Inspection·November 2, 2023

F 0656 Level of Harm - Minimal harm or potential for actual harm intellectual disabilities, ileostomy (an opening in the abdomen for draining stool from the small intestines), and difficulty walking. Resident #6's Quarterly MDS dated [DATE], Section C 0500 BIMS Score Summary revealed the resident scored 03 out of 15 indicating severe cognitive impairment. Residents Affected - Some Record review of Resident #6's Comprehensive Care Plan reviewed and revised 09/19/2023 revealed objectives lacking ability to be evaluated or quantified were: [resident] will not exhibit signs of dehydration ., [resident] will have interventions in place to reduce possible exposure to COVID-19. , [resident] will not experience any social isolation and will have no impact on interpersonal relationships . as evidenced by verbalization or documentation of contentment with routine, facility will ensure [resident] receives referrals and assessments to identify his needs related to the diagnosis of IDD. Identified resources will be coordinated and incorporated into his daily care to allow him to achieve optimal functioning, [resident] will remain clean, dry, and odor free and no occurrence of skin break down will occur., ostomy care will be managed appropriately: (e.g., appropriate amount type, color, odor of drainage; stoma the correct size, pink, free of breakdown, or infection; surrounding skin free of breakdown, rash, or infection, stool will not leak.) ., [resident] will be able to use the environment with little or no difficulty . , [resident] will maintain a sense of dignity by being clean, dry, odor free and well groomed ., [resident] will have interventions in place to reduce the risk of major injuries with falls ., [resident] will have interventions to prevent skin breakdown., [resident] will verbalize & show signs of relief of pain ., Staff will anticipate and meet all needs that [resident] is not able to communicate effectively ., [resident] will be able to function in current environment . His needs will be anticipated and met by staff, [resident] will be informed of his right to complete advanced directives to direct his medical care and make his values and treatment goals known. His stated desires will be honored, Will have interventions in place to maintain a stable weight., [resident] will actively engage in music activity . Further review of the comprehensive care plan revealed no evidence of timeframes for evaluating the effectiveness of the planned interventions in the areas of PASRR positive status and advanced care planning. Resident #19 Record review of Resident #19's electronic face sheet revealed a [AGE] year-old male admitted to the facility on [DATE] with medical diagnoses of Parkinson's disease, dementia, and dysphasia (difficulty speaking). Resident #19's Annual MDS dated [DATE], Section C 0500 BIMS Score Summary revealed the resident scored 01 out of 15 indicating severe cognitive impairment. Record review of Resident #19's Comprehensive Care Plan reviewed and revised 09/13/2023 revealed objectives lacking ability to be evaluated or quantified were: maintain airway and oxygen exchange as evidenced by O2 SATS and Respiratory Rate WNL, [resident] will not exhibit signs of dehydration . , [resident's] use of medication will result in maintenance or improvement in his functional status as evidenced by: less sadness, crying, greater participation in social and leisure activities, [resident's] use of medication will result in improvement in his functional status as evidenced by fewer behavioral episodes, [resident] will verbalize feelings underlying difficulty concentrating, [resident] will have interventions in place to reduce possible exposure to COVID-19 ., [resident] will return to his/her usual pattern of behavior, [resident] will not harm self or others secondary to hallucinations ., [resident] will not experience any social isolation and will have no impact on interpersonal relationships . as evidenced by verbalization or documentation of contentment with routine ., (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675279 If continuation sheet Page 2 of 13 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 675279 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Haven Health and Rehabilitation Center 300 S Jackson St Breckenridge, TX 76424 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 - Some Resident will have better control of his behaviors with the help of coping skills and or/new medication management, Minimize risk for hypoglycemia/hyperglycemia ., Staff will anticipate and meet all needs that [resident] is not able to communicate effectively ., [resident] will not exhibit signs of isolation, such as, dull affect, withdrawn, or inattention to self-care, [resident's] use of medication (Nuplazid) will result in maintenance in his functional status AEB reduced paranoid behaviors and stable cognitive status ., [resident] will achieve the highest level of functioning .,[resident] will increase active joint range of motion in BLE & BUE. AROM up to 7 days per week. To maintain extensive assist with dressing and transfers, [resident] will transfer self with extensive assistance ., [Resident] will be informed of his right to complete advanced directives to direct his medical care and make his