Health inspection·December 18, 2025

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of email dated 12/18/25 at 04:40 PM from HSA, an attorney for an out of state Human Services agency reflecting a request for records made by ADM C on 12/18/25, I have attached a screenshot of the summary of findings from the APS investigation that was completed by the agency in 2021. The summary of findings reflected allegations made between Resident #1 and FM A:- Caretaker Maltreatment: NeglectUnsubstantiated - Caretaker Maltreatment: Abuse- Unsubstantiated- Caretaker Maltreatment: Verbal Abuse- Inconclusive- Caretaker Maltreatment: Exploitation- Unsubstantiated In an interview on 12/18/25 at 11:51 AM with SW, she stated that based on what she could see from Resident #1's chart, there was nothing restricting Resident #1 from being pulled from the facility or giving one family member more power or authorization than another. She stated Resident #1 did not have an active POA or guardianship granting anyone control over medical decisions. SW stated that she did not have additional information on the events that occurred on 10/17/25 since she was not the social worker at that time and only recently started 12/10/25. In an interview on 12/18/25 at 12:00 PM with Resident #1 in the company of SW, Resident #1 stated that he recalled FM A had spoken to him about his wishes to leave the facility and to live with her. Resident #1 stated he wanted to be able to leave and to live with his family member FM A. Resident #1 stated that he recalled the last time FM A visited the facility and stated that the facility did not treat her respectfully. Resident #1 stated that the facility told her to leave and it really upset him as he believed she did not give them a reason to be that way and kick her out. Resident #1 acknowledged that another family member FM B had been involved while he was being cared for at the facility, but that it was his wishes that he preferred to discharge with FM A. Resident #1 stated he felt FM A would be able to provide care that met his needs outside of the facility, and stated he did not have any safety concerns with regard to living with FM A. At this time Resident #1 was observed to be oriented to self and place, he recalled the last time he had interaction with FM A, recalled questions related to his family and spoke to SW about his history and service. In an interview on 12/18/25 at 01:52 PM with DON, she stated she was at the facility on 10/17/25 and recalled the event. DON stated that at the time the social worker previously employed notified her that FM A wanted to take Resident #1 out of the facility. She stated while they did not know who FM A was initially, her relationship was verified by Resident #1 who recognized her and FM B when they spoke to him over the phone. The DON stated while she was aware guardianship paperwork was being filed there was not any active enforceable POA or guardianship in place for Resident #1. DON stated that on 10/17/25 ADM D was the one to speak to FM A and was the one who denied the removal of Resident #1. DON stated that she believed the decision was made on 10/17/25 to remove FM A because she was being loud and disruptive when she argued with ADM D about not being allowed to discharge Resident #1, so ADM D along with the police asked her to leave. DON stated that after the incident there was an in-service to staff that FM A was no longer allowed at the facility and that if she were to come that staff should contact the police; this was due to in part by FM B not wanting FM A to have contact with Resident #1. She stated FM A was also not allowed to take Resident #1 on pass. In an interview on 12/18/25 at 02:45 PM with Ombudsman, she stated that she recalled the event on 10/17/25. She stated she was contacted by FM A in early October 2025 about getting guidance to discharge Resident #1 from the facility. Ombudsman stated she had also spoken to the facility and FM B who expressed having concerns with FM A. She stated FM B made allegations against FM A of incidents of mistreatment against Resident #1 dating back to 2020/2021 in in another state. She stated she was presented with a booking detail from out of state with alleged charges (NOT conviction) against FM A on 11/02/2020. She stated on 10/17/25 she was contacted by ADM D for guidance on what to do since FM A was at the facility wanting to proceed with a discharge. ADM D did not feel comfortable (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675095 If continuation sheet Page 2 of 4 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 12/18/2025 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 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few proceeding with the discharge and at the time Ombudsman stated she did advise that if FM A was being disruptive that she could be asked to leave the premises in that moment. Ombudsman stated she did have concerns with the facility not having any POA or guardianship documents and that one family member did not have more authority than another to make decisions due to the lack of legal paperwork. In an interview on 12/18/25 at 03:17 PM with ADM D, he stated he was the administrator filling in on 10/17/25 when the incident occurred with FM A attempting to discharge Resident #1. ADM D stated he contacted Ombudsman to get advice on what he should do since she was there trying to take Resident #1 but at that point FM A had become disruptive by being loud and argumentative in his face. He stated that since FM A was being disruptive at the time the facility was in their right per Ombudsman to ask her (FM A) to leave. ADM D stated initially he did not feel comfortable releasing Resident #1 to FM A due to the appearance of her car. He stated she was using a spare tire, and her bumper was missing and it looked unsafe. He stated the vehicle appearance in addition to her behavior was enough for him to have her removed and not release Resident #1. He stated the facility attorney also stated she did not have valid documents to make the decision to take the resident, but also confirmed the facility at the time did not have a POA or guardianship documents which made the decision difficult to determine if Resident #1 should be released. ADM D stated that after the incident he also did an in-service with staff to advise them that FM A would not be allowed on the property and she could not take Resident #1 out with her or discharge the resident and that this decision was made due to allegations of mistreatment of FM A to Resident #1 made by FM B and the documentation of the