Health inspection·July 13, 2023

F 0580 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Record review of incident report dated 1/16/23 for Resident #186 indicated that he had suffered an unwitnessed fall resulting in large gash above right eye and swelling and bruising to right eye. Record review of a care plan, undated, for Resident #186 indicated he was at risk for bleeding and injury associated with daily use of anti-platelet medications (Clopidogrel). Care plan also indicated that he had an actual fall on1/16/23 with injury and interventions included to monitor, document, and report to MD any signs/symptoms of pain, such as bruises, change in mental status, or agitation. Record review of a facility 24-hour report dated 7/12/23 for the dates of 1/16/23 through 1/17/23 indicated that resident had fallen on 1/16/23 and neurological assessments were initiated immediately after fall. 24-hour report indicated that Resident #186's neurological assessment on 1/16/23 at 5:41 pm his CGS was 15 indicating mild head injury. At 6:12 pm on 1/16/23, his score was a 10, indicating a moderate head injury. There was no documentation of physician notification regarding this decline. Record review of hospital paperwork in Resident #186's electronic medical record indicated that Resident #186 was admitted to ICU on 1/17/23 at 5:40 pm. Record review of progress note dated 1/19/23 indicated that Resident #186 readmitted to facility with diagnoses: right frontal intraparenchymal hemorrhage (a bleed that occurs within the brain parenchyma, the functional tissue in the brain); right temporal horn IVH (a bleeding into the brain's ventricular system, where the cerebrospinal fluid is produced and circulates through towards the subarachnoid space. It can result from physical trauma); bilateral subdural hematomas (a dangerous condition where blood collects under the skull, putting pressure on the brain and causing damage or death); left temporal horn IVH (a bleeding into the brain's ventricular system, where the cerebrospinal fluid is produced and circulates through towards the subarachnoid space. It can result from physical trauma). Record review of a progress note dated 1/21/23 for Resident #186 indicated that he passed away on 1/21/23 at 9:23 am. During an interview with DON on 7/11/23 at 4:00 pm, she said that she was not employed by this facility at that time but that she was employed by hospice services on 1/16/23. She said that she had started as the facility DON in February 2023. She said that she had come to the facility to assess Resident #186 on 1/16/23 and she noticed a change from his baseline, and he was unresponsive. She said that she was unable to reach a family member to see what they wanted to do, so she had him sent out to the emergency room. She said in cases where she could not reach family members regarding hospice residents, she would use nursing judgement and sent out for evaluation. She said that any resident that suffered a fall with possible head injury should be sent out for evaluation. During an interview with Resident #186's family member on 7/11/23 at 4:34 pm, she said that the facility did notify her of the fall on 1/16/23 and that she had told them to send him to the ER if they thought that he needed to go. She said that she was under the impression that the nurse would use her judgement to decide if he needed to go. She said that if she had known the severity of the situation, she would have insisted they send him out. She said that once he was in the ICU at the hospital, the doctors there told her that he had five brain bleeds and that there was nothing that they could do. She said that before the fall, he had been active and alert, he just was unable to speak due to a stroke. She said that she had him sent back to the nursing facility because the hospital said that they could not do anything for the bleeding on his brain. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675940 If continuation sheet Page 2 of 63 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 675940 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hemphill Care Center 2000 Worth St Hemphill, TX 75948 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 0580 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few During an interview with physician office staff on 7/12/23 at 9:00 am, surveyor was informed the physician was not currently in office, but staff could take a message. Message left with return phone number for physician to call regarding incident on 1/16/23. No return call received from physician before exit from facility. During an interview with LVN L on 7/12/23 at 10:18 am, she said she had worked for the facility from November of 2022 to March of 2023. She said she had worked days in the unit and was working the day of the fall. She said she had been at the nurse's station and was notified by a CNA of the resident's fall. She said she did an assessment and took vital signs on Resident #186. She said around 3:30 pm, he was found laying on the floor and had been trying to get up on his own without assistance. She said that he fell in his room while ambulating unassisted, and he pointed to the bathroom to indicate he was trying to go to the bathroom. She said he had a gash on his forehead on the right side. She said she called the hospice nurse, and the DON at the time. She said the DON at that time came back to the unit and assessed the resident, cleaned his wound, and put steri-strips in place. She said he was not sent to the hospital. She said she was monitoring him every 30 minutes and the wound was still bleeding. She said she notified hospice again about the bleeding. She said she was doing neurological checks, checking pupils with her penlight, and checking his grips. She said his grips were strong. She said his pupils were not dilated; they were normal at 2mm. She said he was moving around a lot, acting restless, moaning, and groaning. She said she worked until 6 pm that evening. She said she had called and spoke to his wife and explained about the fall. She said their protocol was to notify hospice regarding incidents with any hospice residents and hospice would instruct on what to do. She said there were no in services done regarding the incident. During an interview with LVN C on 7/12/23 at 3:00 pm, she said she had called hospice the night that Resident #186 fell because she had wanted to send him to the emergency room because the wound continued to bleed, but hospice said that they were against sending him out unless the wife wanted to send him out. She said she spoke to the sister-in-law and notified her of his condition regarding the contusion and that it continued to bleed, but she said to just monitor him for now. She said she did not notify the physician because it was their policy to notify hospice for hospice residents. Record review of a facility policy titled Falls - Clinical Protocol dated 2001, with revision date of March, 2018, indicated .the nurse shall assess and document/report the following: .recent injury, especially fracture or head injury .neurological status . and .the physician will identify medical conditions .and the risk for significant complications of falls (for example .increased risk of bleeding in someone taking an anticoagulant) . and .The staff, along with the physician's guidance, will follow up on any fall with associated injury until the resident is stable and delayed complications such as .subdural hematoma have been ruled out or resolved . Record review of a facility policy titled Change in a Resident's Condition or Status dated 2001, with revision date of February 2021 indicated .the nurse will notify the resident's attending physician or physician on call when there has been a(an): .significant change in the resident's physical/emotional/mental condition . This was determined to be an Immediate Jeopardy (IJ) on 07/12/23 at 11:15 am. The Administrator was notified. The Administrator was provided with the IJ template on 07/12/23 at 11:30 am. The facility's plan of removal was accepted on 7/13/23 at 9:05 am and included: 1) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675940 If continuation sheet Page 3 of 63 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 