Health inspection·November 11, 2022

F 0558 Level of Harm - Minimal harm or potential for actual harm Interview with the resident on 11/08/2022 at 1:40 PM resident # 61 stated, I don't know why they leave my call light so far from me; what if I need to call for help. Record review of the facility's policy titled Call Lights: Accessibility, Implemented 10/13/2022, revealed, Staff will ensure the call light is within reach of resident and secured as needed. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675226 If continuation sheet Page 2 of 7 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 675226 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Stevens Nursing and Rehabilitation Center of Halle 106 Kahn St 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 Residents Affected - Some 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 prepare and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for food service safety, in that: 1. A one-gallon jar of dill pickle relish in the walk-in cooler was undated. 2. A 5 lb container of tuna in the walk-in cooler was undated. 3. A 5 lb container of chicken salad in the walk-in cooler was undated. 4. A 2 x 3 foot vent unit in the food storage unit was covered with dust and dirt particles 5. Two vents measuring 2 x 3 feet in the main dining room next to the kitchen entry door were covered with dust and dirt particles. These deficient practices could place residents at risk of consuming spoiled food and maintained an unsafe food sanitation environment. Findings included: Observation in the kitchen on 11/08/22 from 8:40 a.m. through 9:15 a.m. revealed a one- gallon jar of dill pickle relish, a 5 lb container of tuna, and a 5 lb container of chicken salad in the walk-in cooler which were undated; the 2 x3 foot wall vent in the kitchen food storage unit was covered with dust and dirt particles; the two wall vents measuring 2x3 feet in the main ding room next to the kitchen entry door were covered with dust and dirt particles. Interviews in the kitchen on 11/8/22 from 8:40 a.m. through 9:15 a.m. revealed the DM stated the one gallon jar of dill pickle relish, the 5 lb container of tuna, and the 5 lb container of chicken salad in the walk-in cooler should have been dated. She stated that containers that do not have a use-by date do not allow staff to determine if the food is still fresh to be served and that the containers would be immediately removed. The DM stated that the 2 x 3 foot wall vent in the food storage room was dirty and could allow dust to come into the food storage room. She stated that the two 2 x 3 foot wall vents in the dining room next to the kitchen door were dirty and could allow dust to come into the dining room. She stated that she would notify the MS immediately to clean the vents. Interview in the kitchen on 11/8/22 from 12:00 p.m. through 12:15 p.m. with the MS and the Regional MS. They stated that the 2 x3 foot wall vent in the kitchen food storage room was dirty and needed to be cleaned which was already done; they stated that the two 2 x 3 foot wall vents in the dining room next to the kitchen door were also dirty and needed to be cleaned and this cleaning process was underway. They stated that the kitchen vent cleaning is the responsibility of the maintenance dept. and the facility used the TELS electronic work order system (an electronic computer system that be used to reqest work repairs ) to notify the maintenance dept of needed repairs. Record review of Nutrition and Food Service Policies and Procedures Manual approved in 2018 stated in section 3-4 that all refrigerated foods are to be dated and labeled; it stated in section 4-5 that non-food-contact services of equipment are to be cleaned as necessary to keep them free of dust (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675226 If continuation sheet Page 3 of 7 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 675226 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Stevens Nursing and Rehabilitation Center of Halle 106 Kahn St 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 and dirt particles. Level of Harm - Minimal harm or potential for actual harm Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2017, U.S. Department of H&HS, revealed 3-501.17 Ready-to-Eat/Time Temperature Control for Safety Food, Date Marking. (A) Except as specified in (E) -(G) of this section, refrigerated, ready-to-eat, time/temperature control for safety food prepared held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature of 5ºC (41ºF) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. Residents Affected - Some Review of the Food Code, U.S. Public Health Service, U.S. FDA, 2017, U.S. Department of H&HS, revealed 3-305.1, Food Storage, (A) Food shall be protected from contamination by storing the food: (1) in a clean, dry location; (2) Where it is not exposited to splash, dust, or other contamination. Record review of the facility's undated work order request policy stated that staff can submit work order requests for needed repairs. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675226 If continuation sheet Page 4 of 7 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 675226 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Stevens Nursing and Rehabilitation Center of Halle 106 Kahn St 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 0944 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program. Based on interviews and record reviews, the facility failed to ensure Quality Assurance and Performance Improvement (QAPI) training that outlines and informs staff of the elements and goals of the facility's QAPI program as set forth at § 483.75. for 18 of 23 staff (Administrator, DON, ADON B, SW, DM, AD, LVN C, LVN D, LVN E, LVN F, CNA G, CNA H, CNA I, CNA J, CNA K, Receptionist L, DA M and CNA M) reviewed for training, in that: The facility failed to ensure that the Administrator, DON, ADON B, SW, DM, AD, LVN C, LVN D, LVN E, LVN F, CNA G, CNA H, CNA I, CNA J, CNA K, Receptionist L, DA M and CNA M had completed QAPI training This deficient practice could place residents at risk for injury or improper care due to lack of training. The findings were: 1. Record review of Staff Roster, undated, revealed the Administrator was hired on 04/25/2019 Record review of the Administrator's training record, undated, revealed no QAPI training. 2. Record review of Staff Roster, undated, revealed the DON was hired on 03/14/1975 Record review of the DON's training record, undated, revealed no QAPI training. 3. Record review of Staff Roster, undated, revealed ADON B was hired on 06/24/1988 Record review staff training record, undated, revealed no QAPI training. 4. Record review of Staff Roster, undated, revealed the SW was hired on 07/26/2021 Record review of SW's training record, undated, revealed no QAPI training. 5. Record review of Staff Roster, undated, revealed DM was hired on 07/22/2008 Record review of DM's training record, undated, revealed no QAPI training. 6. Record review of Staff Roster, undated, revealed the AD was hired on 05/30/1989 Record review of AD's training record, undated, revealed no QAPI training. 7. Record review of Staff Roster, undated, revealed LVN C was hired on 01/29/2019 Record review of LVN C's training record, undated, revealed no QAPI training. 8. Record review of Staff Roster, undated, LVN D was hired on 11/22/1993 Record review of LVN D's training record, undated, revealed no QAPI training. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675226 If continuation sheet Page 5 of 7 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 675226 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Stevens Nursing and Rehabilitation Center of Halle 106 Kahn St 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 0944 9. Record review of Staff Roster, undated, revealed LVN E was hired on 11/01/2019 Level of Harm - Minimal harm or potential for actual harm Record review of LVN E's training record, undated, revealed no QAPI training. 10. Record review of Staff Roster, undated, revealed LVN F was hired on 11/30/2011 Residents Affected - Some Record review of LVN F's training record, undated, revealed no QAPI training. 11. Record review of Staff Roster, undated, revealed CNA G was hired on 12/29/2017 Record review of CNA G's training record, undated, revealed no QAPI training. 12. Record review of Staff Roster, undated, revealed CNA H was hired on 06/04/2015 Record review of CNA H's training record, undated, revealed no QAPI training. 13. Record review of Staff Roster, undated, revealed CNA I was hired on 10/14/2021 Record review of CNA I's training record, undated, revealed no QAPI training. 14. Record review of Staff Roster, undated, revealed CNA J was hired on 02/22/2012 Record review of CNA J's training record, undated, revealed no QAPI training. 15. Record review of Staff Roster, undated, revealed CNA K was hired on 08/26/2021 Record review of CNA K's training record, undated, revealed no QAPI training. 16. Record review of Staff Roster, undated, revealed Receptionist L was hired on 09/02/2021 Record review of Receptionist L's training record, undated, revealed no QAPI training. 17. Record review of Staff Roster, undated, revealed DA M was hired on 10/15/2021 Record review of DA M's training record, undated, revealed no QAPI training. 18. Record review of Staff Roster, undated, revealed CNA N was hired on 10/14/2021 Record review of CNA N's training record, undated, revealed no QAPI training. During an interview on 11/11/2022 at 2:39 p.m., HR stated she was not aware it was a requirement for staff to complete QAPI training. She also stated their corporate office was responsible for assigning a staff member's required training in the online training website. HR further stated that staff were only able to complete courses that are selected for that specific staff member to complete in the online training website. HR stated the potential for harm to residents was staff not knowing what to do, procedure wise, for abuse. During an interview on 11/11/2022 at 2:39 p.m., the Administrator stated he was not aware QAPI training was required for staff. He also stated that their corporate office was responsible for adding (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675226 If continuation sheet Page 6 of 7 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 675226 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Stevens Nursing and Rehabilitation Center of Halle 106 Kahn St 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 0944 Level of Harm - Minimal harm or potential for actual harm the correct courses for a specific staff member in the online training website. The Administrator was not aware of a potential harm to residents by staff not having completed this training. Per email sent on 11/15/2022 at 7:44 p.m., the Administrator stated the facility did not have a policy for QAPI training. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675226 If continuation sheet Page 7 of 7