Inspection·May 24, 2024

F 0689 Level of Harm - Actual harm Residents Affected - Few Parkland Hospital due to local hospitals being on divert, for further evaluation. Frontal chest radiograph revealed: 1. The eighth right rib is not completely visualized. Cannot rule out a fracture at this location. Recommend correlation with point tenderness. In addition, patient positioning makes evaluation of the lower right ribs difficult. Recommend dedicated right rib radiographs if there is continuing clinical concern. 2. No obvious pneumothorax. 3. Bronchial wall thickening and interstitial prominence, nonspecific, but can be seen with pulmonary edema, reactive airway disease, or viral infection. Component of chronic interstitial disease cannot be excluded. 4. Left basilar atelectasis. Blunting of the left costophrenic angle may be due to trace effusion or pleural scar. No additional recommendations. Xray of right ribs on 03/11/2024 revealed Suspected subtle nondisplaced fracture of the posterior right 11th rib. Suggest correlation with area of tenderness. The attending physician note stated, upon arrival patient is pleasant and denying medical complaints aside from mild cough which she states she has had for several weeks. Of note patient is a poor historian with baseline dementia, EMS reports that she is in a wheelchair however she reports she is ambulatory. Patient does not recall any trauma to the chest or any part of her body. Musculoskeletal General: no swelling; Cervical back: normal range of motion; Comments: No obvious point tenderness to the thoracic chest, no skin changes. Resident was also diagnosed with a urinary tract infection. ER report stated, Upon assessment pt noted to have nonproductive cough. Pt endorsing pain with deep inhalations during assessment RLL noted to be diminished. Pt currently denies CP, abd pain, NVD, neuro concerns. Resident was transferred from Parkland back to facility on 03/12/2024 at 12:33 am. Record review of Resident #7's facility face sheet dated 05/09/2024 indicated Resident #7 was an [AGE] year-old female admitted to the facility on [DATE] with a diagnosis of unspecified dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities). Record review of a quarterly MDS assessment dated [DATE] indicated Resident #7 had a BIMS of 03 indicating severely impaired cognition. MDS indicated Resident #7 was dependent on chair/bed-to-chair transfers. It did not indicate how many staff required for transfers. It stated, Helper does all of the effort. Resident does none of the effort to complete the activity. Or the assistance of two or more helpers is required for the resident to complete the activity. Review of Quarterly MDS for Resident#7 dated 01/25/2024 revealed the resident was dependent with 1- or 2-person transfer. Record review of the comprehensive care plan initiated 10/06/2023 with revision of transfers on 03/13/2024 indicated Resident #7 was at risk for falls and required assist of two staff with Hoyer lift transfers. Review of Care Plan on Resident #7 dated 10/06/2023 and revised on 02/15/2024 reflected resident is at risk for falls with interventions for one staff to assist with transfers. Review of records dated 03/13/2024 for Resident #7 indicated head to toe assessment was completed on all sixteen residents that require transfer assist and care plans of each of those residents reflected transfer status. Review of Inservice records dated 03/11/2024 reflected training provided to all staff regarding abuse and neglect; how to use [NAME]; and Moving a Resident, Bed to Chair/Chair to Bed Transfers, Gait Belt Transfers. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675867 If continuation sheet Page 2 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675867 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kerens Care Center 809 NE 4th St Kerens, TX 75144 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 0689 Level of Harm - Actual harm Residents Affected - Few Review of personnel record reflected disciplinary action for CNA A for improper transfer was initiated on 03/11/2024. Staff suspension removed following one on one inservice on proper transfers/using gait belt, using [NAME] correctly and abuse & neglect dated 03/18/2024 Record review of the CNA Proficiency Audit dated 07/29/2023 indicated CNA A was observed and was competent on transfers. Record review of therapy records for Resident #7 indicated no therapy evaluation for accuracy of transfer assistance was completed due to rural area of facility not physical therapy available. Record review of weekly audits to focus on s/s of staff performing duties in a neglectful manner, interview staff about observing transferring without gait belt, interview residents about staff using gait belt with transfers, and observe 10 ADL's were completed from 03/11/2024 through 05/04/2024. Record review of MAR for Resident #7 dated 03/01/2024 through 03/31/2024 reflected resident had Tylenol with Codeine #3, 300/30mg one tablet by mouth scheduled twice daily. She was also ordered Tylenol with Codeine #3 on 03/12/2024, one tablet by mouth every 8 hours as needed for pain for 14 days. Do not exceed 2600 mg in 24 hours. No as needed pain medications were given from 03/13/2024 through 03/27/2024. Record review of injury nurses notes on Resident #7 dated 03/11/2024 through 03/14/2024 indicated resident was assessed each shift for ADL decline, pain and change in condition requiring physician notification due to fracture and no changes had occurred. During an interview on 05/09/2024 at 1:05 pm, CNA A said she was a student nurse aide and she transferred Resident #7 as a one person assist. She said she was trained on the use of a gait belt for transfers but did not have one available at that time. She said she should not have had the resident hug her around the neck and pull her to a standing position by the waist of her pants. She reported the resident never hollered, showed discomfort or anything at that time. She said she should have placed a gait belt around the resident to transfer properly. During an interview on 05/09/2024 at 2:58 pm, the DON said it was facility's policy to use a gait belt for transfers. She said the nursing administration was responsible to ensure training was completed for all staff regarding proper transfer techniques. She said all staff were trained on hire, annually, with any incident or change in status on transfers. She said she was responsible for competency checks for the nurses and aides. She said that CNA A was trained on proper transfer technique using a gait belt and Resident #7 required a one person assist with a gait belt for all transfers at that time. She reported the care plan was updated on 3/13/2024 to reflect that Resident #7's transfer status changed and required two staff and Hoyer lift for transfers. She said that each resident had a care plan regarding their transfer status and the aides were aware of each resident's transfer needs. She said if a resident were not properly transferred it could result in injury. She said she expected all staff to transfer residents properly according to policy. Interview with Resident #7 on 05/24/2024 at 3:30 pm. She was pleasant and said she was doing ok. She said that no one in the facility had ever hurt or mistreated her and she felt safe. When asked how the food was, she was confused. When asked if the cooks were good, she said, No he died, and I don't cook. She said she goes to the church for lunch, and she feels ok. Resident requested help to straighten her legs and wanted to go to dinner. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675867 If continuation sheet Page 3 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675867 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kerens Care Center 809 NE 4th St Kerens, TX 75144 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 0689 Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Interview with NP on 05/24/2024 at 3:40 pm who reported resident has history of upper respiratory infections with cough. She reported she suspects the fractures that were noted on x-rays were more likely to be caused due to coughing rather than due to the transfer from bed to wheelchair but cannot be certain. Record review of the facility's policy titled Moving a Resident, Bed to Chair/Chair to Bed dated 2003 indicated, .Position a gait belt around the resident's waist and clasp it. Make sure it is tight enough that only a slight hand movement will guide the patient, but not so tight that you cannot firmly grasp the belt without making the patient uncomfortable . Event ID: Facility ID: 675867 If continuation sheet Page 4 of 4