675940 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hemphill Care Center 2000 Worth St Hemphill, TX 75948 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 0580 Level of Harm - Immediate jeopardy to resident health or safety All nursing staff will be in serviced over physician notification regarding change in assessment per policy and procedure. Inservice to include: 2) Residents Affected - Few Notification-Change of Condition - in service completed by RDC (regional director of clinical and/or nursing administration designee once trained. All abnormal findings including change of vital signs, change of mobility, change of mental status, and/or decline in ADL's must be reported to the Medical Director (regardless of hospice physician notification), Director of Nursing, Assistant Director of Nursing, Administrator, and Responsible Representative/Emergency Contact immediately. Notification to physician regarding fall with or without injury. Notification to physician regarding blood thinners as applicable on active orders or medications with anticoagulant similarities on active orders. To assess baseline, the Charge Nurse may utilize previous assessment and/or the comprehensive care plan in Point Click Care. Progress notes must reflect the changes observed, interventions, and notification. Neuro Checks - RDC regional director of clinical and/or nursing administration designee once trained. Post fall neuros must be conducted for 30 hours. ? Q 15 minutes for a duration of 1 hour ? Q 30 minutes for a duration of 1 hour ? Q 1 hour for a duration of 4 hours ? Q 4 hours for a duration of 24 hours All neuros MUST be completed for falls with head injury and unwitnessed fall. Abnormal findings will be reported to Medical Director (regardless of hospice physician notification), Director of Nursing, and Assistant Director of Nursing; and will be extended for an additional (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675940 If continuation sheet Page 4 of 63 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 675940 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hemphill Care Center 2000 Worth St Hemphill, TX 75948 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 0580 24 hours to be monitored Q 4 hours (unless otherwise directed by physician). Level of Harm - Immediate jeopardy to resident health or safety Review & Reporting - -in-service completed by RDC (regional director of clinical) on 8/12/23. Residents Affected - Few The Administrator and DON, along with IDT will review each incident in the Stand Up meeting to determine possible cause, interventions, documentation, follow-up, and reporting status according to HHSC reporting guidelines. All residents have the potential to be affected by this alleged deficient practice. The Medical Director was initially made aware of the immediate jeopardy 7/12/23 and has been involved in the development of the plan to removal. These conversations are considered a part of the QA process. To monitor for compliance the Administrator and/or designee will review all Accident/Incident reports and follow up accordingly. The IDT will review and assess the Accident/Incident to determine what further actions if needed are necessary. Members of this meeting are to include the Administrator, Director of Nursing, Assistant Director of Nursing, MDS Coordinator, Social Worker, and Therapy Representative. In addition, designated members of the corporate staff will review all Accident/Incidents daily for 6 months and reevaluate the need for continued review. Any negative findings will be forwarded to the Administrator and the QA committee. This plan was initially implemented 7/12/23 and will be monitored through completion by corporate and regional staff. Plan of Removal completion date is 7/12/23 by 8:00 pm with continued follow up for oncoming staff. Verification of POR: Verified MDS and Corporate MDS completed a review of all residents fall assessments completed in the last quarter for current interventions and effectiveness with completion date 7/12/23 at 8:00 pm Staff interviews 7/13/23 10:45 am-2:50 pm completed with DON, ADON, and RN F were able to verbalize the Fall/Interventions/Documentation policy including neuro checks, documentation of incident, notification to physician, specific interventions, and monitoring or resident condition; Resident assessment and fall documentation policy and procedure; Neuro checks policy including must be conducted for 30 hours, Q 15 minutes for 1 hour, Q 30 minutes for 1 hour, Q 1 hour for 4 hours, and Q 4 hours for 24 hours, abnormal findings will be reported to physician (regardless of hospice notification), DON, ADON, and will be monitored for an extended 24 hours; Notification of Change in residents condition to be reported to physician; notification to physician regarding blood thinners/anticoagulants as applicable. Admin, DON, ADON verbalized review and reporting procedures for daily stand-up meetings. Verified Medical director was notified of IJ and participated in POR. 7/12/23 QA meeting held with medical director and IDT members. On 7/13/23 at 3:35 pm, the facility was informed the IJ was removed. However, the facility remained out of compliance at a severity level of actual harm that is not immediate with a scope of isolated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675940 If continuation sheet Page 5 of 63 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 675940 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hemphill Care Center 2000 Worth St Hemphill, TX 75948 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 0580 due to the facility's need to monitor and evaluate the effectiveness of their plan of removal and corrective actions. Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675940 If continuation sheet Page 6 of 63 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 675940 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hemphill Care Center 2000 Worth St Hemphill, TX 75948 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure residents were free from abuse for 4 of 10 residents (Resident #12, Resident #184, Resident #185, and Resident #186) reviewed for Resident Abuse. 1. The facility failed to protect Resident #185 from abuse by Resident #2. On 11/22/2022 Resident #185 wandered by Resident #2's door on the secured unit, and Resident #2 grabbed Resident #185's arm and struck her in the upper chest. 2. The facility failed to protect Resident #185 from abuse by Resident #2. On 12/05/2022 Resident #185 wandered into Resident #2's room on the secured unit, and Resident #2 punched Resident #185 in the face causing an abrasion to her left check . 3. The facility failed to protect Resident #186 from abuse by Resident #2. On 01/15/2023 Resident #2 grabbed and yanked Resident #186's arm backwards. 4. The facility failed to protect Resident # 184 from abuse by Resident #2. On 03/04/2023 Resident #2 hit Resident #184 with an open hand on the left side of his face . 5. The facility failed to protect Resident # 12 from abuse by Resident #2. On 03/09/2023 Resident #12 wandered by Resident #2's door on the secured unit. and Resident #2 grabbed Resident #12's right arm pulling her to the floor. 6. The facility failed to protect Resident # 184 from abuse by Resident #2. On 04/27/2023 Resident #184 wandered into Resident #2's room on the secured unit and Resident #2 hit Resident #184 in the mouth . An IJ (immediate jeopardy) was identified on 07/11/2023 at 4:13 PM. The IJ template was provided to the facility on [DATE] at 4:13 PM. While the IJ was removed on 07/13/2023 at 3:35 PM, the facility remained out of compliance at a severity level of actual harm that is not immediate with a scope of pattern due to the facility's need to monitor and evaluate the effectiveness of their plan of removal and corrective actions. These failures placed all residents at risk of physical harm, mental anguish, emotional distress, or death. Findings included: 1. Record review of facility face sheet dated 7/11/2023 indicated Resident #2 was a [AGE] year-old male admitted to the facility on [DATE] with a primary diagnosis of bipolar disorder (mood disorder), psychosis (mental disorder), and anxiety. Record review of comprehensive MDS dated [DATE] indicated Resident #2 had a BIMS of 99 indicating Resident #2 was unable to complete interview. Section C for cognition indicated Resident #2 had disorganized thinking. Section E for behaviors indicated Resident #2 had verbal behaviors directed toward others and resident had wandered. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675940 If continuation sheet Page 7 of 63 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 675940 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hemphill Care Center 2000 Worth St Hemphill, TX 75948 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Record review of care plan dated 05/08/2023 indicated Resident #2 required psychotropic medications for diagnosis of behavior management, bipolar disorder, and psychosis. Resident #2 had impaired cognitive function and dementia or impaired thought processes related to dementia and psychosis and required the secured unit due to risk of elopement and wandering. Resident #2 had physical behaviors towards residents and staff with interventions added on 03/04/2023 to separate from resident and redirect to room, 3/09/2023 Seroquel increased, and 4/27/2023 resident #2 was sent to a Behavioral Hospital for evaluation and treatment. Record review of physician orders dated 7/11/2023 indicated Resident #2 had order for behavior monitoring, lorazepam 1 mg by mouth as needed for anxiety and Seroquel 100mg by mouth at bedtime. Record review of facility incident report dated 11/23/2022 revealed a resident-to-resident altercation that occurred between Resident # 2 and Resident #185. Resident #185 wandered by Resident #2's door on the secured unit, and Resident #2 grabbed Resident #185's arm and struck her in the upper chest. Resident #185 was removed from area, the responsible parties, physician, and administrator was notified. Record review of facility progress note dated 11/22/2023 at 6:18 pm stated LVN P was called to Resident #2's room by the aide working on the unit and the aide reported Resident #185 was walking by Resident #2's room when he grabbed Resident #185's arm and hit her in the chest before the aide was able to intervene. The aide separated the resident's and nurse notified the administrator. The administrator said an incident report was not needed due to resident's mental status. Record review of a facility progress note dated 12/05/2022 at 3:14 pm LVN L stated Resident #185 entered Resident #2's room, stooped down towards his face and Resident#2 punched Resident #185 on the left side of the face. Resident #185 was redirected and continue to monitor for behaviors. Record review of incident report log from November 2022 to present date and no incident recorded on 12/05/2022 regarding incident between Resident #2 and Resident #185. Record review of incident report dated 01/15/2023 stated Resident #2 rolled up to Resident #186 at the dining table and Resident #2 pulled, twisted, and yanked Resident #186's right arm. CNA A attempted to separate the residents and Resident #2 punched CNA A in the jaw. Administrator and physician were notified. Record review facility progress note dated 01/15/2023 at 11:33 am LVN P stated upon entering the unit, was notified Resident #2 had attacked Resident #186 and CNA A. Record review of incident report dated 03/04/2023 stated Resident #2 hit Resident#184 with an open hand on the left side of the face. Residents were separated and head to toe assessment completed. DON, physician, and families notified. Record review of progress note dated 03/05/2023 at 2:54 am stated LVN C was notified by RA assigned to the unit; Resident #2 had hit Resident #184 with an open hand to the left side of the face when Resident #184 had gotten to close to Resident #2. RA was advised to do frequent monitoring and hallway checks. Record review of incident report dated 03/09/2023 stated Resident #2 grabbed Resident #12 by the right arm and pulled her to the floor in the hallway. Head to toe assessment complete, physician, DON, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675940 If continuation sheet Page 8 of 63 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 675940 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hemphill Care Center 2000 Worth St Hemphill, TX 75948 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 0600 and families notified. Level of Harm - Immediate jeopardy to resident health or safety Record review of progress note dated 03/09/2023 at 4:36 am stated LVN C was notified by RA assigned to the unit Resident #12 was on the floor. RA reported that Resident #2 was sitting in the hallway when Resident #12 attempted to wander into Resident #2's room. Resident #2 grabbed Resident #12 by the right forearm pulling her to the floor. Head to toe assessment completed with no injuries noted to Resident #12. Resident #2 was redirected into his room and assisted to bed. Residents Affected - Some Record review of incident report dated 4/27/2023 stated Resident #2 hit Resident #184. Resident #2 was noted to have two skin tears on his right knuckle. The CNA assigned to the unit reports when she was coming up the hall she noticed Resident #184 was no longer at the dining table. She then heard Resident #2 yelling from his room and when she entered the Resident #2's room, Resident #184 was sitting in a chair and had blood coming from his mouth on the left side. Both residents separated, assessed for injuries, Resident #2 placed on every 15-minute checks and referral sent to a behavioral hospital. Physician, Administrator, DON and families notified. 2. Record review of facility face sheet dated 7/11/2023 indicated Resident #12 was a [AGE] year-old female admitted to the facility 9/19/2020 with the diagnosis of Alzheimer's disease. Record review of quarterly MDS dated [DATE] indicated Resident #12 had a BIMS of 99 indicating Resident #12 was unable to complete the interview. Section E for behaviors indicated Resident #12 wandered daily. Record review of comprehensive care plan dated 4/25/2023 indicated Resident #12 required secured unit placement due to elopement risk and Resident #12 had potential to demonstrate physical behaviors with interventions to analyze what deescalates behavior and document and intervene before agitation escalates. Record review of incident report dated 03/09/2023 stated Resident #12 was grabbed by the right arm and pulled to the floor by Resident #2 in the hallway. Head to toe assessment complete, physician, DON, and families notified. Record review of progress note dated 03/09/2023 at 5:20 am stated LVN C was notified by RA assigned to the unit Resident #12 was on the floor. RA reported that Resident #12 attempted to wander into Resident #2's room. Resident #2 grabbed Resident #12 by the right forearm pulling her to the floor. Head to toe assessment completed with no injuries noted to Resident #12. 3.Record review of facility face sheet dated 7/12/2023 indicated Resident #184 was an [AGE] year-old male admitted to the facility on [DATE] with a diagnosis of Alzheimer's disease. Record review of admission MDS dated [DATE] indicated Resident #184 had a BIMS of 99 indicating Resident #184 was unable to complete the interview. Section E for behaviors indicated verbal behaviors directed towards others and wandered daily. Record review of comprehensive care plan dated 02/26/2023 indicated Resident # 184 had a potential to demonstrate physical behaviors with interventions to analyze triggers and what de-escalates behaviors and document and was an elopement risk requiring a secured unit. Record review of nurse progress note dated 3/05/2023 at 2:15 am stated LVN C was notified by RA (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675940 If continuation sheet Page 9 of 63 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 675940 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hemphill Care Center 2000 Worth St Hemphill, TX 75948 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some assigned to the unit Resident #184 had been hit to the left side of the face with an open hand by Resident #2. CNA was advised to do frequent checks on Resident #184 and monitor the hallway. Responsible party, DON, ADON and physician notified. Record review of nurse progress note dated 4/28/2023 at 3:57 pm stated ADON was alerted by CNA assigned to the unit that Resident #2 had hit Resident #184. ADON entered the unit and Resident #184 was standing in the hall with the CNA and had a gash and blood to left side of his mouth. 