Inspection·September 27, 2023

F 0755 Level of Harm - Minimal harm or potential for actual harm posted on the medication room refrigerator for September 2023 indicated, instructions to check the medication refrigerator and freezer at least once each day and log temperatures for the refrigerator and freezer daily. The log indicated no temperatures were recorded for the freezer on 09/08/23, 09/09/23, 9/22/23, 09/23/23, 09/24/23 and 09/26/23. The log indicated no temperatures were recorded for the refrigerator on 09/08/23, 09/09/23, 09/22/23, 09/23/23, 09/24/23 and 09/26/23. Residents Affected - Few During an interview on 09/26/2023 at 2:15 PM LVN C stated that the insulin for Resident #27 was given at night before bedtime. LVN C said sge did not give the nighttime insulin, so she did not check it for expiration . She stated multi-use vials of insulin were to be dated when opened and they were usually only good for 28 days. She stated she had received training on multi use vials use by dates. She stated the risk could be ineffective medication. She stated the temperature of the refrigerator and freezer should be logged at least once each day and recorded. During an interview on 09/26/2023 at 3:20 PM the DON stated the nurses were responsible for monitoring the medication refrigerator, removing expired medications, and dating all multiuse vials when opened. She stated the nurses had training and they had started in-servicing on expired medications and logging the temperature of the refrigerator. She stated it was her responsibility to provide oversight. She stated the risk could be ineffective medication. During an interview on 09/26/2023 at 4:30 PM the Administrator stated the DON and ADON were responsible for medication storage and removing expired medications for destruction. She stated she was not sure how long multiuse vials were good for but if a resident were to receive expired medications it could not work or make them sick. Record review of a manufacturer for Lantus Insulin expiration dates indicated, Lantus Insulin discard 28 days after opening. Record Review of policy for Storage of Medications dated 2018 Pharm script Indicated, . II. Temperature 1. All medications are maintained within the temperature ranges . c. Refrigerated: 36-46 degrees [Fahrenheit] with a thermometer to allow temperature monitoring. d. Frozen: In the freezer at -13 to 14 degrees [Fahrenheit] 4. Medications requiring refrigeration are kept in a refrigerator at temperatures between 36 and 46 degrees [Fahrenheit] with a thermometer monitoring . 6. The facility should maintain a temperature log in the storage area to record temperatures at least once a day or in accordance with facility policy. 7. The facility should check the Refrigerator or Freezer in which vaccines are stored at least two times a day, per CDC guidelines 14. Outdated, contaminated, discontinued, or deteriorated medications and those in containers that (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675624 If continuation sheet Page 2 of 5 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 675624 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Whitehall Rehab & Nursing 1116 E Loop 304 Crockett, TX 75835 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 0755 are cracked, soiled or without secure closures are immediately Level of Harm - Minimal harm or potential for actual harm removed from stock, disposed of according to procedures for medication disposal and reordered from the pharmacy, if a current order exists, . Residents Affected - Few III. Expiration Dating (beyond use dating) 3. Certain medications or package types, such as IV solutions, multi dose injectable vials require an open date and expires as indicated by manufacturer use by date. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675624 If continuation sheet Page 3 of 5 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 675624 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Whitehall Rehab & Nursing 1116 E Loop 304 Crockett, TX 75835 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 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 infections for 2 of 5 staff (CNA A, and CNA B) and 1 of 4 residents (Resident #27) reviewed for infection control in that: Residents Affected - Few CNA A and CNA B did not wash or sanitize their hands in between glove changes or change gloves when going from dirty to clean while performing incontinent care to Resident #27. These failures could place residents at risk of exposure to communicable diseases and infections. Findings included: Record review of an admission Record dated 9/25/2023 for Resident #27 indicated he admitted to the facility on [DATE] and was [AGE] years old with diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side (paralyzed on left side following a stroke), chronic diastolic congestive heart failure (inability of the heart to pump efficiently), type 2 diabetes, and hypertension. Record review of an Annual MDS Assessment for Resident #27 dated 6/23/2023 indicated he had moderate impairment in thinking with a BIMS score of 11. He required extensive assistance with bed mobility, transfers, dressing, toilet use and personal hygiene with one to two-person assist. He was always incontinent of