2024 reflected an [AGE] year-old female admitted on [DATE] and readmitted on [DATE] with diagnoses of fracture of unspecified part of neck of left femur, subsequent encounter for closed fracture with routine healing (breaks or rupture in bone situated between the hip and the knee), difficulty with walking ( problems with bones or pain can make it difficult to walk properly), abnormalities in gait and mobility ( an injury or underlying medical condition can cause an abnormal gait), Alzheimer's disease ( a brain disease that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks), unspecified lack of coordination ( muscle control problem that causes an inability to coordinate movements. It leads to jerky, unsteady, to and from motion of the middle of the body and an unsteady walking style), and unspecified fall (finding of sudden movement downward, usually resulting in injury). Record review of Resident #1's Annual MDS Assessment, dated 04/11/2024, reflected Resident #1 had a BIMS score of 0 indicated severe cognitive impairment. She was assessed to have poor short- and long-term memory recall. Her decision-making ability was severely impaired. Resident #1 was assessed to require assistance with ADLs including the following: transfers, eating, personal hygiene, showers, and dressing. Record review of Resident #1's Comprehensive Care Plan revised on 05/31/2024 reflected Resident #1 had impaired cognitive function or impaired thought process related to Alzheimer's Disease. Intervention: Keep resident's, routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion. Resident #1 was prone to skin tears and bruising related to fragile skin. Intervention: all injuries will be monitored until they are resolved. Notify charge nurse of any new bruising or skin tears. She was high risk for falls related to unsteady balance, incontinence, poor safety awareness and being forgetful. Interventions: educate the resident/ family and care givers about safety reminders and what to do if a fall occurs. Anticipate and meet the resident's needs. Follow facility protocol. Record review of Resident #1's electronic medical records reflected Resident #1 did not have any (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676089 If continuation sheet Page 22 of 31 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 05/31/2024 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 0684 nursing note entries on 05/03/2024. Level of Harm - Immediate jeopardy to resident health or safety Record review of Resident #1's electronic medical records reflected Resident #1 did not have a pain assessment or incident/accident report on 05/03/2024. There was one entry at 10:38 AM B/P was 129/79 mmHg. Residents Affected - Few Record review of Resident #1's Nurses notes, at 1:13 PM on 05/04/2024, reflected Resident #1 continued to decline with a B/P of 96/55 and pulse of 55 within an hour of having elevated blood pressure earlier in AM. Resident #1 had a glazed (expression is dull, usually because a person is tired or had difficulty concentrating on something) look to her eyes and small pinpoint pupils. Her 02 sats dropped from 94 % R/A to 86 % R/A. O2 per nasal cannula put on Resident #1 to aid in oxygen saturation. O2/3L/NC 93%. NP was notified and new order to send Resident #1 to the emergency room for evaluation and treatment. Resident #1 was transported by EMS to the emergency room at 11:44 AM. Family and ADON was notified of Resident #1 being transported to the Emergency Room. Written by RN C. Record review of Resident #1's Nurses Notes, at 1:49 PM on 05/04/2024, reflected Resident #1 was hospitalized . Record review of Resident #1's Hospital Records dated 05/04/2024 reflected minimally displaced left sub capital femoral neck fracture (these fractures occur in the neck of the thighbone). There were no other injuries according to the x-ray report. Observation and interview on 05/30/2024 at 9:00 AM, Resident #1 were sitting in the common area beside another resident. She smiled and she did not respond to questions. Resident #1 did not show any signs or symptoms of any distress. She was relaxed and watching people. In an interview on 05/30/2024 at 9:12 AM, CNA B stated on 05/03/2024 CMA A came to her after lunch when she was giving Resident #2 a shower and requested if she had time to assist her in transferring Resident #1 from the floor to the wheelchair. She stated CMA A explained she found Resident #1 lying on the floor. CNA B stated she asked CMA A to find CNA D she was unable to leave the shower. CNA B stated she was assigned to Resident #1 on 05/03/2024. She stated she went to the nurse's desk after giving Resident #2 a shower and assisted Resident #2 to her room. CNA B also stated she observed Resident #1 sitting in her wheelchair and she was her normal self. She stated she would stand and walked from chair to chair. She stated this was her usual routine when sitting in the common area near nurses' desk. She stated she received a verbal report from LVN E and she stated she believed Resident #1 slid out of her wheelchair. She also stated she had been in-serviced on what to do if a resident fell or was found on the floor. CNA B stated only nurses was allowed to touch the resident and complete a skin assessment, pain assessment and if there was an injury to call the physician and the non-nursing staff including CMAs was expected to wait and follow the nurses' directions on what to do with the resident and when to move the