4. Record review of facility face sheet dated 7/12/2023 indicated Resident #185 was a [AGE] year-old female admitted to the facility on [DATE] with diagnosis of Alzheimer's disease. Record review of admission MDS dated [DATE] indicated Resident #185 had a BIMS of 01 indicating severe cognitive deficit. Section E for behaviors indicated Resident # 185 had physical behavioral symptoms directed towards others and had wandered. Record review of comprehensive care plan dated 11/16/2022 indicated Resident #185 had potential for psychosocial problem and required secured unit and was an elopement risk for wandering. Record review of nurse progress note dated 11/23/22 at 8:28 pm stated on 11/22/2023 LVN P was notified by the aide working the secured unit that Resident #185 was attempting to wander into Resident #2's room. Resident #2 grabbed Resident #185 by the arm and struck her in the chest twice before the aide could stop him. One on one care being provided to keep resident from wandering back into Resident #2's room until Resident #185 can be transferred to an all-female secured unit on Monday 11/28/2022. Record review of electronic health record for Resident #185 indicated no documentation of one-on-one monitoring initiated after incident on 11/22/2022. Record review of nurse progress note dated 12/2/2023 at 5:08 pm LVN C stated Resident #185 was hit in the face by Resident #2 causing an abrasion to her left cheek. On review, the dates documented for the incident for Resident #185 and Resident #2 do not match. No record of incident report found in the electronic health record. 5. Record review of facility face sheet dated 7/12/2023 indicated Resident # 186 was a [AGE] year-old male admitted to the facility on [DATE] with diagnosis of hemiplegia following cerebral infarction (paralysis following a stroke). Record review of admission MDS 12/12/2022 indicated Resident #186 had moderately impaired cognition requiring supervision and wandered. Record review of comprehensive care plan dated 12/20/2022 indicated Resident # 186 had a communication problem and to provide a safe environment. Record review of Resident #186's electronic health record with no documentation related to altercation with Resident #2 on 01/15/2023. During an observation on 07/10/23 at 09:12 am CNA A and CNA B were present on the secured unit that housed 10 residents. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675940 If continuation sheet Page 10 of 63 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 675940 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hemphill Care Center 2000 Worth St Hemphill, TX 75948 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some During an observation on 7/10/2023 at 12:10 pm Resident #2 was up in his wheelchair in his room eating lunch. Resident #2 propels self in wheelchair and resides in a private room. During an interview on 07/10/2023 at 12:15 pm CNA A stated she had worked at the facility for 8 months and primarily was assigned to the secured unit. She stated the residents on the unit need supervision as they wander and get into things. She stated Resident #2 had been at the facility a long time and had a history of being aggressive if other residents entered his space. She stated she tried to keep everyone else away from him. She stated there was an incident when Resident #2 pulled another resident's arm in the dining room and when she intervened Resident #2 hit her. She stated the nurse was notified and Resident #2 returned to his room. She stated she had training on caring for residents with behaviors and incidents or abuse as to be reported to the nurse and administrator. During an interview on 07/10/20023 at 12:40 pm CNA B stated she had worked at the facility almost 2 years and worked the secured unit. She stated that during the day there are 2 CNAs on the unit and the nurse comes on and off the unit throughout the day. She stated that the residents on the unit have behaviors and she had been trained on how to control outburst but it does not always work. She stated Resident #2 did have some issues a few months ago but in the last few months had been better. She stated as long as no one messes with him he was fine. She stated there had not been any special interventions for Resident #2 and she just tried to keep an eye on him and prevent the other residents from going around him. During an interview on 7/11/2023 at 10:11 AM the RA stated he had been employed at the facility for 3 months part time. He said when he worked he worked all over the facility. He stated Resident #2 was on the secured unit and stayed in a wheelchair usually in his doorway of his room. He stated the incident with Resident #2 and Resident #184 he had worked that night and witnessed the incident. He stated Resident #184 walked up to Resident #2's wheelchair and Resident #2 hit Resident #184 in the face. He said he reported to the nurse LVN C and immediately separated both residents. He stated LVN C told him to write a witness statement and she called the hospice nurse. He stated he stayed in the hallway in the secured unit and put Resident #184 back to bed. He stated Resident #184 was a wanderer and he did not go back into the room of Resident #2. He stated LVN C checked on Resident #184 but could not recall any in-services or other interventions following that incident. He stated the incident with Resident #2 and Resident #12 was witnessed by him. He stated Resident #2 was sitting in the doorway of his room and Resident #12 went into his room but by the time he made it there, Resident #2 had already grabbed her by the arm and she fell to her knees. He stated Resident #12 jumped back up and he called to the nurse station to notify LVN C. He stated LVN C came and provided first aide to Resident 12's arm because she had a skin tear. He stated he was instructed by the nurse to write out a witness statement but no other special instructions were given. He said he had received training on abuse/neglect. He stated Resident #2 liked to sit in the doorway of his room and did not like other residents going in his room. He stated he was told by facility staff prior to working on the secured unit to monitor Resident #2 to ensure no residents entered his room. He stated at the time of both incidents, he was the only staff on the secured unit. He stated both incidents occurred on the night shift and usually there was only 1 aide on the unit at night. He stated the nurse stayed at the nurse station outside of the unit and they would come to the unit about 2-3 times a night. Attempted phone interviews on 7/11/2023 with LVN C at 10:34 am and at 4:43 pm with no answer and voicemail messages were left for a return phone call. During an interview on 7/11/2023 at 11:01 am the DON stated she had started as the facility DON in February 2023. She stated that when she first started she was told that resident to resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675940 If continuation sheet Page 11 of 63 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 675940 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hemphill Care Center 2000 Worth St Hemphill, TX 75948 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some altercations was not abuse if it occurred between residents on the secured unit that had cognitive delays and did not have to be investigated or reported to the state unless the other resident suffered a significant injury. She stated she had knowledge of the altercations regarding Resident #2 and the nurse had notified her with each incident but had missed that the altercations were abuse. She stated the administrator was aware and he did not treat the altercations as abuse either. She stated that with each incident the aide separated the residents, the nurse was notified, and the victim was assessed. She stated she knew the facilities policy on abuse and the process of investigation and reporting but with the