values and treatment goals known. [Resident's] stated desires will be honored ., [resident] will express an improved mood or behaviors ., He will engage in activities of his interest and begin to develop social relationships at facility, intervention in place to keep a stable weight ., [resident] will have socialization and stimuli thru daily care routine and actively engage in one on one activity, [resident] will remain clean, dry, and odor free and no occurrence of skin break down ., [resident] will have interventions to prevent skin breakdown ., [resident] will verbalize relief of pain ., [resident] will maintain sense of dignity by being clean, dry, odor free and well groomed ., [resident] will have interventions in place to prevent major injuries with falls. Further review of the comprehensive care plan revealed no evidence of timeframes for evaluating effectiveness of the planned interventions in the areas of psychotropic drug use, mood distress, behaviors, depression, inability to perform ADL's, advanced care planning, and participation in activities. Resident #30 Record review of Resident #30's electronic face sheet revealed an [AGE] year-old female, admitted to the facility on [DATE] with medical diagnoses of dementia, asthma, difficulty communicating, and diabetes type 2. Resident #30's Quarterly MDS dated [DATE], Section C 0500 BIMS Score Summary revealed the resident scored 01 out of 15 indicating severe cognitive impairment. Record review of Resident #30's Comprehensive Care Plan reviewed and revised 08/24/2023 revealed objectives lacking ability to be evaluated or quantified were: Resident will be informed of her right to complete advanced directives to direct her medical care and make her values and treatment goals known. Residents stated desires will be honored, [resident] will not exhibit any further decline in her mood or her signs of depression. She will be able to make decisions based on her wants and desires ., [resident] will have interventions in place to minimize distress d/t cognitive impairment ., Staff will anticipate and meet all needs that [resident] is not able to communicate effectively ., [resident] will maintain a sense of dignity by being clean, dry, odor free and well groomed ., [resident] will remain clean, dry and odor free and no occurrence of skin break down will occur ., [resident] will have interventions in place to reduce the risk of major injuries with falls ., [resident] will have interventions to prevent skin breakdown ., Minimize risk for hypoglycemia/hyperglycemia (low or high blood sugar) ., [resident] will verbalize relief of pain ., [resident] will not exhibit signs of dehydration ., will maintain nutritional status as evidenced by no significant weight change . Will receive appropriate diet as ordered by physician, [resident] will actively engage in bingo ., [resident] will not experience any social isolation and will have no impact on interpersonal relationships . as evidenced by verbalization or documentation of contentment with routine, [resident] will have interventions in place to reduce possible exposure to COVID-19 ., [resident] will be capable of performing personal hygiene with limited assist from staff, [resident] will maintain joint range of motion in BLE & BUE. AROM up to 7 days a week. To maintain extensive assist with transfers and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675279 If continuation sheet Page 3 of 13 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 675279 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Haven Health and Rehabilitation Center 300 S Jackson St Breckenridge, TX 76424 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 - Some dressing, Resident will achieve the highest level of functioning. Further review of the comprehensive care plan revealed no evidence of timeframes for evaluating effectiveness of the planned interventions in the areas of advanced care planning, inability to perform ADL's, and participating in activities. During an interview on 11/02/2023 at 12:50 PM, the ADON/MDS Coordinator stated she was responsible for creating the baseline and comprehensive nursing care plans. The ADON stated the SW was responsible for addressing the social services problems identified on the comprehensive care plans. She stated the effect on a resident when a goal was not met or was not measurable would depend on what the problem was. The ADON stated an unmeasurable goal could lead to a resident experiencing a physical or emotional decline, harm, or loss of function. The ADON explained training for her position included learning on the job during her 15 + years working at the facility, computer-based training, and training meetings with the corporate case mix director. During an interview on 11/02/23 at 1:09 PM, the SW stated her expectations on care plans was guidance for measurable progress by a certain goal date. The SW stated the care plan and measurable goals were the basis for evaluation on whether to change, discontinue, or continue with the current plan. The SW stated this was her first position in a long-term care facility. She explained her previous work experience included IDD and ICF where she was responsible for all aspects of care planning. The SW stated the effect a goal without a means to measure effectiveness for