resident. Interview on 05/30/2024 at 10:03 AM, LVN F stated he was coming on duty for the night shift on 05/03/2024 and LVN E was giving him verbal report of what occurred on the day shift on 05/03/2024. He stated during the verbal report LVN E informed him Resident #1 had a fall and she did not report anything else about Resident #1. He stated he monitored her on the night shift for any changes in her mental or physical condition. LVN F stated Resident # 1 never complained of pain and was at her baseline physically and mentally on his shift (from 6:00 PM on 05/03/2024 to 6:00 AM on 05/04/2024). He stated he had been in-serviced on fall protocol. He stated only nurses are allowed to complete range of motion, neuro checks, pain assessment and completed incident/ accident report. LVN F stated the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676089 If continuation sheet Page 23 of 31 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 05/31/2024 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 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few physician, DON, and family was expected to be notified. He also stated he would follow the physician directions of what treatment he believed the resident needed. Interview on 05/30/2024 at 10:15 AM, CMA A stated she was walking by the activity area near the nurse's desk and observed Resident #1 on the floor in front of the television. She stated Resident #1's wheelchair was a few feet away from her by a table. She stated Resident #1 was not a good historian and unable to give any information of the incident of her lying on the floor. CMA A stated Resident #1 was lying on her back. She also stated she went to get assistance from CNA B. She stated CNA B was giving another resident a shower and was unable to assist her with transferring Resident #1 from the floor to her wheelchair. She stated she found LVN E. She stated LVN E was busy with a new admission and was unable to assist her with Resident #1. CMA A stated there were other nurses in the facility and did not think about going to find another nurse. CMA A stated she did not want Resident #1 laying on the floor any longer and she had observed nurses perform range of motion on residents after they had fall and she decided she would perform range of motion and she asked a CNA to assist her in transferring Resident #1 to the wheelchair. She stated she put the vital signs on a piece of paper and laid it on the desk and she does not know if the Nurse completed an assessment on Resident #1. She stated she did not follow up on the incident. CMA A stated she had been in-service on fall protocol. She stated she was instructed during the in-service the nurses was the only staff was allowed to assess a resident found on the floor and complete range of motion. She stated she was not to assess Resident #1 or complete range of motion. She stated she was wrong, and she knows she did everything wrong in the situation of finding Resident #1 on the floor. She stated it was a busy day and she did not think to go and report it to DON or Administrator. She stated she could have asked another nurse but she was wanting to assist resident off the floor as soon as possible. In an interview via phone on 05/30/2024 at 10:38 AM, LVN E stated 05/03/2024 was her last day to work at this facility. She stated it was a very busy day. LVN E stated she did not recall anyone come to her and report anyone on the floor. She stated she was busy with a new admit all day and if anyone fell it would have been when LVN G worked on 05/02/2024. LVN E stated to contact LVN G and ask her about anyone falling. She stated I think Resident #1 fell on LVN G's shift on 05/02/2024. She stated she was at work and needed to go back to work. LVN E stated she did not have anything else to say about Resident #1. In an interview on 05/30/2024 at 10:50 AM, LVN G stated she did work on 05/02/2024. She stated no one fell on her shift. LVN G stated Resident #1 did not fall or was found on the floor the date of 05/02/2024. LVN G stated when she came back to work on 05/06/2024 it was reported to her Resident #1 was in the hospital with a hip fracture during the morning meeting. LVN G stated it was not mentioned she was found on the floor or had a on 05/03/2024. She stated it was unknown how she fractured her hip. She stated she had been in-serviced on falls assessments and what to do if a resident fell. LVN G stated if a resident was found on the floor or witnessed a fall only the nurses was allowed to assess the residents and do range of motion. She stated the nurse would complete head to toe skin assessment, neuro checks, vitals and call the physician immediately if there was an injury. LVN G also stated she would follow the physician directions and would also contact the DON and the responsible party of the resident. She stated a nurse's note was required to be completed after any incident of a resident. In an interview on 05/30/2024 at 11:20 AM, CNA D stated No when asked if he was aware of anything happening to Resident #1 on 5/3/2024. CNA D would only answer yes/no type questions. He would not respond to any questions that required detailed information. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676089 If continuation sheet Page 24 of 31 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 05/31/2024 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 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few In an interview on 05/30/2024 at 11:55 AM, CMA H stated he did work with LVN G on 05/02/2024. He stated if there were any changes with a resident including finding a resident on the floor or witnessing a fall, they reported to each other. He stated he was not aware of Resident #1 falling on 05/02/2024. CMA H stated he would definitely know if anyone fell when he is working in the facility. He stated he had been in-serviced on fall protocol. CMA H also stated only nurses was allowed to assess a resident if a resident was found on the floor or if it was a witnessed fall. He stated no one but the nurse was complete entire assessment such as neuro checks, pain assessment, incident/ accident report or do range of motion on a resident. CMA H stated other staff was allowed to assist resident with transfer only after the nurse completed assessments and gave instructions to other staff it was safe to transfer the resident. He stated if he found someone on the floor and the nurse supervisor for that particular resident was not available, he would find another nurse and would not touch the resident until the nurse did their assessment. In an interview on 05/30/2024 at 1:30 PM, the DON stated she was working on 05/03/2024 and no one reported to her of Resident #1 being found on the floor or any incident with Resident #1. She stated there were two nurse supervisors, MDS Nurse and she was in the facility on 05/03/2024. She stated only a LVN or RN was allowed to complete pain assessments, head to toe skin assessments, neuro checks, incident/ accident reports. She stated if a resident was injured the nurse would contact the physician and follow the physician orders. She also stated if a resident was not injured, she expected the physician to be contacted. The DON also stated the responsible party of the resident was also expected to be contacted. She stated the nurse would direct other staff what to do after she had assessed the resident and contacted the physician. She also stated CMA was not qualified to do range of motion on a resident or to do any type of pain assessments or neuro checks. She stated if the nurse responsible for Resident #1 was not available CMA A was expected to find another nurse to assess Resident #1. The DON also stated the nurse was expected to complete incident/ accident report, pain assessment, and a nurses note. She also stated the CMA or LVN E was expected to notify DON or ADON when there is a fall or a resident found on the floor. She stated she was not aware of Resident #1 was found on the floor. The DON stated there was not incident report, pain assessment, nurses note or any documentation in the electronic medical record about Resident #1 found on the floor. In an interview on 05/30/2024 at 2:15 PM, the ADON stated she reviewed Resident #1's electronic medical record and there was not any documentation of any type of incident on 05/03/2024 of Resident #1 being found on the floor. She stated CMA A or any CMA was not qualified to do range of motion, skin assessments, neuro checks or determine if a resident was injured. She stated if CMA A reported to a nurse and the nurse was busy it was expected for any staff including CMA A to find another nurse in the facility to assess Resident #1. She also stated Resident #1 was required to be assessed by a nurse before anyone transferred her from the floor to the wheelchair. She stated CMA A was not qualified to determine if it was safe to transfer Resident #1. The ADON stated she was not working on 05/03/2024, however, there were 2 nurse supervisors, DON, and MDS nurse in the facility. She stated CMA A did not follow the facilities fall protocol. In an interview on 05/30/2024 at 3:10 PM, the Administrator stated he was not notified of Resident #1 being found on the floor. He stated his expectations was for a nurse to assess a resident anytime a resident is found on the floor or any type of incident. The Administrator stated CMA A was not qualified to do range of motion, complete pain assessments or incident /accident reports. He stated if a nurse was busy, he expected the staff to find another nurse in the facility and have them to assess a resident or give care to a resident in an emergency. He stated this was not the correct (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676089 If continuation sheet Page 25 of 31 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 05/31/2024 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 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few protocol for this facility for a non- licensed nurse to do any type of nursing treatment on a resident. CMA A was given written disciplinary action. In an interview on 05/30/2024 at 3:40 PM, the Physician stated he was not notified of any incident in May of Resident #1 except when the Administrator did contact him about her fracture and being in the hospital. He stated he was not notified of Resident #1 being found on the floor. The Physician stated the Administrator, DON, ADON or a nurse always contacted him if there was a fall or any change of condition with a resident. He stated the Administrator would always contact him about any incident with a resident when he was notified. He also stated the nurses always notified him but the Administrator would contact him also. The Physician stated Resident #1 could have broken any bone without falling. He stated she does have brittle bones and it would be difficult for him to determine if Resident #1 may have broken a bone without knowing if she actually fell or laid on the floor. Record review of Inservice on Falls, dated 04/14/2024 reflected the following was discussed during the in-service: 1. When a resident falls all non- licensed nursing staff will notify the nurse. Once the Nurse assess the resident such as: vitals, does a resident have an injury, change of condition then the nurse will make decision of whether to transfer resident back to bed or wheelchair or does the resident require to be transferred to the hospital. All unwitnessed falls must have neuros. 