Health inspection·August 16, 2023

F 0578 impaired cognition. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #17's orders, revised 5/31/23, indicated resident's orders include a DNR status. Residents Affected - Some Record review of Resident #17's advanced directives indicated a DNR form dated 5/13/19. Review indicates legal guardian signature in last section of the form is blank. Resident #37 Record review of Resident #37's face sheet, not dated, revealed a [AGE] year-old female, admitted to the facility on [DATE]. Diagnoses included but are not limited to dementia unspecified, anorexia, anxiety, chronic kidney disease (Stage 4). Record review of Resident #37's BIMS score revealed no score due to questions and answers provided in other sections. Record review of Resident #37's orders provided by DON via computer, indicated that resident has a DNR order since day of admission. Record review of Resident #37's advanced directives indicated a DNR form dated 5/31/23. Record showed guardian/agent/proxy or relative signature blank in last section of document. Resident #39 Record review of Resident #39, not dated, revealed an [AGE] year-old male, admitted into the facility on 5/31/23. Diagnoses include but are not limited to pneumonia, unspecified organism, anxiety disorder, anorexia, emphysema (lung condition that causes shortness of breath), hypertensive heart disease with heart failure, and acute and chronic respiratory failure with hypoxia (condition where lungs cannot deliver enough oxygen to the blood). Resident #39's face sheet indicated a DNR status. Record review of Resident #39's MDS, dated [DATE], revealed Resident #39's BIMS score is 6 indicating that resident has a severe cognitive impairment. Record review of Resident #39's advanced directives indicated a DNR form dated 8/8/23. Record review indicated that physician's license number is missing from in PHYSICIAN'S STATEMENT section. Resident #48 Record review of Resident #48, dated 8/15/23, revealed an [AGE] year-old male admitted to the facility on [DATE]. Resident #48's diagnoses included but are not limited to aphasia, type 2 diabetes, dementia in other diseases classified elsewhere, major depressive disorder, and atherosclerotic heart disease of native coronary. Record review of Resident #48's orders, revised 5/31/23, indicated resident has an order for DNR status. Record review of Resident #48's care plan, dated 8/4/23, revealed no goal for resident's advanced directives. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675098 If continuation sheet Page 2 of 17 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 675098 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Farwell Care and Rehabilitation Center 305 Fifth St Farwell, TX 79325 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 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of Resident #48's advanced directives indicated a DNR form dated 8/3/23. Document is was not signed by a physician in the PHYSICIAN STATEMENT section of the document. Record showed guardian/agent/proxy or relative signature and physician statement blank in last section of document. In an interview on 8/15/23 at 10:00 AM, LVN D indicated that the physician, two witnesses or nursing and the admin or the DON are the required signatures for a valid DNR form. LVN D stated has seen a completed DNR. LVN D identified missing legal guardian signature. Negative outcome would be that a full code would have to be performed. In an interview on 8/15/23 at 10:09 AM, ADON stated that a DNR is signed by Physician, resident or POA. The ADON was shown Resident #17's DNR and confirmed that POA signature was missing. The ADON was shown Resident #37's DNR and confirmed it was missing the same signature as Resident #17. The ADON was shown Resident #13 and confirmed that the physician signature is missing. She stated a negative outcome is that it is not a valid DNR and they would have to perform a full code. In an interview dated 8/15/23 at 1:36 PM, the DON stated the DNRs are inaccurate. The DON indicated that families are being called to correct the legal documents and a negative outcome is facility would be performing a full code against the resident's wishes. Record review of the Frequently Asked Questions for DNR authored by Department of Health and Human Services in 2023 indicated that all persons who have signed the DNR form must sign at the bottom of the page to acknowledge that the document has been properly completed. Record review of Operating Policies/Resident Handbook, dated 2/13/17, under heading Advance Directives, (Line 7), states Facility will follow any advance directive executed in accordance with Texas law. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675098 If continuation sheet Page 3 of 17 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 675098 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Farwell Care and Rehabilitation Center 305 Fifth St Farwell, TX 79325 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 1 (Resident #14) of 13 residents reviewed for abuse and neglect. The facility failed to report to the ADM and State Survey Agency a bruise on Resident #14's forehead within 24 hours of discovery of the injury. This failure could place residents at risk of continued and/or unrecognized abuse or neglect. Findings included: Record review of Resident #14's face sheet, dated 08/15/23, revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, Alzheimer's (a progressive disease that destroys memory and other important mental functions), schizoaffective disorder (a mental health condition including schizophrenia and mood disorder symptoms), major depressive disorder (a mental disorder characterized by persistent low mood, low self-esteem, and loss of interest or pleasure in normally enjoyable activities), insomnia, generalized anxiety disorder (inability to control constant worrying), high blood pressure, and delusional disorders (an unshakable belief in something that is untrue). Record review of Resident #14's Quarterly MDS, with a completion date of 05/23/23, revealed no BIMS as the resident is rarely/never understood. The staff assessment revealed Resident #14's cognition was moderately impaired. Section G of the MDS indicated Resident #14 was totally dependent and required assistance by one or two staff members across all ADLs except for eating where she required supervision by one staff member. Record review of Resident #14's care plan, dated 07/25/23, revealed, in part, The resident has an ADL self-care performance deficit r/t: weakness & cognitive impairment. The resident has impaired cognitive function/dementia or impaired thought processes r/t Alzheimer's disease . During an observation on 08/14/23 at 10:15 AM, Resident #14 was sitting in her w/c with her legs extended in front of her. She was asleep under a blanket from her chest down. She had a bruised lump in the center of her forehead. The bruised lump was approximately the size of a 50-cent piece and was greenish and purple in color. During an interview on 08/15/23 at 08:43 AM DON stated she was told the bruise on Resident #14's forehead came from Resident #14 leaning her head forward and hitting it on the table. During an interview on 08/15/23 at 10:14 AM Resident #14's family member stated, I was wondering (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675098 If continuation sheet Page 4 of 17 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 675098 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Farwell Care and Rehabilitation Center 305 Fifth St Farwell, TX 79325 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few about that bruise on her forehead. They [facility staff] said she leaned her head down onto a table. He stated it had been about a week since he first noticed the bruise. He said facility staff are usually really good at communicating with him but this time they did not. He said staff did not tell him anything about the bruise until he asked them about it. He stated, Leaning her head on a table would not cause a bruise like that. He said staff told him they did not witness Resident #14 leaning her head onto the table. Resident #14's family member stated staff told him they figured that was how the bruise happened. He could not remember which staff member told him this information. During an interview on 08/15/23 at 10:18 AM Resident #14's family member stated Resident #14 was occasionally able to answer questions. He stated, She has days. He said he asked Resident #14 about the bruise on her forehead, and she told him someone hit her on the head to wake her up. He stated he did not believe that was what happened. He said Resident #14 did not tell him who hit her on the head to wake her up. During an interview on 08/15/23 at 10:25 AM DON said MA C and RN A are the staff members who told her about the bruise on Resident #14's forehead resulting from Resident #14 leaning her head forward onto the table. During an interview on 08/15/23 at 10:29 AM MA C stated she did tell DON about Resident #14's bruise. She stated she told DON the bruise was a result of Resident #14 leaning her head onto the table. MA C stated she did not see this happen but had seen Resident #14 with her head resting on the table at mealtimes. During an observation and interview on 08/15/23 at 11:22 AM Resident #14 was seated in her w/c at a table in the dining room. She had her arms crossed across her chest. She stated she did not know how she got the bruise on her forehead. During an interview on 08/15/23 at 11:29 AM RN A stated she noticed Resident #14 had the bruise the last time she (RN A) was a work. She said, Somebody said she had laid her head on the table in the dining room. RN A said she did not remember who told her about Resident #14 laying her head on the table in the dining room. RN A said she first saw the bruise on Resident #14's forehead on Friday 08/11/23. She stated this was her first day back on shift as she only works Friday, Saturday, and Sunday. RN A said she noticed the bruise and asked the aides about it and that was when she was told how it happened. During an interview on 08/16/23 at 10:58 AM RN A stated normal procedure upon discovering an injury on a resident was to investigate and see if I could find out what happened. She continued, I would call the family and I would call the doctor and make sure everyone knew. RN A said with Resident #14's bruise she assumed someone had dealt with her bruise because she