Health inspection·August 25, 2023

F 0550 B and continued to feed Resident #5 while standing. Level of Harm - Minimal harm or potential for actual harm Interview on 08/24/2023 at 1:39 p.m. with LVN A who fed Resident #5 revealed she did not know she was supposed to sit to feed a residents and that she was upset to think that she might have affected Resident #5's dignity by looking down on her. Residents Affected - Few Interview on 08/24/2023 at 1:50 p.m. with LVN B who brought a chair for LVN A to sit in when she fed Resident #5 revealed when she gave LVN A the chair she stated, the look LVN A gave me told me to not go any further with it. LVN B stated it was important to maintain self- esteem and respect a resident's dignity, and staff were trained to sit when they fed residents. Interview on 08/25/2023 at 11:01 a.m. with the DON revealed LVN A should have sat down in a chair to maintain eye level with Resident #5 when she fed her. The DON stated staff were trained to respect the residents who needed assistance with feeding and to sit next to them, not stand. The DON stated that standing and looking down on a resident could make them feel worthless. Review of the facility policy and procedure titled Promoting/Maintaining Resident Dignity During Mealtimes dated 01/13/2023 revealed It is the practice of this facility to treat each resident with respect and dignity and care for each resident in a manner an in an environment that maintains or enhances his or her quality of life, recognizing each resident's individuality and protecting the rights of each resident .all staff will be seated .while feeding a resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675095 If continuation sheet Page 2 of 11 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 675095 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hallettsville Nursing and Rehabilitation 825 W Fairwinds Hallettsville, TX 77964 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 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record reviews, the facility failed to ensure the assessment accurately reflected the resident's status for 1 of 8 residents (Resident #12) reviewed for MDS assessments, in that: Residents Affected - Few Resident #12's MDS assessment inaccurately reflected he had a stage 3 pressure ulcer. This deficient practice could affect residents who require assessments and could result in missed or inaccurate care. The findings were: Review of Resident #12's electronic face sheet dated 08/24/2023 revealed he was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of cerebral infarction (refers to death of tissue, and a brain lesion in which a cluster of brain cells die when they don't get enough oxygen), peripheral vascular disease (a systemic disorder of narrowed peripheral blood vessels resulting from a buildup of plaque. Characterized by reduced circulation of blood to body part, other than the brain or heart), and chronic osteomyelitis (long-lasting or recurrent infection of the bone and its surrounding tissues). Review of Resident #12's quarterly MDS assessment, with an ARD of 07/31/2023, revealed he had 1 Stage 3 pressure ulcer. Further review revealed the resident had scored a 12/15 on his BIMS which indicated he was moderately cognitively impaired. Review of Resident #12's comprehensive care plan, with a revised date of 06/08/23, revealed, has a stage 3 pressure ulcer of the left lateral leg r/t prosthetic use .Interventions .administer treatments as ordered. Review of Resident #12's Wound Evaluation & Management Summary, dated 06/26/2023, revealed, stage 3 pressure wound to left, distal, lateral knee (Resolved on 06/26/2023). Review of the facility Weekly Pressure Injury Treatment Report, dated 06/29/2023, revealed, Resident #12 .stage 3 left lateral leg .resolved. Observation on 08/24/2023 at 1:30 p.m. of Resident #12 revealed the resident was sitting in his room with his bilateral prosthetic lower legs in place. Interview on 08/24/2023 at 1:35 p.m. with Resident #12, when asked by the surveyor if the resident had a wound still on his left leg, the resident stated no, it healed out a while ago. Interview on 08/25/2023 at 10:00 a.m. with LVN A, LVN A stated Resident #12's pressure sore should have been resolved on the MDS and the comprehensive care plan. LVN A did not know how she missed that it was healed. LVN A stated the MDS triggers areas on the care plan. Interview on 08/25/2023 at 11:01 a.m. with the DON revealed Resident #12's pressure sore healed and she did not know why it was still reflected. The DON stated it was important for both the MDS and the care plan to be accurate to communicate the type of care required for the resident. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675095 If continuation sheet Page 3 of 11 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 675095 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hallettsville Nursing and Rehabilitation 825 W Fairwinds Hallettsville, TX 77964 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 0641 Level of Harm - Minimal harm or potential for actual harm Review of the Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.17.1, October 2019 revealed Section M0300C: Stage 3 Pressure Ulcers revealed Enter the number of pressure ulcers that are currently present and whose deepest anatomical stage is Stage 3. Further review revealed The RAI process increases clinical relevancy, data accuracy, clarity, and notably adds more to the resident voice in the assessment process. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675095 If continuation sheet Page 4 of 11 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 675095 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hallettsville Nursing and Rehabilitation 825 W Fairwinds Hallettsville, TX 77964 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that include measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 8 residents (Resident #72) reviewed for comprehensive care plans, in that: Resident #72's wishes for DNR status was not reflected in her comprehensive care plan. This deficient practice could result in residents wishes for advanced directives to not be honored and could result in residents who do not want CPR getting CPR performed on them. The findings were: Review of Resident #72's electronic face sheet dated [DATE] revealed she was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of hypothyroidism (condition where the thyroid gland doesn't make enough thyroid hormone affecting the body's metabolism), cerebral infarction (refers to death of tissue, and a brain lesion in which a cluster of brain cells die when they don't get enough blood), and acute pain (pain that begins suddenly and does not last long). Review of Resident #72's quarterly MDS assessment, with an ARD of [DATE], revealed the resident had scored a 12/15 on her BIMS which indicated the residentwas moderately cognitively impaired. Further review revealed the resident could understand others and be understood. Review of Resident #72's comprehensive care plan, with a revised date of [DATE], revealed, Problem .is a full code .Interventions .if resident has a cardiac arrest, initiate CPR. Review of Resident #72's Active Orders As of: [DATE] revealed DNR .Order Date [DATE] .Start Date XXX[DATE]. Further review revealed the DNR order for Resident #72 was entered into the facilty's electronic medical records system by LVN C. Review of Resident #72's Out-of-Hospital DNR paperwork, dated [DATE], revealed it was completed and signed. Observation on [DATE] at 2:00 p.m. of Resident #72 in the resident's room revealed the resient was sitting in a wheelchair reading a book. Interview on [DATE] at 2:05 p.m. with Resident #72, the resident stated she was [AGE] years old and that she did not want anything extra done to her and wished to have DNR status. Interview on [DATE] at 10:00 a.m. with LVN A revealed she was one of the staff who completed the residents' care plans and she also did the MDS assessments. LVN A stated Resident #72's DNR status should have been reflected in the resident's care plan and that she did not know why it was not. LVN A stated it was important because Resident #72 did not want CPR and that needed to be communicated. Interview on [DATE] at 10:09 a.m. with LVN C revealed she put Resident #72's DNR order into the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675095 If continuation sheet Page 5 of 11 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 675095 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hallettsville Nursing and Rehabilitation 825 W Fairwinds Hallettsville, TX 77964 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few electronic medical record. LVN C stated that when a resident returned from the hospital, the comprehensive care plan needed to be revised to reflect the resident's changes and current preferences. LVN C stated she did not know how the care plan update was missed, but it could result in a resident getting CPR when they did not want to have those measures taken. Interview on [DATE] at 11:01 a.m. with the DON, the DON stated she did not know how Resident #72's DNR order was missed and not placed into a revised comprehensive care plan for the resident. The DON stated that it was important for staff to know what the resident's preferences are for advanced directives and care requirements. Review of the facility policy and procedure titled Comprehensive Care Plans dated [DATE] revealed The comprehensive care plan will be developed within 7 days after the completion of the comprehensive MDS assessment .Other factors identified by the interdisciplinary team, or in accordance with resident's preferences, will also be addressed in the plan of care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675095 If continuation sheet Page 6 of 11 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 675095 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hallettsville Nursing and Rehabilitation 825 W Fairwinds Hallettsville, TX 77964 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record reviews, the facility failed to review and revise the comprehensive care plan by the multidisciplinary team after each assessment, including both the comprehensive and quarterly review assessments for 1 of 8 residents (Resident #12) reviewed for comprehensive care plans, in that: Resident #12's comprehensive care plan was not revised to reflect he no longer had a Stage III pressure sore. This deficient practice could affect residents with comprehensive care plans and could result in missed or unnecessary care. The findings were: Review of Resident #12's electronic face sheet dated 08/24/2023 revealed he was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of cerebral infarction (refers to death of tissue, and a brain lesion in which a cluster of brain cells die when they don't get enough oxygen), peripheral vascular disease (a systemic disorder of narrowed peripheral blood vessels resulting from a buildup of plaque. Characterized by reduced circulation of blood to body part, other than the brain or heart), and chronic osteomyelitis (long-lasting or recurrent infection of the bone and its surrounding tissues). Review of Resident #12's quarterly MDS assessment, with an ARD of 07/31/2023, revealed the resident had 1 Stage 3 pressure ulcer. Further review revealed the resident had a score of 12/15 on his BIMS which indicated he was moderately cognitively impaired. Review of Resident #12's comprehensive care plan with a revised date of 06/08/23 