2. Nurse will notify the Administrator, Director of Nurses, Responsible Party, and the Physician. Incident report completed by the nurse and sign/ date the report. (the in-service was signed by CMA A). Record review of Facility Policy on Falls- Clinical Protocol, revised March 2018, reflected the nurse shall assess and document the following: a. Vital signs. b. Recent injury, especially fracture or head injury. c. Musculoskeletal function, observing for change in normal range of motion, weight bearing, etc. d. Change in condition or level of consciousness. e. Neurological status. f. Pain g. Frequency and number of falls since last physician visit. h. Precipitating factors, details on how falls occurred. i. All current medications, especially those associated with dizziness or lethargy. j. All active diagnoses. The Administrator was notified on 05/30/2024 at 6:19 PM,that an Immediate Jeopardy had been (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676089 If continuation sheet Page 26 of 31 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 05/31/2024 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 0684 identified due to the above failures and an IJ template was provided. Level of Harm - Immediate jeopardy to resident health or safety The following POR was accepted on 05/31/2024 at 1:44 PM: Residents Affected - Few On 05/30/2024 a facility self-reportable investigation was initiated at the facility. Date 05/31/2024 05/30/2024 the surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an Immediate Jeopardy to resident health and safety. The notification of Immediate Jeopardy states as follows: The facility failed to ensure care was provided by qualified persons in accordance with professional standards of practice. Interventions: 1. On 5/30/24 safe surveys with all oriented residents were completed by administrative staff to ensure no other falls/incidents have not been reported or addressed. 2. On 5/30/24 pain assessments on all residents were started by nursing administration to ensure all pain needs were addressed with interventions in place. 3. On 5/30/24 disciplinary action was begun for CMA A and CNA B by the DON/ Administrator for practicing outside their practice by moving and assessing resident #1, and not reporting incident to the Administrator or DON. 4. Nurse in question no longer works at facility. 5. Administrator/DON initiated an in-service for all staff on 5/30/24 on incident/accident policy, incident communication between staff and administration, abuse neglect exploitation, assessments post fall/incident to be completed by licensed nurse only, and scope of practice by position. A post-test will be performed with staff over information in-serviced on by administration, and a score of 100% must be achieved. If less than 100%, staff will be reeducated and retest until 100% is achieved. 6. Administrator/DON initiated an in-service for nursing staff on 5/30/24 on physician and family notification of incidents or change in status, neuro protocol for unwitnessed falls or falls with head injury, completing a new fall risk assessment after fall, and assessing residents after a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676089 If continuation sheet Page 27 of 31 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 05/31/2024 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 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few fall/incident by licensed nurse only. A post-test will be performed with staff over information in-serviced on by administration, and a score of 100% must be achieved. If less than 100%, staff will be reeducated and retest until 100% is achieved. 7. Administrator/DON initiated an in-service for CMA A and CNA B a one-on-one in-service about notification of administrator/DON of a fall/incident, and to stay within scope of practice for their position. A post-test will be performed with staff over information in-serviced on by administration, and a score of 100% must be achieved. If less than 100%, staff will be reeducated and retest until 100% is achieved. 8. Administrator and DON were in-serviced on 5/31/24 by Regional Director of Operations on all the policies mentioned above, and to notify regional/corporate staff of ALL falls/incidents and are to notify regional/corporate staff of any discrepancies. Regional/corporate staff will follow-up on each fall/incident in question and direct with appropriate interventions. If staff are unable to attend any of the in-services, they will be required to complete the in-service before starting their assigned shift. Any agency will be in-serviced prior to the beginning of their shift. Any new hires will be in-serviced on hire, prior to working a shift. The Medical Director was made aware of the Immediate Jeopardy 5/30/24 at 9:00 PM and has been involved in developing the Plan of Removal. These conversations are considered part of the QA process. A QAPI meeting was held on 5/30/24 with attendance of Administrator, Director of Nursing, Assistant Director of Nursing, MDS Coordinator, Regional Director of Clinical Services, and Regional Director of Operations. This plan was initially implemented 5/30/24 and will be monitored through completion by corporate and regional staff. Plan of Removal completion date is 5/31/24 by 5:00 PM with continuation of oncoming staff and follow-up. The Surveyor monitored the POR on 05/31/2024 as followed: 1. Review of the facility's safe surveys with all the oriented residents reflected it was completed and conducted by the Director of Nurses on 05/31/2024. The safe surveys revealed any additional falls/ incidents had not been reported. 