residents was not knowing if a goal was met or if a resident was improving. She stated if there was nothing to measure against it was difficult to determine the effectiveness of interventions. During an interview on 11/02/23 at 1:20 PM, the Admin stated her expectation of care plan goals was for the statement to be measurable in order to know if goal had been achieved. She stated goals were the guidelines to evaluate if a resident did not improve or declined. The Admin stated her expectations for developing care plan goals was for the goals to align with current guidelines and standards of care. Review of facility policy titled Care Plan Process, Person-Centered Care revision date May 5, 2023, revealed The facility will develop and implement a baseline and comprehensive care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. Procedures, item #3. Revealed Following RAI Guidelines develop and implement a comprehensive person-centered care plan that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675279 If continuation sheet Page 4 of 13 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 675279 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Haven Health and Rehabilitation Center 300 S Jackson St Breckenridge, TX 76424 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for 1 of 1 kitchen's reviewed for food service safety. The facility failed to properly label food items in the refrigerators. The facility failed to separate spoiled food from other food items in the refrigerators. The facility failed to seal items to protect them from freezer burn in freezers. The facility failed to discard expired food items in the dry food storage areas. The facility failed to wash dishes at a safe temperature in a low temperature setting dishwashing machine. The facility staff failed to practice good hand hygiene while preparing and serving food. These failures placed residents at risk of food borne illnesses that ate from the facility kitchen. Findings included: During an observation and interview on 10/31/23 at 10:10 AM revealed: Refrigerator #2 1 package of meat in a deep-dish metal pan that had no label to identify the food item. The DM said it was stew meat for tomorrow (11/01/23). 3 bags containing 16 heads of lettuce that had brown and/or black spots on them. The DM said they came in like that, but the vendor would not take them back without seeing them again. Freezer #11 box of popsicles with frozen water on and inside the box. The DM said they needed to be thrown away and they were the Activities Department. Freezer #2 1 box of puff pastries that was not sealed and exposed to air. The DM said the packaging should have been closed as well as the box. Dry Food Storage 1-5gal tub of pinto beans with dates 3/21/23-9/21/23. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675279 If continuation sheet Page 5 of 13 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 675279 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Haven Health and Rehabilitation Center 300 S Jackson St Breckenridge, TX 76424 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 1-5gal tub of rice with the dates of 4/11/23-10/11/23. Level of Harm - Minimal harm or potential for actual harm 1-5gal tub of cornmeal with dates of 9/15/22-9/15/23. The DM said the first date was when the items were put in the tubs and the second date was when they should have been thrown out. The DM said the beans, rice and cornmeal should have already been thrown out. Residents Affected - Some During an observation on 10/31/23 at 11:03 AM, of the preparation of mixed moist and pureed meal, the DC was observed to not wash her hands prior to putting on gloves, and when removing her gloves not washing her hands. Then while wearing gloves she would adjust her facemask and her clothing then go back to mixing the altered food items. The DC went outside of the kitchen to the steam table in the dining room several times then back into the kitchen wearing the same gloves, having touched the doorknobs and would again begin mixing the altered food items. The DA was observed to not wash his hands and wore the same gloves, going in and out of the kitchen to the steam table and back touching the doorknob with his gloved hands; then coming back into the kitchen and preparing residents' drinks wearing the same gloves having never removed his gloves or washed his hands. During an observation and interview on 10/31/23 at 11:35 AM the DC utilized the dishwasher to clean the blender during the altered meal food items. The dishwasher came up to 120 degrees F after running the machine 3 times. She said when the dishwasher wasn't in use for a while, it needed to be ran a few times before it would come to temp. The machine had a sticker on it that reflected to wash/rinse at 120 degrees Fahrenheit. Review of the dishwasher temp log revealed steady morning temperatures of 110F. The DA said the wash temp was 110 F and the rinse temp was 120F. Review with DA the paper log for the month of October 2023 reflected to wash/rinse at 120 degrees F and sticker on the dishwasher reflected to wash/rinse at 120 degrees F. Later the DM verified that the paper log had 110 degrees F written routinely but the paper log and dishwasher both clearly identified to wash/rinse at 120 degrees F. The DM said the sanitation company