had it when I got here. During an interview on 08/16/23 at 11:18 AM ADM said the normal policy and procedure with injuries of unknown source was to call it in within 2 hours unless it is documented. He said of Resident #14's forehead bruise, Apparently, she had hit her head on a bedside cart is what I heard. No one saw it happen, she told them. He stated he was not sure why the injury was not reported as per the facility's policy. ADM said the family and the doctor should have been notified a soon as staff noticed the bruise. He said a possible negative outcome of one reporting injuries of unknown source was, You could get in serious trouble and you gotta explain it to the family if it is unknown origin. During an observation and interview on 08/16/23 at 11:25 AM DON said it was normal policy and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675098 If continuation sheet Page 5 of 17 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 675098 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Farwell Care and Rehabilitation Center 305 Fifth St Farwell, TX 79325 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few procedure to investigate an injury of unknown source and if there was a suspicion of abuse then report it. She stated, When I found out about [Resident #14's forehead bruise] I asked the nurse and several staff members, and they stated she leaned her head on the table and that is what caused the bruise so there was no further investigation conducted. She stated she did not remember if any of the staff members asked had witnessed the injury. She stated she did not have written statements from the staff in regard to Resident #14's bruise. DON said the facility Abuse, Neglect, and Exploitation policy instructed staff to just basically if there is any suspicion of abuse to investigate and report if needed. DON stated she did not know why Resident #14's family was not notified of the bruise on her forehead. She searched on her computer and could not find documentation of the family or hospice being notified of the bruise on Resident #14's forehead. DON stated a possible negative outcome of not reporting injuries of unknown source was just further decline in health condition of the resident. During an interview on 08/16/23 at 01:34 PM CNA B stated if she found an injury of unknown source on a resident her response would be to report it immediately to the charge nurse. Record review of facility policy dated 2023 and titled, Compliance with Reporting Allegations of Abuse/Neglect/Exploitation revealed, in part: It is the policy of this facility to report all allegations of abuse/neglect/exploitation or mistreatment including injuries of unknown sources .to the Administrator of the facility and to other appropriate agencies in accordance with current state and federal regulations within prescribed timeframes. Injuries of unknown source: Includes circumstances when both the following conditions are met; i. The source of injury was not observed by any person or could not be explained by the resident. ii. The injury is suspicious because of the extent of the injury, location of the injury, the number of injuries observed at one particular point in time, or the incidence of injuries over time. Record review of facility policy dated 3/2023 and titled, Abuse, Neglect and Exploitation revealed, in part: . C. Training topics will include: . 4. Reporting process for abuse, neglect, exploitation, and misappropriation of resident property, including injuries of unknown sources . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675098 If continuation sheet Page 6 of 17 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 675098 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Farwell Care and Rehabilitation Center 305 Fifth St Farwell, TX 79325 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 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 interviews and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet residents' medical, nursing, and mental and psychosocial needs for 5 of 5 residents (Residents #13, #17, #37, #39, #48) whose care plans were reviewed. The facility failed to develop a comprehensive person-centered care plan honoring Residents #13, #17, #37, #39, and #48 advance directives. This failure could place all residents at risk of receiving care by the facility that is against resident's wishes and not creating objectives to meet resident's medical needs. Findings included: Resident #13 Record review of Resident #13's face sheet, no date, revealed an [AGE] year-old female admitted to the facility 06/29/2017. Diagnoses include but are not limited to unspecified dementia, paroxysmal arial fibrillation (irregular heartbeat), and major depressive disorder. Resident #13's face sheet indicated resident is a DNR. Resident is admitted to hospice. Record review of Resident #13's Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview of Mental Status (BIMS) of 07 indicating severe cognitive impairment. Record review of Resident #13's advanced directives indicated a DNR form dated 6/29/17. Record review of Resident #13's care plan, dated 7/17/23, revealed no goal regarding Resident's advance directives of a DNR. Resident #17 Record review of