alleged charges they had for FM A from 2020. In an interview on 12/18/25 at 04:12 PM with FM A, she stated that on 10/17/25 she arrived at the facility to attempt to take Resident #1 and requested the paperwork that needed to be completed in order to discharge him. FM A stated at this time multiple staff arrived to notify her that she was not able to take Resident #1. She stated they alleged they did not know who she was but that she explained she was family which was confirmed through Resident #1 himself and with FM B since the facility had spoken to him as well. FM A stated that she was informed that she would not be able to discharge Resident #1 and became upset. She stated that she was kicked out of the facility by staff including the Administrator at the time and was told she was no longer allowed on the property and no longer allowed to visit or call the resident as she was deemed a threat to him. She stated this upset her because she was never deemed a threat to Resident #1 before and was able to visit him until she attempted to discharge him which she believed upset the facility and another family member involved. FM A stated that to her knowledge there was no legal documentation that gave any other family member more authority to act on Resident #1's behalf such as a POA or guardianship. She stated she currently still had no access to Resident #1 and that the facility had no reason to keep her from her family member, or prevent his right to discharge. In an interview and record review on 12/18/25 at 05:22 PM with ADM C, the facility current Administrator stated that if a resident voices wanting to discharge it is the process that they would work to do a safe discharge with a resident and get the guidance of the ombudsman as needed. ADM C stated that they would also work with the resident's POA or guardianship if one was available. ADM C stated if the discharge was against the guidance of the facility it was their policy to alert the physician of a discharge AMA, follow the discharge AMA policy, and if there was concern with the resident's safety then to do an APS referral after the discharge. ADM C stated for Resident #1 there was no active POA or guardianship available. She stated she was out of the office on 10/17/25 which is why ADM D was present at the time but she was updated on the events after. She stated at the time the facility was made aware of FM A's history of alleged mistreatment of Resident #1 by FM A and that along with her behavior on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675095 If continuation sheet Page 3 of 4 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 12/18/2025 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 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete 10/17/25 was enough that they did not feel comfortable allowing FM A to discharge the resident. ADM C stated that after the incident an in-service was completed to prevent FM A from returning or allowing her to take Resident #1 and that her picture and name were posted near the front desk to make staff aware. ADM C stated that at the time it was confirmed that FM A was a family member, and this was confirmed by FM B, another family member, and Resident #1 himself recognized her. She stated currently FM A was not allowed on the property because FM B did not want her to talk to Resident #1. ADM C stated right now they have followed FM B's wishes even though they do not have the legal documentation that allows him to solely make those decisions. She stated FM B had made allegations at the time against FM A of alleged abuse/ mistreatment of Resident #1 and presented them with the booking details of alleged misconduct 11/02/20; charges which ADM C also acknowledged were dropped based on her knowledge. ADM C confirmed that prior to FM A attempting to discharge Resident #1 on 10/17/25 there were no notes or allegations of misconduct by FM A notated or alleged by FM B, and it was only after the attempted discharge this was coming out. ADM C also acknowledged that the alleged abuse/neglect investigated out of state by Human Services between Resident #1 and FM A was unsubstantiated based on the report received 12/18/25; something that was not requested or looked into prior to that day. Review of the booking detail (arrest record- out of state) dated 11/02/20 presented by ADM C at this time that had been used to make the decision of determining FM A to be unsafe for Resident #1 included 2 charges of pending allegations and a disclaimer An arrest does not mean that the inmate has been convicted of the crime. The information on this website should not be relied upon for any type of legal action. ADM C stated she was not able to provide anything that was substantiated that would indicate FM A was a threat to Resident #1 or a legal document such as an active POA or guardianship paperwork granting one family member the sole authorized decision maker. Review of the facility undated resident rights policy included as part of the admission packet Rights and Obligations of the Resident reflected: Resident Rights: As a resident of facility, resident is entitled to various rights that facility encourages resident to exercise. A statement of rights is available on the Texas Secretary of State website and is attached hereto including: Rights upon room change, transfer, and discharge. Review of the facility Transfer and Discharge (including AMA) policy dated 03/05/25 reflected:Discharge Against Medical Advice (AMA)- AMA only applies when a resident expresses their wishes to be discharged earlier than outlined in the care plan. These situations do not apply if the facility offers to discharge a resident to a location which does not meet their health and/or safety needs, and the resident agrees. - The resident and family/ legal representative should be informed of the risks involved, the benefits of staying at the facility, and the alternatives to both. Under no circumstances will the facility force, pressure, or intimidate a resident into leaving AMA. - The physician should be notified of the intent AMA discharge and be encouraged to speak with the resident to encourage them to stay at the facility. Documentation of this notification should be entered in the nurses notes by the nursing department. The social services designee should document any discussions held with the resident/ family in the social service progress notes if present. - Notify adult protective services, or other entity as appropriate, if self-neglect is suspected. Document accordingly. Event ID: Facility ID: 675095 If continuation sheet Page 4 of 4