revealed has a stage 3 pressure ulcer of the left lateral leg r/t prosthetic use .Interventions .administer treatments as ordered. Review of Resident #12's Wound Evaluation & Management Summary dated 06/26/2023 revealed stage 3 pressure wound to left, distal, lateral knee (Resolved on 06/26/2023). Review of the facility Weekly Pressure Injury Treatment Report dated 06/29/2023 revealed Resident #12 .stage 3 left lateral leg .resolved. Observation on 08/24/2023 at 1:30 p.m. of Resident #12 revealed he was sitting in his room with his bilateral prosthetic lower legs in place. Interview on 08/24/2023 at 1:35 p.m. with Resident #12, when asked by the surveyor if he had a wound still on his left leg, he stated no, it healed out a while ago. Interview on 08/25/2023 at 10:00 a.m. with LVN A, LVN A stated Resident #12's pressure sore should have been resolved on the comprehensive care plan. LVN A stated she did not know how she missed that it was healed. LVN A stated the MDS triggers areas on the care plan. Interview on 08/25/2023 at 11:01 a.m. with the DON revealed Resident #12's pressure sore healed and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675095 If continuation sheet Page 7 of 11 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 675095 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hallettsville Nursing and Rehabilitation 825 W Fairwinds Hallettsville, TX 77964 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 0657 Level of Harm - Minimal harm or potential for actual harm she did not know why it was still reflected on his care plan. The DON stated it was important for both the MDS and the care plan to be accurate to communicate the type of care required for the resident. Review of the facility policy and procedure titled Comprehensive Care Plans dated 10/24/2023 revealed The comprehensive care plan will be reviewed after each comprehensive and quarterly MDS assessment. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675095 If continuation sheet Page 8 of 11 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 675095 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hallettsville Nursing and Rehabilitation 825 W Fairwinds Hallettsville, TX 77964 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen, in that: Residents Affected - Many 1. There were storage containers of food in the reach in cooler that were not properly sealed. 2. [NAME] E wore jewelry on both hands while engaged in food preparation in the kitchen. 3. [NAME] E portioned food onto plates in an unsanitary manner during the lunch meal service on 08/24/2023. These failures could place residents who received meals and/or snacks from the kitchen at risk for food borne illness. The findings included: 1. Observation on 08/22/2023 at 10:20 a.m. in the reach in cooler revealed a clear, plastic 2-quart container filled with sliced American cheese. One corner of the lid on the container was not sealed, revealing a gap between the container and the lid and exposing the cheese to potential contamination. Further observation in this reach-in cooler revealed a 2-quart container filled with sliced deli ham, a 2-quart container with chicken gravy, and a 2-quart container with chopped beef. All of the containers had lids that were sealed on three sides but had one side that was not sealed onto the container, revealing a gap between the lid and container and exposing the contents of the containers to the ambient air in the cooler and potential contamination by pathogens and bacteria. Interview on 08/22/2023 at 10:22 a.m. with the DM revealed all four plastic containers of food in the reach-in cooler were not tightly sealed. The DM stated she did not know why the containers were not properly sealed and that dietary employees were trained to label, date and completely seal all food stored in the coolers. The DM further stated that the container of chopped beef had to be discarded because, I can't get the lid to stay down. The DM stated it was important to ensure food was completely sealed prior to storage to ensure the food was not subject to cross contamination and also to prevent spoilage which could lead to food borne illness. The DM stated both she and the consultant dietitian trained dietary employees on various food service and sanitation topics monthly. Food service sanitation was also a topic included in the facility's online training program. 2. Observation on 08/24/2023 at 10:32 a.m. in the kitchen revealed [NAME] E was preparing food for the lunch meal. [NAME] E had a wedding band set that included a diamond ring on the ring finger of both her left and right hands. Without donning gloves, [NAME] E placed a pan of ham inside the oven, dropped French fries in a pan of oil on the stove, and poured rice in a pan of water on the stove and stirred it periodically. 3. Observation on 08/24/2023 at 11:53 a.m. revealed [NAME] E portioned food from the steam table onto plates while assembling trays for the lunch meal. [NAME] E did not wear gloves. [NAME] E grasped the plates in a manner whereby the lip of the plate was between her thumb and forefinger and her thumb pressed down on the well of the plate where she placed the food. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675095 If continuation sheet Page 9 of 11 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 675095 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hallettsville Nursing and Rehabilitation 825 W Fairwinds Hallettsville, TX 77964 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Interview on 08/24/2023 at 11:56 a.m. with the Consultant Dietitian revealed he observed [NAME] E's jewelry on her hands and her bare thumb on the plates but had been focusing on ensuring the serving sizes were correct. The Consultant Dietitian further stated [NAME] E should not have been wearing more than a solid wedding band on one hand and [NAME] E should have worn gloves while portioning food onto the plates to prevent potential cross contamination of the food. Residents Affected - Many Interview on 08/24/2023 at 12:01 p.m. with the DM revealed she noted [NAME] E was wearing jewelry on her hands and should not have been, and also that [NAME] E was plating food without gloves. The DM stated she trained all her dietary staff they could not wear jewelry on their hands because the food could be contaminated by bacteria and cause food borne illness. The DM further stated [NAME] E always wore gloves and this was not common for her. Interview on 08/24/2023 at 12:01 p.m. with [NAME] E revealed she knew she could not wear bracelets or a watch while preparing food in the kitchen but she was never told she could not wear her rings in the kitchen. [NAME] E further stated she wore gloves on and off during her shift in the kitchen that day and had simply forgot to put them on prior to plating food for the lunch service. Record review of facility policy 03.003 Food Storage revised 06/01/2019 revealed, 2. Refrigerators. d. Date, label and tightly seal all refrigerated foods using clean, nonabsorbent, covered containers that are approved for food storage. Record review of facility policy 04.001 Employee Sanitation dated 10/01/2018 revealed, 3.f. No jewelry can be worn on the arms and hands while preparing food, except for a single plan ring such as a wedding band. 4. Other practices. b. Cups, glasses and bowls must be handled so that fingers or thumbs do not contact inside surfaces or lip-contact outer surfaces. 6. Use of gloves. d. Change gloves: i. Between each food preparation task. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2017, U.S. Department of H&HS, 3-305.11, revealed: Preventing Contamination from the Premises - Food Storage. (A) Except as specified in (B) and (C) of this section, FOOD shall be protected from contamination by storing the FOOD: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination; and (3) At least 15 cm (6 inches) above the floor. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2017, U.S. Department of H&HS, 2-303.11, revealed, Jewelry Prohibition. Except for a plain ring such as a wedding band, while preparing food, food employees may not wear jewelry including medical information jewelry on their arms and hands. Review of the Food Code, U.S. Public Health Service, U.S. FDA, 2017, U.S. Department of H&HS, 3-301.11, revealed, Preventing Contamination from hands. (B) Except when washing fruits and vegetables as specified under §3-302.15 or as specified in (D) and (E) of this section, FOOD EMPLOYEES may not contact exposed, READY-TO-EAT FOOD with their bare hands and shall use suitable UTENSILS such as deli tissue, spatulas, tongs, single-use gloves, or dispensing EQUIPMENT. Review of the Food Code, U.S. Public Health Service, U.S. FDA, 2017, U.S. Department of H&HS, 4-904.11, revealed: Kitchenware and Tableware. (A) SINGLE-SERVICE and SINGLE-USE ARTICLES and cleaned and SANITIZED UTENSILS shall be handled, displayed, and dispensed so that contamination of FOOD-and lip-contact surfaces is prevented. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675095 If continuation sheet Page 10 of 11 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 675095 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hallettsville Nursing and Rehabilitation 825 W Fairwinds Hallettsville, TX 77964 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections, for 2 residents of 7 residents (Residents #34 and #183) observed for infection control, in that: Residents Affected - Few LVN D failed to sanitize the blood pressure cuff between Residents #34 and #183 to prevent cross contamination. This deficient practice had the potential to affect residents in the facility by placing them at risk of contracting, spreading and/or exposing them to pathogens that could lead to the spread of communicable diseases. The findings included: In an observation on 08/23/2023 at 9:17 a.m. LVN D was observed to take Resident #183's blood pressure prior to administering her anti-hypertensive medication and did not sanitize the blood pressure cuff. In an observation on 08/23/2023 at 9:22 a.m. LVN D was observed to take Resident #34's blood pressure prior to administering her anti-hypertensive medication after Resident #183's and did not sanitize the blood pressure cuff. In an interview on 08/23/2023 at 9:22 a.m. with LVN D he stated he was not aware of any of the residents to whom she had administered medications that morning who might have a communicable illness. LVN D stated it was possible that any of the residents might be asymptomatic for a contagious illness such as COVID as it could take several days before symptoms appeared. LVN D stated he knew he was supposed to sanitize the pressure cuff or other equipment between residents to prevent cross contamination. In an interview on 08/25/2023 a.m. with the DON, she stated the facility policy was for multiuse equipment to be sanitized after each use to ensure cross contamination did not occur. The DON stated her expectation was that equipment be cleaned after each resident to prevent the spread of illness. Review of the facility policy and procedure titled Infection Prevention and Control Program dated 05/13/23, revealed Standard Precautions .All staff shall assume that all residents are potentially infected with an organism that could be transmitted during the course of providing resident care services .all reusable items and equipment shall be cleaned in accordance with our current procedures. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675095 If continuation sheet Page 11 of 11