incidents that occurred since she had been DON with Resident #2 were missed. She stated in April her regional nurse notified her that all resident-to-resident altercations were to be investigated, reported and followed through to prevent further abuse. She stated by not following the abuse program the risk to the residents could be significant. During an interview on 7/12/23 at 7:32 am CNA D stated she had been a CNA for 6 years and employed at the facility for 2 months. She stated she worked all units and shifts. She stated on the night shift there was only 1 CNA and the nurse came back and forth as needed. She stated if a resident-to-resident altercation occurred on her shift she would report it to the nurse and separate the residents. She stated she was aware of each resident and their moods and Resident #2 prefers to stay to himself and no one be in his space. She stated at night when she worked on the unit by herself, if she was in another resident's room, she just tried to listen for any noise indicating a resident had gotten up or needed help. She stated she had not had any issues with any residents on the unit since starting to work at the facility. During an interview on 7/12/2023 at 7:48 am Resident #2 stated he did not remember any incidents occurring between him and another resident. He stated he was not sure how long he had been at the facility but there were a lot of people who lived there. He stated if someone were to come in his room that would be just fine but if they messed with him or his stuff he was not sure what he would do. He stated he was not a mean person and tried to get along with everyone. He stated he stayed in his room and kept to himself. During an interview on 7/12/2023 at 7:53 am CNA E stated she had been a CNA for 21 years and employed at the facility 6 months. She stated she was not working during any of the incidents with Resident # 2. She stated when she was hired she had to go through a full training program on the facilities computer-based training program before she could start to work. She stated the training included signs of abuse, types of abuse and reporting abuse to the administrator. She stated there was training on behavior monitoring and if there was an altercation between residents that they were to be separated and monitored to make sure the incident did not occur again. She stated the nurse was informed and the nurse did a report. She stated when she had worked the unit there were 2 CNA's working during the day. She stated if she and the other CNA were busy she would ask the nurse to come to the unit and help supervise if it was needed. She stated that if residents are not properly supervised and the abuse program was not followed a resident could get hurt. During an interview on 07/12/2023 at 8:01 am RN F stated she was new to the facility as of 2 weeks but had worked in long term care for over 20 years. She stated abuse training was completed when she was hired through the facilities online training program. She stated resident to resident altercations are to be reported to the abuse coordinator. The residents were to be separated, the victim assessed, and the perpetrator should be monitored 1 on 1 if needed. She stated she worked the secured unit and was on and off the unit throughout her shift and as needed by the CNA. During an interview on 7/12/2023 at 9:44 am, the Psychiatrist stated that residents that received (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675940 If continuation sheet Page 12 of 63 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 675940 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hemphill Care Center 2000 Worth St Hemphill, TX 75948 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some hospice services were not typically seen by psychiatric services, but he did follow them if it was requested by the doctor or hospice. He stated he did complete an evaluation on Resident #2 on 7/11/2023 and with coordination of the son was able to develop a past history and adjust his diagnosis. He stated he did a medication review and made some adjustments with dose times of his antipsychotic and anxiety medications. He stated he would continue to monitor for any symptoms and make other adjustments if needed. He stated the facility had put in place one on one monitoring to monitor for any negative outcomes to his interventions. He stated he was going to provide the facility staff with more in-depth training today 7/12/2023 on how to care for aggressive residents, behavior monitoring and interventions, pharmacological interventions, and regulations for abuse. During an interview on 7/12/2023 at 10:05 am, the Administrator stated he had been at the facility since mid-December 2022 and was aware of each incident regarding Resident #2. He stated he monitored all incidents that occurred in the facility through the morning meetings. He stated he did not recognize that the incidents were abuse and because of that did not follow the facility abuse program in all aspects. At the time he did not see any risk to the residents but looking back now he could see the risk of injury to the other residents on the unit. He stated going forward he would follow the abuse program. During a phone interview on 7/12/2023 at 3:08 pm, LVN C stated she had been employed at the facility about 9 months but no longer was working at the facility. She stated she remembered the incidents between Resident #2 and Resident #184 and Resident #12. She stated Resident #2 was territorial and the staff tried to keep other residents out of Resident #2's room but at times she and the aides were busy with other task and could not keep their eyes on him all the time. She stated when Resident #2 hit Resident #184 she was notified by the CNA working the hall and she assessed both residents and there were no injuries. She stated she called the doctor, DON and each residents responsible person and notified them of the incident but did not do any special monitoring. She stated when Resident #2 grabbed and pulled Resident #12 to the ground, the CNA got her that time as well. She stated she assessed each resident and called the doctor, DON, and each residents responsible person. She stated Resident #2 and Resident #12 were separated and no other special monitoring was done. She stated the nights she worked at the facility there was only 1 CNA on the secured unit and she would go to the unit if needed. She stated she knew the types of abuse and resident to resident altercations was abuse. She stated when she was hired she was trained on abuse and to report abuse to the DON or abuse coordinator. Record review of facility in-service sign in sheet dated 1/15/2023 indicated a training on abuse and neglect and on 3/6/2023 training on abuse and neglect, types, reporting, policy, and abuse coordinator. Record review of facility policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program dated April 2021 indicated, .Residents have the right to be free from abuse. 1. protect residents from abuse, 2. develop and implement policies and protocols to prevent and identify abuse, 3. ensure adequate staffing, 8. identify and investigate all possible incidents of abuse, 9. Investigate and report any allegations within timeframe required by federal requirements, 10. protect residents from any further harm. Record review of facility policy titled Protection of Residents During Abuse Investigations dated April 2021 indicated, .3. if the alleged abuse involves another resident, there may be restrictions on the accused resident's freedom to visit other resident rooms unattended, 5. The victim is evaluated for safety, measures are taken such as more supervision. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675940 If continuation sheet Page 13 of 63 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 675940 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hemphill Care Center 2000 Worth St Hemphill, TX 75948 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Record review of facility policy titled Identifying Types of Abuse dated April 2021 indicated, .5. Physical abuse includes but is not limited to hitting, slapping, punching. Record review of facility policy titled Abuse and Neglect Clinical Protocol dated March 2018 indicated, .The staff will investigate alleged abuse, the facility management will institute measures to address the needs of residents and minimize the possibility of abuse, the management will address situations of suspected or identified abuse and report them in a timely manner, and the staff and physician will monitor individuals who have been abused to address any issues regarding their medical condition, mood and function. Record review of facility policy titled Coordinating/Implementing Abuse, Neglect and Exploitation indicated, .the administrator is responsible for the overall coordination and implementation of the facility's policies and procedures against abuse. 1. Policies are in place that: a. prohibit and prevent resident abuse, b. establish processes to investigate such allegations, 2. policies address the following as part of abuse: c. prevention, d. identification of violations, e. investigative processes, f. protection of residents during investigations, g. reporting of and response to investigations, 3. the administrator has the overall responsibility for the coordination and implementation for facility's policies and procedures. Record review of facility policy titled Resident-to-Resident Altercations dated September 2022 indicated, .1.facility staff monitor residents for aggressive behaviors towards other residents, 3. Occurrences of such incidents are promptly reported to the nurse supervisor, DON, and administrator. The administrator will report the incident in accordance with the criteria established under Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, 4. If two residents are involved in an altercation staff: a. separate the residents b. identify what happened c. notify each resident's representative and the attending physician d. review the event with the DON e. consult the attending physician f. make changes to care plan if necessary g. document in the resident's clinical record h. consult psychiatric services as needed i. complete a report of Incident/Accident form j. report the incident, findings and corrective actions to appropriate agencies.5. Inquiries concerning resident-to resident altercations are referred to the DON or the administrator. Record review of facility policy titled Abuse, Neglect, Exploitation or misappropriation - Reporting and Investigating dated April 2021 indicated .All reports of resident abuse are reported to local, state and federal agencies and thoroughly investigated by facility management. 1. Resident abuse must be reported immediately to the administrator and to other officials according to state law, 3. Immediately is defined as within 2 hours of allegation involving abuse, 6. Upon receiving any abuse allegation the administrator is responsible for determining what actions are needed for the protection of residents. The facility Administrator was notified on 07/11/2022 at 4:13 PM that an Immediate Jeopardy situation had been identified due to the above failures and the IJ template was given at that time. The facility's plan of removal was accepted on 07/13/2022 at 3:35 PM and included: The facility will in-service all staff on abuse policy and procedure. To include types of abuse, reporting abuse, prevention of abuse, resident protection during abuse allegations and incidents, and signs and symptoms of abuse. Staff will be trained in de-escalation techniques and interventions to prevent resident to resident altercations. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675940 If continuation sheet Page 14 of 63 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 675940 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hemphill Care Center 2000 Worth St Hemphill, TX 75948 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 0600 The facility will assess all residents on the secured unit for changes in their behavior monitoring or notations of emotional distress. Level of Harm - Immediate jeopardy to resident health or safety The facility will in-service all staff on providing an environment free of hazards. Residents Affected - Some The facility will have psychiatric service provider in-service the DON/ADON/RDC (regional director of clinical) on de-escalation techniques and protecting residents to provide to all staff. The facility will in-service all staff on abuse policy-protection, protecting residents from abuse from residents with history of multiple physical incidents and recognizing patterns of behaviors. The facility will in-service any agency staff on all related in-services before being permitted to work. The facility will complete an elopement assessment on Resident #2 to ensure that the resident still needed a secure unit. Resident #2 will be placed on Q15 monitoring until psychiatric telehealth review could be achieved. Resident #2 will be assessed via psychiatric telehealth services and placed on 1:1 to initiate nursing assessment review of psychiatric medication changes regarding behavior changes or safety measures because of these changes. A 30-day discharge will be initiated due to IDT determination. The facility will assign 1:1 designated staff to Resident #2 x 3 days following psychiatric evaluation. The facility will adjust staffing with the day shift having 2 nurse aides assigned to the secured unit and night shift having 1 nurse aide and 1 nurse assigned to the secured unit. Facility will complete weekly QAPI review pertaining to abuse/neglect and accident and incidents. The RDO (regional director of operations) will complete an in-service with the administrator and DON regarding abuse policy and procedure for types of abuse, reporting and investigating according to facility policies. The facility administrator or designee will monitor and review all Accident/Incident reports and follow up accordingly. The IDT will review and assess each Accident/incident to determine any further actions needed. IDT members to include the administrator, DON, ADON, MDS coordinator, Social Worker, and therapy representative. The corporate staff will review all incident/accidents daily for 6 months and reevaluate the need for continued review. On 07/13/2023, the surveyors confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy by: During an observation on 7/12/2023 at 7:40 am Resident #2 was up in his wheelchair eating breakfast with a facility staff present in room for 1 on 1 monitoring. During an interview on 7/12/2023 at 7:43 am laundry aide O stated she worked at the facility in laundry but was asked to sit and provide 1 on 1 supervision to Resident #2 to prevent any altercations with other residents. During an observation on 7/12/23 at 3:10 pm 1:1 sitter present with Resident #2 in his room. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675940 If continuation sheet Page 15 of 63 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 675940 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hemphill Care Center 2000 Worth St Hemphill, TX 75948 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 0600 During an observation on 7/13/23 at 7:25 am and 1:10 pm 1:1 sitter present with Resident #2. Level of Harm - Immediate jeopardy to resident health or safety Staff interviews on 7/13/2023 10:45-2:50 pm completed with Administrator, DON, ADON, BOM, Activity Director, Housekeeping Supervisor, MDS coordinator, Maintenance supervisor, DM, dietary cook, CNA A, CNA E, CNA I, CNA N, Restorative aide, transportation aide, LVN J, LVN M, RN F, HSK K, and laundry aide H was able to verbalize the abuse policy and procedure, de-escalation techniques, interventions to prevent resident to resident altercations, providing environment free of hazards, protecting residents and recognizing patterns of behaviors. The DON and administrator verbalized abuse policy, reporting and investigating per facility policies, and agency staff permitted to work after in-services received. Residents Affected - Some During a phone interview on 7/13/2023 at 2:35 pm LVN M stat[TRUNCATED] FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675940 If continuation sheet Page 16 of 63 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 675940 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hemphill Care Center 2000 