told her it was a low temp dishwasher, and it was ok to run at a lower temperature. The DM said she had an email from the sanitation company that stated the dishwasher could be ran at a lower temperature. During an observation on 10/31/23 at 11:51 AM, while awaiting meal service the DA was observed with his gloved hands inside his pants pockets. Then as meal service began, he did not remove his gloves, wash his hands and put on new gloves. The DC was observed to change her gloves just prior to the meal service due to hands being very moist inside her gloves. She rubbed her hands off on her uniform top and then she put new gloves on without washing her hands and began meal service. During an interview on 10/31/23 12:09 PM, the DM said they were supposed to wash hands and change gloves between each task. She said they were supposed to wear gloves at all times when handling the food. She said they were supposed to wash their hands between removing gloves and putting new gloves on. The DM said they were not supposed to touch their clothing, adjust their hair or facemasks and keep the same gloves on then handle the food. The DC verified that she had not washed her hands when she changed her gloves and that she had adjusted her mask, hair and clothing while wearing the same gloves and went back to preparing food items. During an exit interview on 11/02/23 at 2:30 PM with all facility management, the DM could not provide an email from the sanitation company. Record review of facility policy labeled Nutrition Policies and Procedures Safe Food Handling revised 6/20/23. Hand Hygiene/Hand Washing. Hand hygiene is the most important component for preventing the spread of infection. Proper hand washing technique will be used when hand washing is indicated. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675279 If continuation sheet Page 6 of 13 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 675279 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Haven Health and Rehabilitation Center 300 S Jackson St Breckenridge, TX 76424 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 Employees keep their hands and exposed portions of arms clean. Wash hands: When hands are visibly soiled. Before starting work. Before putting on gloves, when changing into a fresh pair of gloves, and immediately after removing gloves. Before handling or eating food . After contact with soiled or contaminated articles, such ass, dirty dishes. After contact with an object or source where there is a concentration of microorganisms, such as, mucous membranes, non-intact skin, body fluids or wounds . Antimicrobial gels cannot be used in place of proper hand washing techniques in a food service setting. (This refers to in the kitchen and food preparation but not to passing of trays.) . Check expiration dates and use-by dates to assure the dates are within acceptable parameters . Refuse contaminated food and return to the vendor for credit. If the food cannot be returned immediately, store it away from other food and supplies to prevent contamination .Food safety in Receiving and Storage. Place food that is repackaged in a leak-proof, pest-proof, non-absorbent, sanitary container with a tight-fitting lid. Label both the container and its lid with the common name of the contents, the date it was transferred to the new container, and the discard date. It is recommended that food stored in bins (e.g., flour or sugar) be removed from its original packaging . Refrigerated condiments and salad dressings are properly covered, labeled, and clearly marked to indicate a use by date two months from the date opened. Food acquisition, storage and distribution will comply with accepted food handling practices. Proper food handling is essential in preventing foodborne illness. Employees wash their hands, and patients or residents are given the opportunity and necessary equipment to wash their hands prior to handling or consuming food. Follow all local, State, and Federal Regulations when handling food. Food/Beverages Prepared and Swerved by Facility Staff for Patients or Residents: All facility staff (culinary, nursing, therapy, activities, etc.) involved in the preparation and service of food adheres to safe food handling techniques. Plates are handled by the edge or bottom; cups by the handles or bottom; and utensils by the handles. All foods are stored, prepared and served at temperatures that prevent bacterial growth. Hot foods are maintained at 135 F or higher and cold foods are maintained at 40 F or below at point of service. At point of delivery, hot foods and cold foods should be palatable and consumed within 2 hours or discarded . Refrigerated Time/Temp Control for Safety (TCS) leftover foods are properly covered, labeled and dated and marked with a use by date TCS leftovers are discarded after 3 days unless otherwise indicated. Items that cannot be used within 3 days may be placed in the freezer . Food is served with clean, sanitized utensils. There is no bare hand contact . All foods removed from the original packaging are stored in a closed container or tightly wrapped package and labeled with the common name of the item and the date it was opened. Review of FDA Food Code 2022 Chapter 3 Food Subsection 3-302 Preventing food and ingredient contamination revealed: (A) FOOD shall be protected from cross contamination by: (1) Except as specified in (1)(d) below or when combined as ingredients, separating raw animal FOODS during storage, preparation, holding, and display from: (a) Raw READY-TO-EAT FOOD including other raw animal FOOD such as FISH for sushi or MOLLUSCAN SHELLFISH, or other raw READY-TO-EAT FOOD such as fruits and vegetables,P (b) Cooked READY-TO-EAT FOOD, P and (c) Fruits and vegetables before they are washed; P (d) Frozen, commercially processed and packaged raw animal FOOD may be stored or displayed with or above frozen, commercially processed and packaged, ready-to-eat food. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675279 If continuation sheet Page 7 of 13 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 675279 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Haven Health and Rehabilitation Center 300 S Jackson St Breckenridge, TX 76424 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 (2) Except when combined as ingredients, separating types of raw animal FOODS from each other such as beef, FISH, lamb, pork, and POULTRY during storage, preparation, holding, and display by: (a) Using separate EQUIPMENT for each type, P or (b) Arranging each type of FOOD in EQUIPMENT so that cross contamination of one type with another is prevented, P and (c) Preparing each type of FOOD at different times or in separate areas; P (3) Cleaning equipment and utensils as specified under ¶ 4-602.11(A) and sanitizing as specified under § 4-703.11; (4) Except as specified under Subparagraph 3-501.15(B)(2) and in ¶ (B) of this section, storing the food in packages, covered containers, or wrappings; (5) Cleaning hermetically sealed containers of food of visible soil before opening; (6) Protecting food containers that are received packaged together in a case or overwrap from cuts when the case or overwrap is opened; (7) Storing damaged, spoiled, or recalled food being held in the food establishment as specified under § 6-404.11; and (8) Separating fruits and vegetables, before they are washed as specified under § 3-302.15 from READY-TO-EAT FOOD. Review of FDS Food Code 2022 Chapter 3 Food Subsection 3-602 Labeling revealed: (A) FOOD PACKAGED in a FOOD ESTABLISHMENT, shall be labeled as specified in LAW, including 21 CFR 101 - Food labeling, and 9 CFR 317 Labeling, marking devices, and containers. (B) Label information shall include: (1) The common name of the FOOD, or absent a common name, an adequately descriptive identity statement; (2) If made from two or more ingredients, a list of ingredients and sub-ingredients in descending order of predominance by weight, including a declaration of artificial colors, artificial flavors and chemical preservatives, if contained in the FOOD; (3) An accurate declaration of the net quantity of contents; (4) The name and place of business of the manufacturer, [NAME], or distributor; and (5) The name of the FOOD source for each MAJOR FOOD ALLERGEN contained in the FOOD unless the FOOD source is already part of the common or usual name of the respective ingredient. Pf (6) Except as exempted in the Federal Food, Drug, and Cosmetic Act § 403(q)(3) - (5), (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675279 If continuation sheet Page 8 of 13 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 675279 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Haven Health and Rehabilitation Center 300 S Jackson St Breckenridge, TX 76424 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 nutrition labeling as specified in 21 CFR 101 - Food Labeling and 9 CFR 317 Subpart B Nutrition Labeling. Level of Harm - Minimal harm or potential for actual harm Review of FDA Food Code 2022 Annex 3 revealed: Time/temperature control for safety refrigerated foods must be consumed, sold or discarded by the expiration date. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675279 If continuation sheet Page 9 of 13 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 675279 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Haven Health and Rehabilitation Center 300 S Jackson St Breckenridge, TX 76424 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to establish and maintain an Infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infection for 2 of 5 residents (Resident #30 and Resident #21) reviewed for infection control, in that: Residents Affected - Some The facility failed to remove COVID-19 negative Resident #30 and Resident #21 away from COVID-19 positive Resident #4 and Resident #19 to the prevent spread of infection. The facility failed to COVID-19 test Resident #30 after a confirmed exposure to COVID-19 positive Resident #4 within 2 days per facility policy. This deficient practice could place residents at-risk for infection due to improper care practices. The findings included: Review of Resident #30's electronic face sheet revealed an [AGE] year-old female admitted to facility on 05/19/2023 with diagnoses to include: dementia, asthma, and pneumonia. Further review revealed no diagnosis of COVID-19. Review of Resident #30's Quarterly MDS, dated [DATE], revealed Section C: Cognitive Patterns: BIMS score 11 (indicating mild cognitive impairment). Review of Resident #30's Comprehensive Care Plan, revised 09/05/2023, revealed: Problem: is at risk for possible