Resident #17's face sheet, not dated, revealed a [AGE] year-old female admitted to the facility on [DATE]. Diagnoses included but are not limited to, unspecified dementia, paranoid schizophrenia (mental disorder that affects perception and behavior), chronic obstructive pulmonary disease, anxiety disorder, and atherosclerotic heart disease (affects blood flow to the heart). Resident is admitted to hospice. Record review of Resident #17's MDS, dated [DATE], revealed a BIMS of 08, indicating moderately impaired cognition. Record review of Resident #17's advanced directives indicated a DNR form dated 5/13/19. Record review of Resident #17's care plan, dated 6/26/23, revealed no goal regarding Resident's advanced directives of a DNR. Resident #37 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675098 If continuation sheet Page 7 of 17 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 675098 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Farwell Care and Rehabilitation Center 305 Fifth St Farwell, TX 79325 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 Record review of Resident #37's face sheet, not dated, revealed a [AGE] year-old female, admitted to the facility on [DATE]. Diagnoses included but are not limited to dementia unspecified, anorexia, anxiety, chronic kidney disease (Stage 4). Record review of Resident #37's BIMS score revealed no score due to questions and answers provided in other sections. Record review of Resident #37's advanced directives indicated a DNR form dated 5/31/23. Record review of Resident #37's care plan, dated 7/26/23, revealed no goal regarding Resident #37's advance directives of a DNR. Resident #39 Record review of Resident #39, not dated, revealed an [AGE] year-old male, admitted into the facility on 5/31/23. Diagnoses include but are not limited to pneumonia, unspecified organism, anxiety disorder, anorexia, emphysema (lung condition that causes shortness of breath), hypertensive heart disease with heart failure, and acute and chronic respiratory failure with hypoxia (condition where lungs cannot deliver enough oxygen to the blood). Resident #39's face sheet indicated a DNR status. Record review of Resident #39's MDS, dated [DATE], revealed Resident #39's BIMS score is 6 indicating that resident has a severe cognitive impairment. Record review of Resident #39's advanced directives indicated a DNR form dated 8/8/23. Record review of Resident #39's care plan revealed no goal for resident's advanced directives. Resident #48 Record review of Resident #48, dated 8/15/23, revealed an [AGE] year-old male admitted to the facility on [DATE]. Resident #48's diagnoses included but are not limited to aphasia (comprehension and communication disorder), type 2 diabetes, dementia in other diseases classified elsewhere, major depressive disorder, and atherosclerotic heart disease of native coronary (disease that may cause chest pain, a heart attack, or heart failure). Record review of Resident #48's care plan, dated 8/4/23, revealed no goal for resident's advanced directives. Record review of Resident #48's advanced directives indicated a DNR form dated 8/3/23. Interview with MDS RN on 8/16/23 at 2:07 PM, the MDS RN indicated care plans are created by reviewing documentation and speaking with staff. MDS RN read the first paragraph of the care plan policy and stated that the care plan means we are not fully measuring the residents wishes and could result in a negative outcome for the resident. Interview on 8/16/23 at 2:15 PM, the DON stated that the MDS RN assists with care plans by staff reports and documentation. The DON read first area of care plan policy titled Policy. After reading, they stated that the DNR should be care planned and the negative outcome is that the staff members may not be aware this is part of the resident's wishes and can assume they are full code. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675098 If continuation sheet Page 8 of 17 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 675098 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Farwell Care and Rehabilitation Center 305 Fifth St Farwell, TX 79325 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 FORM CMS-2567 (02/99) Previous Versions Obsolete Record review of policy titled Comprehensive Care Plans, dated 1/31/23, under title Policy states that it is policy of the facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights .to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. Under title Policy Explanation and Compliance guidelines, paragraph 1, the policy states that the process will include an assessment of the resident's personal and cultural preferences in developing goals of care. Paragraph 3 indicated the comprehensive care plan will describe, at minimum, (Line d) the resident's goals for admissions, desired outcomes, and preferences for future discharge. Event ID: Facility ID: 675098 If continuation sheet Page 9 of 17 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 675098 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Farwell Care and Rehabilitation Center 305 Fifth St Farwell, TX 79325 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and record review; it was determined the facility failed to ensure