2. Review of the facility's pain assessments on all residents were completed on 05/31/2024 by the Director of Nurses, LVN I and LVN J. 3. Review of the facility's disciplinary action for CMA A and CNA B for performance and safety. Violated policy performance expectations, inefficient, intentional, careless or any poor / substandard performance of duties, conducting endangering life, safety or health of others and failure to comply with business rules, regulations, and policies/ procedures. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676089 If continuation sheet Page 28 of 31 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 05/31/2024 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 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few 4. Verified LVN E no longer is an employee at the facility. Reviewed LVN E personnel record. LVN E resigned from the facility. LVN E resigned on 05/05/2024. 5. Review of the following in-service conducted on 05/30/2024 for nursing staff and other disciplines: a. Accidents and Incidents- Accidents and incidents should be reported immediately to the nurse on duty. The nurse to intervene immediately. All accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated and reported to the administrator. The nurse supervisor/ charge nurse/or the department or supervisor shall complete a Report of Incident/ Accident form and submit the original to the Director of Nurses within 24 hours of the incident or accident. b. Disciplinary action for all staff involved with communication failure. It is expected for all staff to communicate as a team. Failure to communicate or report a change of condition, a fall, etc. could result in discipline up to termination. If a staff member does not take appropriate action after staff has communicated an issue, please contact the Administrator or Director of Nurses immediately. c. Abuse and Neglect- All residents have the right to be free from any abuse, neglect or exploitation. Staff is expected to report any abuse or neglect to the nurse on duty then immediately to the administrator for immediate intervention. d. Falls - If a resident falls, the nurse must be notified immediately. If your nurse is unavailable, someone will need to send an aide to the other hall so that the nurse from the other unit can come and assess the resident. The Director of Nurses, Assistant Director of Nurses, and MDS nurse are also available to do assessments for falls as well. No one other that the nurse should assess or move the resident. When a resident falls, no matter your title, please let the Administrator, Director of Nurses and Assistance Director of Nurses know so that the fall will be followed up as soon as possible. e. Scope of Practice and Duties- All staff have job duties and are expected to complete them. Any job no completed or doing a job or duties that is beyond your training or scope of practice is not allowed. Discipline will follow. Only nurses can assess a resident and do range of motion. (job duties for all disciplines were reviewed). f. Post Test- reviewed the post tests given to staff after the in-services. There were 32 staff had taken the post test and made 100 on the test. g. Physician and responsible party notification- NP/ Physician must be notified and documented for all incidents including falls and behaviors and document/complete all incidents neuros, and pertinent information. Family, responsible party and/ or resident needs to be notified in the event of a fall or change of condition. h. Neuro checks protocol for unwitnessed falls or falls with head injury. Fall assessment to be completed after each fall and quarterly. Neuro checks must follow any unwitnessed fall or evidence of head trauma. Incident reports are completed fore each fall. Documentation of incidents must be charted in the progress note, and must contain investigation of cause of fall, interventions to prevent further falls, assessment summary including injuries, vital signs, and initiation neuros indicated. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676089 If continuation sheet Page 29 of 31 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 05/31/2024 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 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few i. Filling out Risk Assessment after fall - Everything must be addressed and completed. Must have vital signs included in the report. Must have an intervention. Include all notified example: Director of Nurses, Administrator, Doctor, and Responsible Party. Do progress note from this report. Be sure to sign report under signature. j. Incident communications- Charge nurses will communicate all incidents on shift change with oncoming nurses and on the hall and specify any adverse findings and document appropriately in resident's record and notify all parties such as: responsible party, Physician, Administrator and the Director of Nurses. Inservice one-on-one on 05/31/2024 with CMA A: if a resident falls the nurse must be notified immediately. If your nurse is unavailable, someone will need to send an aide to the other hall so that the nurse from the other unit can come assess the resident. The Director of Nurses, Assistant Director of Nurses and the MDS Nurse are also available to do assessments for falls. No one other than the nurse should assess or move the resident. When a resident falls, no matter your title, please let the Administrator, Director of Nurses and the Assistant Director of Nurses know about the fall. Inservice one-on-one on 05/31/2024 with CNA B: If a resident is found on the floor, a nurse must immediately assess the resident before moving the resident. If one (nurse) is not available one from another hall must be summons. Resident is not to be moved or assessed by a non-nurse. After every fall, please notify the Administrator. The Director of Nurses or the Assistant Director of Nurses will go follow up with nursing to ensure documentation has been completed and the family and physician has been notified. The Administrator and Director of Nurses was in-serviced by the Regional Director of Operations on 05/31/2024 on the following topics: a. Incident/ Accident policy b. Incident communication between staff and Administrator c. Abuse, neglect, and exploitation d. Assessment post fall e. Incident report to be completed by licensed nurse only. f. Scope of practice by position g. Physician and family notification of residents or change in status. h. Neuro protocol for unwitnessed falls or falls with head injuries. i. Completing a new fall risk assessment after a fall. j. All staff will be required to complete all required in-services prior to the beginning of their first shift. Review of the QAPI Meeting Report dated 05/30/2024 reflected the following were in attendance: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676089 If continuation sheet Page 30 of 31 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 05/31/2024 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 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Administrator, Director of Nurses, Assistant Director of Nurses, MDS Coordinator, Regional Director of Clinical Services, and Regional Director of Operations. The Medical Director was made aware of the Immediate Jeopardy on 05/30/2024 at 9:00 PM and was involved with the Plan of Removal. Observation on 05/30/2024 at 5:45 PM- 6:05 PM the ADON and the DON was conducting in-services and the post test before the 6:00 PM - 6:00 AM staff could give care to the residents. This was ongoing on 05/30/2024. In an interview on 05/31/2024 at 2:10 PM, Laundry Aide K stated she had been in-service on Incident/ Accidents- if she saw a resident fall, she was to find a nurse immediately. She stated she was not to touch the resident and report what happened to the nurse. She stated she was in-service on abuse and neglect. She stated abuse was if a staff yelled at a resident or hit a resident. She stated neglect was when a staff refused to give resident a drink of water or food. She stated she did take a test and made 100 on it. She also stated only the nurse was allowed to touch the resident until she assessed the resident. In an interview on 05/31/2024 at 2:15 PM, LVN F stated he had been in-service on incident and accidents policy/protocol. He stated only nurses was allowed to assess a resident after a fall, or if found on floor and/or any type of incident/accident. LVN F stated the nurse completed neuro checks, completed head to toe skin assessment, vital signs and if there was an injury the physician was called immediately and follow the orders from the Physician. He stated he was also not to move the resident if there was an injury until EMR transported the resident to hospital. LVN F stated the family, DON and Administrator was also to be notified immediately if there were any change of condition with a resident. He stated if the nurse assigned to the resident who was found on the floor and that nurse was busy it was expected any nurse can assess the resident. He stated he was inserviced on abuse and neglect. LVN F stated abuse was when a staff or another resident slapped a resident, cussed a resident and neglect was when staff refused to give resident their scheduled medication or refused to assist resident to the bathroom. He stated job duties was discussed and to follow your job duties. He stated only nurses are allowed to complete the nursing documentation of incident/ accident reports, nurses notes, skin assessments, etc. He stated if it is a new fall it is required to complete a new fall risk assessment. LVN F also stated after any incident / accident the physician, family and the DON/ Administrator was to be contacted immediately. He stated he did take a posttest and made 100 on the test. In an interview on 05/31/2024 at 2:26 PM, Dietary Aide/CNA L stated she worked as a CNA and some days in the kitchen. She stated she was in-service on 5/31/2024 on the following: 1. Abuse and neglect 2. Not to move a resident or touch a resident until nurse assess the resident if they had fallen. The nu[TRUNCATED] FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676089 If continuation sheet Page 31 of 31