exposure to COVID-19 & prefers to not social distance or wear a face covering. Res declines COVID vaccine, educated on risks expressed understanding. Goal: will have interventions in place to reduce possible exposure to COVID-19 over the next 90 days. Approach: is encouraged to wear a mask when out of room and encourage social distancing. Encourage hand hygiene. COVID-19 testing per policy. Staff to DON/DOFF PPE per policy. Review of Resident #30's MAR, dated October 2023 and November 2023, revealed no evidence of COVID-19 testing from 10/30/23-11/01/23. Review of Resident #21's electronic face sheet revealed an [AGE] year-old male admitted to facility on 07/24/2020 with diagnoses to include: anxiety, high blood pressure, and heart disease. Further review revealed no diagnosis of COVID-19. Review of Resident #21's Annual MDS, dated [DATE], revealed Section C: Cognitive Patterns: BIMS score not performed. Review of Resident #21's Comprehensive Care Plan, revised 09/19/2023, revealed: Problem: is at risk for possible exposure to COVID-19 & prefers to not social distance or wear face covering. Goal: will have interventions in place to reduce possible exposure to COVID-19 over the next 90 days. Approach: is encouraged to wear a mask when out of room and encourage social distancing. Encourage hand hygiene. COVID-19 testing per policy. Staff to DON/DOFF PPE per policy. Res family request res eat & have activities with multiple other residents & roommate, educated family on COVID-19 risks & states (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675279 If continuation sheet Page 10 of 13 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 675279 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Haven Health and Rehabilitation Center 300 S Jackson St Breckenridge, TX 76424 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 understanding. Level of Harm - Minimal harm or potential for actual harm Review of Resident #21's MAR, dated October 2023, revealed COVID-19 test performed on 10/31/2023 with a negative result. Residents Affected - Some Review of Resident #4's electronic face sheet revealed a [AGE] year-old female admitted to facility on 09/16/2019 with diagnoses to include: dementia, high blood pressure, and heart failure. Review of Resident #4's Quarterly MDS, dated [DATE], revealed Section C: Cognitive Patterns: BIMS score 03 (indicating severe cognitive impairment). Review of Resident #4's Comprehensive Care Plan, revised 10/30/2023, revealed: Problem: Resident with COVID - 19 Test Positive with Symptoms. Goal: Maintain airway and oxygen exchange as evidenced by oxygen saturation and Respiratory Rate within normal limits. Approach: Observe for respiratory distress. Observe for signs and symptoms of pneumonia. Observe and document presence of sputum, color, viscosity, odor, amount. Observe for signs and symptoms of dehydration. Encourage and record fluid intake. Observe for signs and symptoms of pain. Medications as ordered (Lageviro). Labs/XRay as ordered. Oxygen at 2LPM/NC PRN. Vital Signs, O2 SAT. Turn and Reposition. Encourage Cough and Deep Breathing Exercise. Oral Care. Maintain an environment conducive to rest and sleep/raise upper body for sleep. Notify provider if symptoms worsen. Review of Resident #4's MAR, dated October 2023 revealed COVID-19 test performed on 10/30/2023 with a positive result. Review of Resident # 19's electronic face sheet revealed a [AGE] year-old male admitted to facility on 02/28/2023 with diagnoses to include: dementia, diabetes, and COVID-19. Review of Resident #19's Annual MDS, dated [DATE], revealed Section C: Cognitive Patterns: BIMS score 01 (indicating severe cognitive impairment). Review of Resident #19's Comprehensive Care Plan, revised 10/31/2023, revealed: Problem: Resident with COVID - 19 Test Positive with Symptoms. Goal: Maintain airway and oxygen exchange as evidenced by oxygen saturation and Respiratory Rate within normal limits. Approach: Observe for respiratory distress. Observe for signs and symptoms of pneumonia. Observe and document presence of sputum, color, viscosity, odor, amount. Observe for signs and symptoms of dehydration. Encourage and record fluid intake. Observe for signs and symptoms of pain. Medications as ordered (Lageviro). Labs/XRay as ordered. Oxygen at 2LPM/NC PRN. Vital Signs, O2 SAT. Turn and Reposition. Encourage Cough and Deep Breathing Exercise. Oral Care. Maintain an environment conducive to rest and sleep/raise upper body for sleep. Notify provider if symptoms worsen. Review of Resident #19's MAR, dated October 2023 revealed COVID-19 test performed on 10/31/2023 with a positive result. During an interview on 10/31/23 at 10:29 AM, the Administrator stated the facility had 3 residents who tested positive for COVID-19. She stated a CNA tested positive for COVID-19 on 10/26/23. She stated the CNA tested at home and had not been in the facility since 10/23/23. She stated all residents were tested on [DATE] and 10/27/23 with only Resident #15 testing positive. She stated Resident #15 was already in a private room, so he was left in place and placed on transmission-based precautions. She stated all staff began wearing a mask and provided source control. She stated in-services were (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675279 If continuation