drugs and biologicals were stored in locked compartments under the proper temperature controls and permit only authorized personnel to have access. -LVN D left medication cart unattended and unlocked on 2 separate occasions while passing medications. -Refrigerator in medication room was not kept between 36-46 degrees. These failures could place residents at risk of having unauthorized access to medications and medications not being maintained at their best therapeutic level. Findings include: Observation on 08/14/23 10:16 AM of Medication room was performed with MA F, medication refrigerator log has not been within a safe temp for medications that are stored there for the past 5 days. Current temperature of fridge is 22 degrees F. Levemir and Lorazepam have been stored in this fridge at a temp of 36-46 degrees according to the packaging that the medication is stored in. This temp range is considered to be ideal storage temp for these medications. The temp log states that the temp for the morning has not been over 34 degrees, the highest temperature logged for the past 5 days had been 21 degrees F. The afternoon log states that the temp has not been over 36 degrees a total of 5 days over the past 14 days, the temperature that has been logged has been zero. Interview on 08/14/23 10:19 AM with MA F was asked who was responsible for taking fridge temps, she stated nurses check temperatures. MA F was asked who is to be notified if the fridge is below a safe temp. MA F stated the charge nurse is to be notified. Interview on 08/14/23 at 10:20 AM with LVN D who is was the charge nurse for this shift. LVN D was asked about the temp of the medication fridge. LVN D was unaware that the temp had been low. LVN D was asked who she would report an out-of-range temp to, she stated the ADON or DON. Observation on 08/14/23 10:49 AM of LVN D did not lock medication cart when she walked away to administer medication. Observation on 08/14/23 10:55 AM of LVN D who did not lock medication cart when she walked away to obtain blood glucose from resident. LVN D walked into residents room while the unlocked cart was left unattended in the hallway. Interview on 08/14/23 11:43 AM with LVN D, LVN D was asked why the medication cart was not locked 2 times while she was performing finger sticks and insulin administration. LVN D's response was I didn't? LVN D was asked what a negative outcome would be from not locking the medication cart. LVN D stated that someone could walk by and take something from the cart, but in my defense the door to the residents room was open and I could see the cart. Interview on 08/15/23 02:42 PM with DON revealed that medication carts should be locked when left (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675098 If continuation sheet Page 10 of 17 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 675098 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Farwell Care and Rehabilitation Center 305 Fifth St Farwell, TX 79325 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 0761 Level of Harm - Minimal harm or potential for actual harm unattended. DON was asked what a negative outcome would be, DON stated that anyone could walk by and take anything out of the cart. DON was asked what a negative outcome would be for medication that has been stored outside of the recommended temperatures. DON stated that the medication will lose its efficacy. Residents Affected - Few Interview on 08/15/23 02:58 PM with ADON revealed that medications should be locked when left unattended. ADON was asked what a negative outcome would be for leaving cart unattended and unlocked. ADON stated that anyone could walk by and have access to the medication cart. ADON was asked what a negative outcome would be if medication is stored outside of the recommended temperature range. ADON stated that the medication would lose its effectiveness. Record Review of policy provided by facility named Medication Storage, dated 01/31/23 states but not limited to the following: Policy: It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. Policy Explanation and compliance guidelines 1. General Guidelines: a. All drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication room) under proper temperature controls. .c. During a medication pass, medications must be under the direct observation of the person administering the medications or locked in the medication storage area/cart. .6. Refrigerated Products: . .b. Temperatures are maintained within 36-46 degrees F. Charts are kept on each refrigerator and temperature levels are recorded daily by the charge nurse or other designee. c. In the event that a refrigerator is malfunctioning, the person discovering the malfunction must promptly report such finding to maintenance Department for emergency repair. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675098 If continuation sheet Page 11 of 17 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 675098 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Farwell Care and Rehabilitation Center 305 Fifth St Farwell, TX 79325 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 observation, interview, and record review, the facility failed to store, prepare, and serve food under sanitary conditions in 1 of 1 kitchen when they failed to properly store, label, and date food in accordance with professional standards for food service safety. The facility failed to: 1. Store food that was not properly sealed. 