Worth St Hemphill, TX 75948 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 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record reviews, the facility failed to implement written policies and procedures that prohibit abuse/neglect for 4 of 10 residents (Resident #12, Resident #184, Resident #185, and Resident #186) ) reviewed for incidents. Residents Affected - Some The facility failed to implement their abuse policy and program to prevent abuse when Resident #2 abused Resident #12, Resident #184, Resident #185, and Resident #186. An IJ (immediate jeopardy) was identified on 07/11/2023 at 4:13 PM. The IJ template was provided to the facility on [DATE] at 4:13 PM. While the IJ was removed on 07/13/2023 at 3:35 PM, the facility remained out of compliance at a severity level of actual harm that is not immediate with a scope of pattern due to the facility's need to monitor and evaluate the effectiveness of their plan of removal and corrective actions. These deficient practices affected all residents and contributed to further abuse. Findings included: 1. Record review of facility face sheet dated 7/11/2023 indicated Resident #2 was a [AGE] year-old male admitted to the facility on [DATE] with a primary diagnosis of bipolar disorder (mood disorder), psychosis (mental disorder), and anxiety. Record review of comprehensive MDS dated [DATE] indicated Resident #2 had a BIMS of 99 indicating Resident #2 was unable to complete interview. Section C for cognition indicated Resident #2 had disorganized thinking. Section E for behaviors indicated Resident #2 had verbal behaviors directed toward others and resident had wandered. Record review of care plan dated 05/08/2023 indicated Resident #2 required psychotropic medications for diagnosis of behavior management, bipolar disorder, and psychosis. Resident #2 had impaired cognitive function and dementia or impaired thought processes related to dementia and psychosis and required the secured unit due to risk of elopement and wandering. Resident #2 had physical behaviors towards residents and staff with interventions added on 03/04/2023 to separate from resident and redirect to room, 3/09/2023 Seroquel increased, and 4/27/2023 resident #2 was sent to a behavioral hospital for evaluation and treatment. Record review of physician orders dated 7/11/2023 indicated Resident #2 had order for behavior monitoring, lorazepam 1 mg by mouth as needed for anxiety and Seroquel 100mg by mouth at bedtime. Record review of facility incident report dated 11/23/2022 revealed a resident-to-resident altercation that occurred between Resident # 2 and Resident #185. Resident #185 wandered by Resident #2's door on the secured unit, and Resident #2 grabbed Resident #185's arm and struck her in the upper chest. Resident #185 was removed from area, the responsible parties, physician, and administrator was notified. Record review of facility progress note dated 11/22/2023 at 6:18 pm LVN P stated was called to Resident #2's room by the aide working on the unit and the aide reported Resident #185 was walking by Resident #2's room when he grabbed Resident #185's arm and hit her in the chest before the aide was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675940 If continuation sheet Page 17 of 63 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 675940 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hemphill Care Center 2000 Worth St Hemphill, TX 75948 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 0607 Level of Harm - Immediate jeopardy to resident health or safety able to intervene. The aide separated the resident's and nurse notified the administrator. The administrator said an incident report was not needed due to resident's mental status. Record review of a facility progress note dated 12/05/2022 at 3:14 pm LVN L stated Resident #185 entered Resident #2's room, stooped down towards his face and Resident#2 punched Resident #185 on the left side of the face. Resident #185 was redirected and continue to monitor for behaviors. Residents Affected - Some Record review of incident report log and no incident recorded on 12/05/2022 regarding incident between Resident #2 and Resident #185. Record review of incident report dated 01/15/2023 stated Resident #2 rolled up to Resident #186 at the dining table and Resident #2 pulled, twisted, and yanked Resident #186's right arm. CNA A attempted to separate the residents and Resident #2 punched CNA A in the jaw. Administrator and physician were notified. Record review facility progress note dated 01/15/2023 at 11:33 am LVN P stated upon entering the unit, was notified Resident #2 had attacked Resident #186 and CNA A. Record review of incident report dated 03/04/2023 stated Resident #2 hit Resident#184 with an open hand on the left side of the face. Residents were separated and head to toe assessment completed. DON, physician, and families notified. Record review of progress note dated 03/05/2023 at 2:54 am LVN C stated was notified by RA assigned to the unit; Resident #2 had hit Resident #184 with an open hand to the left side of the face when Resident #184 had gotten to close to Resident #2. RA was advised to do frequent monitoring and hallway checks. Record review of incident report dated 03/09/2023 stated resident #2 grabbed Resident #12 by the right arm and pulled her to the floor in the hallway. Head to toe assessment complete, physician, DON, and families notified. Record review of progress note dated 03/09/2023 at 4:36 am LVN C stated notified by RA assigned to the unit resident #12 was on the floor. RA reported that Resident #2 was sitting in the hallway when Resident #12 attempted to wander into Resident #2's room. Resident #2 grabbed Resident #12 by the right forearm pulling her to the floor. Head to toe assessment completed with no injuries noted to Resident #12. Resident #2 was redirected into his room and assisted to bed. Record review of incident report dated 4/27/2023 stated Resident #2 hit Resident #184. Resident #2 was noted to have two skin tears on his right knuckle. The CNA assigned to the unit reports when she was coming up the hall she noticed Resident #184 was no longer at the dining table. She then heard Resident #2 yelling from his room and when she entered the Resident #2's room, Resident #184 was sitting in a chair and had blood coming from his mouth on the left side. Both residents separated, assessed for injuries, Resident #2 placed on every 15-minute checks and referral sent to Behavioral Hospital. Physician, Administrator, DON and families notified. 2. Record review of facility face sheet dated 7/11/2023 indicated Resident #12 was a [AGE] year-old female admitted to the facility 9/19/2020 with the diagnosis of Alzheimer's disease. Record review of quarterly MDS dated [DATE] indicated Resident #12 had a BIMS of 99 indicating (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675940 If continuation sheet Page 18 of 63 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 675940 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hemphill Care Center 2000 Worth St Hemphill, TX 75948 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 0607 Level of Harm - Immediate jeopardy to resident health or safety Resident #12 was unable to complete the interview. Section E for behaviors indicated Resident #12 wandered daily. Record review of comprehensive care plan dated 4/25/2023 indicated Resident #12 required secured unit placement due to elopement risk and Resident #12 had potential to demonstrate physical behaviors with interventions to analyze what deescalates behavior and document and intervene before agitation escalates. Residents Affected - Some Record review of incident report dated 03/09/2023 stated resident #12 was grabbed by the right arm and pulled to the floor by Resident #2 in the hallway. Head to toe assessment complete, physician, DON, and families notified. Record review of progress note dated 03/09/2023 at 5:20 am LVN C stated was notified by RA assigned to the unit Resident #12 was on the floor. RA reported that Resident #12 attempted to wander into Resident #2's room. Resident #2 grabbed Resident #12 by the right forearm pulling her to the floor. Head to toe assessment completed with no injuries noted to Resident #12. 