sheet Page 11 of 13 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 675279 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Haven Health and Rehabilitation Center 300 S Jackson St Breckenridge, TX 76424 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some provided regarding infection control. She stated Resident #4 had signs and symptoms of COVID-19 and was tested on [DATE] with a positive result and Resident #19 had signs and symptoms of COVID-19 and was tested on [DATE] with a positive result. She stated Resident #30 who was Resident #4's roommate and Resident #21 who was Resident #19's roommate were both tested with negative results. She stated the COVID-19 positive residents were not isolated from the COVID-19 negative roommates. She stated the facility just isolated all 4 residents to their rooms since the residents had already been exposed. During an observation on 10/31/23 at 12:00 PM, revealed Resident #30 and Resident #4 were in the same room with a privacy curtain drawn between them and Resident #21 and Resident #19 were in the same room with a privacy curtain drawn between them. Review of the facility COVID-19 testing log revealed: Resident #4 was tested on [DATE] with a positive result; Resident #19 was tested on [DATE] with positive result' and Resident #21 was tested on [DATE] with negative result. Further review revealed no evidence of Resident #30 being tested after exposure was confirmed by Resident #4 testing positive on 10/30/23. During an interview on 11/02/23 at 10:24 AM, the DON stated she did not separate Resident #30 from Resident #4 or Resident #21 from Resident #19 because they had already been exposed. She stated she was trying to minimize spreading COVID-19 across the facility. She stated privacy curtains were drawn between the residents to prevent the spread of infection and new PPE was changed in between each resident's care. She stated she was instructed by corporate not to separate the residents. She stated Resident # 30 was not tested because she had no COVID-19 symptoms. She stated per policy the facility was only supposed to test if resident was symptomatic. During an interview on 11/02/23 at 10:40 AM, the IP stated Resident #30 should have been tested and she thought it had been done. She stated all at risk or exposed residents should have been tested within 2 days of a confirmed or suspected exposure. During an interview on 11/02/23 at 11:00 AM, the DON stated after review of the facility policy, Resident #30 should have been tested. She stated after review of the facility policy she could not find a definite answer on separating the COVID-19 positive residents from the COVID-19 negative residents. She stated that since she was unclear, she would separate the residents now. Record review of the facility policy, titled Infection Prevention and Control Policies and Procedures, complete revision 05/12/2023, revealed SUBJECT: CORONAVIRUS DISEASE (COVID-19): POLICY: In the event of a suspected or actual case of SARS-CoV-2/COVID-19, the Facility provides notification to the Clinical Services Director (CSD) and Regional [NAME] President (RVP) and initiates involvement of federal, state, and local health agencies for direction regarding current recommended strategies for prevention of spread of the disease and treatment methods. PROCEDURES: .6. Facility will test those residents identified by root cause analysis and contact tracing if they were a high-risk exposure to the positive individual. Testing will be completed via Point of Care Antigen test and/or PCR test. The test will be performed within 2 days of the positive individual .14. The facility will place residents who test positive for COVID-19 in transmission-based precautions until criteria is met to discontinue transmission-based precautions. The facility will implement the Coronavirus Disease 2019 Pandemic Prevention and Response Plan if multiple residents are identified with COVI D-19 infection. The facility may open a hall/unit to cohort like infections to a designate area of the facility to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675279 If continuation sheet Page 12 of 13 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 675279 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Haven Health and Rehabilitation Center 300 S Jackson St Breckenridge, TX 76424 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 reduce the spread of infection. Level of Harm - Minimal harm or potential for actual harm Review of Centers for Disease Control and Prevention accessed on 11/15/2023 at https://www.cdc.gov/coronavirus/2019-ncov/your-health/isolation.html revealed If you have COVID-19, you can spread the virus to others. There are precautions you can take to prevent spreading it to others: isolation, masking, and avoiding contact with people who are at high risk of getting very sick. Isolation is used to separate people with confirmed or suspected COVID-19 from those without COVID-19. Residents Affected - Some Review of Centers for Disease Control and Prevention accessed on 11/15/2023 at https://www.cdc.gov/coronavirus/2019-ncov/your-health/if-you-were-exposed.html revealed If you develop symptoms: isolate immediately, get tested FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675279 If continuation sheet Page 13 of 13