2. Properly label items for proper identification. 3. Properly date items of received, opened, or use by date. This failure has the potential to affect all residents by causing food-born illnesses, weight loss, and a diminished meal experience. Findings included: On 8/14/23 at 9:39 AM, and observation of the following were found: 1. (2) 1 gallon Block and [NAME] Dill Pickle Relish with no received date. 2. (2) 20 oz yellow mustard plastic bottle with no received date. 3. (1) 20 oz Smuckers Caramel Sunday syrup with no received date. 4. (42) 2 ½ ounces Grandmas Chocolate Brownie Cookies with no received date. 5. (17) 1.5 bags Cheez-its with no received date. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675098 If continuation sheet Page 12 of 17 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 675098 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Farwell Care and Rehabilitation Center 305 Fifth St Farwell, TX 79325 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 6. Level of Harm - Minimal harm or potential for actual harm (7) bags appearing to be corn tortilla chips with no label and no date. 7. Residents Affected - Some (1) gallon sized sandwich bag with food appearing to be bacon with no label. 8. (1) gallon sized sandwich bag with food appearing to be sausage patties with no label. 9. (3) bags containing rolls of various size, shapes, and color with no labels. 10. (5) bags of 24 items appearing to be rolls with no labels 11. (3) items appearing to be hamburger buns in plastic bag with no labels and no date 12. (1) 12 count of items appearing to be hot dog buns with no label. 13. (1) gallon Mayo jar with no open date. 14. (1) gallon Red Boy Mustard jar not properly sealed with mustard leaking onto side of container. 15. (1) 5lb bag of shredded cheese with no date. 16. (12) bags with items appearing to be 6 pancakes no label and no dates 17. (1) tub of vanilla ice cream on freezer floor mat. An observation at approximately 10:05 AM on 8/14/23, a tub of vanilla ice cream was identified to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675098 If continuation sheet Page 13 of 17 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 675098 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Farwell Care and Rehabilitation Center 305 Fifth St Farwell, TX 79325 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 be sitting on freezer floor. Observed tub of vanilla ice cream remained on freezer floor after inspection of kitchen completed at approximately 10:35 AM on 8/14/23. An interview on 8/14/23 at 2:04 PM, the DM stated that all items that do not have a clear label are to be labeled and dated. The DM was shown several items with no labels or dates and stated, I just thought bread was bread. Inquired about ice cream on floor and provided timeline surveyor was in kitchen. The DM indicated that the person who delivers groceries put it there. The DM stated that there is an employee who was hired to specifically put groceries away. An interview on 8/15/23 at 3:59 PM, interview with DM revealed that no one puts their food away immediately on grocery day. Advised of timeline surveyor was in the kitchen for observation and no items had been dated or placed on food racks, and tub of ice cream was still located on the floor mat in the freezer. The DM stated that a negative outcome of this practice is the food can become contaminated. Interview on 8/14/2023 at 2:04 PM the DM was asked for in-services. The DM unable to provide in-services for labeling, dating, or storing food items prior to exit. Record review of Policy and Procedure for Food/Food Preparation Food Storage, under heading PROCEDURE, foods which have been opened or prepared will be placed in an enclosed container, dated, and labeled. Policy and Procedure also state to use FIFO as dating can demonstrate this is practiced. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675098 If continuation sheet Page 14 of 17 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 675098 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Farwell Care and Rehabilitation Center 305 Fifth St Farwell, TX 79325 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 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 infections for 2 of 2 residents (Resident #12 and Resident #14) reviewed for infection control. Residents Affected - Some The facility failed to ensure that facility staff perform hand hygiene appropriately during medication preparation, medication administration and incontinent care. This failure could place the residents at an increased risk for potentially exposing them to viral infections, secondary infections, tissue breakdown, communicable diseases and feelings of isolation related to poor hygiene. Findings include: Observation on 08/15/23 8:42 AM of LVN D while she was preparing medications for a g-tube medication administration. LVN D did not perform hand hygiene before preparing medications. LVN D did take a capsule and touch it with her bare hands to open capsule and