bladder/bowel. Record review of a care plan dated 8/2/2022 for Resident #27 indicated he was incontinent of bowel/bladder related to advancing dementia with post CVA which is a stroke, with hemiplegia (paralysis on one side of the body) and weakness with interventions for incontinent care to check frequently for wetness and soiling and change as needed. During an observation on 9/25/2023 at 9:44 AM, revealed CNA A and CNA B were in the room to provide care to Resident #27. Both aides placed gloves on their hands without washing their hands and opened Resident #27's brief and pulled it down between his legs. CNA A removed wipes from the container and wiped Resident #27's penile area using multiple wipes and placed them in the trash. Resident #27 was rolled to his left side assisted by CNA B and CNA A removed wipes from the container and wiped his rectal area front to back and placed the wipes in the trash. CNA A removed the brief and placed it in the trash. CNA A removed her gloves and placed them in the trash and reached in her pocket and placed gloves on both hands without washing or sanitizing them. CNA A removed the drawsheet and placed it in a plastic bag. CNA A placed a clean drawsheet underneath Resident #27's buttocks and a brief. Resident #27 was rolled onto his back by CNA A and CNA B and the brief was secured. Both CNA A and CNA B removed their gloves and placed them in the trash. Both went to the restroom and washed their hands. Both applied gloves that they removed from their pockets and repositioned Resident #27 in bed. During an interview on 9/25/2023 at 10:46 AM, CNA B said she had been employed at the facility for 11 years and worked the day shift. She said she was not prepared while incontinent care was provided to Resident #27. She said she was not expecting to perform incontinent care because the hospice aide had just left, and she thought they were just going to change Resident #27's shirt after he had (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675624 If continuation sheet Page 4 of 5 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 675624 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Whitehall Rehab & Nursing 1116 E Loop 304 Crockett, TX 75835 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 eaten breakfast. She said she should have washed her hands before starting the care, in between times when going from dirty to clean and after the care was completed. She said she was not prepared to be observed by the Surveyor. She said the ADON, and DON had checked her off on incontinent care. She said the gloves should have been in a bag and not kept in her pocket. She said residents could be at risk for infection if staff did not wash or sanitize their hands during care. Residents Affected - Few Record review of an annual CNA skills/competency checklist dated 6/15/2023 for CNA B indicated she demonstrated competency with incontinent care for a male resident and hand washing. During an interview on 9/25/2023 at 11:45 Am, CNA A said she had been employed at the facility for 5 years. She said she worked full time, but she was scheduled off today and they called her in to work. She said the incontinent care provided to Resident #27, she should have washed her hands before she started care and made sure gloves were in a plastic bag instead of her pocket. She said she should have washed her hands after incontinent care and between glove changes. She said she normally did all the things but was nervous today. She said she had been checked on her skills with incontinent care by the DON. She said residents could be at risk of infection if staff did not wash or sanitize their hands during care. Record review of an annual CNA skills/competency checklist dated 7/5/2023 for CNA A indicated she demonstrated competency with incontinent care for a male resident and hand washing. During an interview on 9/27/2023 at 9:15 AM, the DON said she had been employed at the facility since 2017. She said she was aware of the incontinent care provided to Resident #27 because both CNAs told her about it. She said the ADON, herself and RN C were responsible for conducting competency skills checks with the staff. She said she had a plan in place and would start with a rotating schedule to check off the nursing staff on hand hygiene and incontinent care. She said staff were supposed to have all supplies in plastic bags and not have gloves stored in their pockets. She said staff should perform hand hygiene before providing care to the residents, when going from dirty to clean, between glove changes and at the end of care provided. She said residents could be at risk of transmission of certain infections or skin issues. Record review of a facility policy titled Hand Hygiene dated 11/12/2017 indicated, .Staff involved in direct resident contact will perform proper hand hygiene procedures to prevent spread of infection to other personnel, residents, and visitors. 1. Hand hygiene is a general term that applied to either handwashing or the use of an antiseptic hand rub, also known as alcohol-based hand rub (ABHR). 6 b. The use of gloves does not replace hand washing. Wash hands after removing gloves FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675624 If continuation sheet Page 5 of 5