placed internal medication into a soufflé cup. Observation on 08/15/23 09:34 AM of LVN D performing wound care for Resident #12. LVN D did not perform hand hygiene before starting wound care for resident. LVN D did not change gloves or wash hands after taking bandage off wound and did not remove gloves or perform hand hygiene after cleaning wound. LVN D did not perform a glove change or hand hygiene before applying Medi honey and calcium alginate dressing to wound. LVN D had the same gloves on at the end of the wound treatment that she started the process with. Interview 08/15/23 09:55 PM with LVN D to ask why hand hygiene was not performed before or during wound care with Resident #12 or the previous medication administration. LVN D started to cry and stated, I didn't? LVN D did not have a clear answer on why she did not perform hand hygiene and LVN D stated that the negative outcome would be increased risk for infections. Observation on 08/15/23 10:53 AM of incontinent care of Resident #14 revealed that CNA E did not perform hand hygiene before starting the process of incontinent care. CNA E also cleaned BM off Resident #14 and did not doff gloves and/or wash hands and don new gloves before placing a clean brief on resident #14. Interview on 08/15/23 10:55 AM CNA E was asked if there was a reason why she did not change gloves or wash hands before placing a clean brief on resident. CNA E stated, that is not how I was trained to do it. CNA E is with Agency. Interview on 08/15/23 01:39 PM with ADON on what the negative outcome would be if hand hygiene was not performed before a medication pass, incontinent care, and wound care, ADON stated that infections would be the negative outcome. Interview on 08/15/23 02:36 PM with DON on what the negative outcome would be if hand hygiene was not performed before a medication pass, incontinent care and wound care, DON stated that it would increase the chance if infections. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675098 If continuation sheet Page 15 of 17 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 675098 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Farwell Care and Rehabilitation Center 305 Fifth St Farwell, TX 79325 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 Record Review of agencies trainings provided by the DON revealed that CNA E was trained on urinary incontinence, and infection control. No date provided on training. Record Review on 08/16/2023 09:57 AM of training provided by the DON on hand hygiene and feeding tube procedure revealed that LVN D was trained on hand hygiene feeding tubes Residents Affected - Some Record Review of policy provided by facility named Medication Administration via Enteral Tube, dated 01/31/2023, states but not limited to the following: Policy: It is the policy of this facility to ensure the safe and effective administration of medications via enteral feeding tubes by utilizing best practice guidelines. Policy Explanation and Compliance Guidelines: .9. Procedure: .g. Perform hand hygiene and apply gloves. Record Review of policy provided by facility named Perineal Care, dated 01/31/23 states but not limited to the following: Policy: It is the practice of this facility to provide perineal care to all incontinent residents during routine bath and as needed in order to promote cleanliness and comfort, prevent infection to the extent possible, and to prevent and assess for skin breakdown Definition Perineal care refers to the care of the external genitalia and the anal area. Policy Explanation and Compliance Guidelines: .6. Perform hand hygiene and put on gloves. Apply other personal protective equipment as appropriate. .10. Re-position resident in supine position. Change gloves if soiled and continue with perineal care. .16. Remove gloves and discard. Perform hand hygiene. Record Review of policy provided by facility named Hand Hygiene, dated 01/31/23 states but not limited to the following: Policy: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675098 If continuation sheet Page 16 of 17 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 675098 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Farwell Care and Rehabilitation Center 305 Fifth St Farwell, TX 79325 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 personnel, residents, and visitors. This applies to all staff working in all locations within the facility. Level of Harm - Minimal harm or potential for actual harm Definitions: Residents Affected - Some Hand hygiene is a general term for cleaning your hands by handwashing with soap and water or the use of an antiseptic hand rub, also known as alcohol-based hand rub (ABHR). Policy Explanation and Compliance Guidelines: 1. Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice. 2. Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to, the attached hand hygiene table .6. Additional considerations: a. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. Hand Hygiene Table states, but not limited to the following: - Before performing resident care procedures - When, during resident care, moving from a contaminated body site to a clean body site. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675098 If continuation sheet Page 17 of 17