3.Record review of facility face sheet dated 7/12/2023 indicated Resident #184 was an [AGE] year-old male admitted to the facility on [DATE] with a diagnosis of Alzheimer's disease. Record review of admission MDS dated [DATE] indicated Resident #184 had a BIMS of 99 indicating Resident #184 was unable to complete the interview. Section E for behaviors indicated verbal behaviors directed towards others and wandered daily. Record review of comprehensive care plan dated 02/26/2023 indicated Resident # 184 had a potential to demonstrate physical behaviors with interventions to analyze triggers and what de-escalates behaviors and document and was an elopement risk requiring a secured unit. Record review of nurse progress note dated 3/05/2023 at 2:15 am LVN C stated was notified by RA assigned to the unit Resident #184 had been hit to the left side of the face with an open hand by Resident #2. RA was advised to do frequent checks on Resident #184 and monitor the hallway. Responsible pat, DON, ADON and physician notified. Record review of nurse progress note dated 4/28/2023 at 3:57 pm ADON stated on 4/27/2023 at 5:18 pm was alerted by CNA assigned to the unit that Resident #2 had hit Resident #184. Nurse entered the unit and Resident #184 was standing in the hall with the CNA and had a gash and blood to left side of his mouth. 4. Record review of facility face sheet dated 7/12/2023 indicated Resident #185 was a [AGE] year-old female admitted to the facility on [DATE] with diagnosis of Alzheimer's disease. Record review of admission MDS dated [DATE] indicated Resident #185 had a BIMS of 01 indicating severe cognitive deficit. Section E for behaviors indicated Resident # 185 had physical behavioral symptoms directed towards others and had wandered. Record review of comprehensive care plan dated 11/16/2022 indicated Resident #185 had potential for psychosocial problem and required secured unit and was an elopement risk for wandering. Record review of nurse progress note dated 11/23/22 at 8:28 pm LVN P stated on 11/22/2023 at 3:30 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675940 If continuation sheet Page 19 of 63 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 675940 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hemphill Care Center 2000 Worth St Hemphill, TX 75948 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 0607 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some pm nurse was notified by the aide working the secured unit that Resident #185 was attempting to wander into Resident #2's room. Resident #2 grabbed Resident #185 by the arm and struck her in the chest twice before the aide could stop him. One on one care being provided to keep resident from wandering back into Resident #2's room until Resident #185 can be transferred to an all-female secured unit on Monday 11/28/2022. Record review of electronic health record for Resident #185 indicated no documentation of one-on-one monitoring initiated after incident on 11/22/2022. Record review of nurse progress note dated 12/2/2023 at 5:09 pm LVN Q indicated Resident #185 was hit in the face by Resident #2 causing an abrasion to her left cheek. On review, the dates documented for the incident for Resident #185 and Resident #2 do not match. No record of incident report found in the electronic health record. 5. Record review of facility face sheet dated 7/12/2023 indicated Resident # 186 was a [AGE] year-old male admitted to the facility on [DATE] with diagnosis of hemiplegia following cerebral infarction (paralysis following a stroke). Record review of admission MDS 12/12/2022 indicated Resident #186 had moderately impaired cognition requiring supervision and wandered. Record review of comprehensive care plan dated 12/20/2022 indicated Resident # 186 had a communication problem and to provide a safe environment. Record review of Resident #186's electronic health record with no documentation related to altercation with Resident #2 on 01/15/2023. During an observation on 07/10/23 at 09:12 AM CNA A and CNA B were present on the secured unit that housed 10 residents. During an observation on 7/10/2023 at 12:10 pm Resident #2 was up in his wheelchair in his room eating lunch. Resident #2 propels self in wheelchair and resides in a private room. During an interview on 07/10/2023 at 12:15 pm CNA A stated she had worked at the facility for 8 months and primarily was assigned to the secured unit. She stated the residents on the unit need supervision as they wander and get into things. She stated Resident #2 had been at the facility a long time and had a history of being aggressive if other residents entered his space. She stated she tried to keep everyone else away from him. She stated there was an incident when Resident #2 pulled another resident's arm in the dining room and when she intervened Resident #2 hit her. She stated the nurse was notified and Resident #2 returned to his room. She stated she had training on caring for residents with behaviors and incidents or abuse as to be reported to the nurse and administrator. During an interview on 07/10/20023 at 12:40 pm CNA B stated she had worked at the facility almost 2 years and worked the secured unit. She stated that during the day there are 2 CNAs on the unit and the nurse comes on and off the unit throughout the day. She stated that the residents on the unit have behaviors and she had been trained on how to control outburst but it does not always work. She stated Resident #2 did have some issues a few months ago but in the last few months had been better. She stated as long as no one messes with him he is fine. She stated there had not been any special interventions for Resident #2 and she just tried to keep an eye on him and prevent the other residents (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675940 If continuation sheet Page 20 of 63 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 675940 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hemphill Care Center 2000 Worth St Hemphill, TX 75948 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 0607 from going around. Level of Harm - Immediate jeopardy to resident health or safety During an interview on 7/11/2023 at 10:11 AM the RA stated he had been employed at the facility for 3 months part time. He said when he worked he worked all over the facility. He stated Resident #2 was on the secured unit and stayed in a wheelchair usually in his doorway of his room. He stated the incident with Resident #2 and Resident #184 he had worked that night and witnessed the incident. He stated Resident #184 walked up to Resident #2's wheelchair and Resident #2 hit resident #184 in the face. He said he reported to the nurse LVN C and immediately separated both residents. He stated LVN C told him to write a witness statement and she called the hospice nurse. He stated he stayed in the hallway in the secured unit and put Resident #184 back to bed. He stated Resident #184 was a wanderer and he did not go back into the room of Resident #2. He stated LVN C checked on Resident #184 but could not recall any in-services or other interventions following that incident. He stated the incident with Resident #2 and Resident #12 was witnessed by him. He stated Resident #2 was sitting in the doorway of his room and Resident #12 went into his room but by the time he made it there, Resident #2 had already grabbed her by the arm and she fell to her knees. He stated Resident #12 jumped back up and he called to the nurse station to notify LVN C. He stated LVNC came and provided first aide to Resident 12's arm because she had a skin tear. He stated he was instructed by the nurse to write out a witness statement but no other special instructions were given. He said he had received training on abuse/neglect. He stated Resident #2 liked to sit in the doorway of his room and did not like other residents going in his room. He stated he was told by facility staff prior to working on the secured unit to monitor Resident #2 to ensure no residents entered his room. He stated at the time of both incidents, he was the only staff on the secured unit. He stated both incidents occurred on the night shift and usually there was only 1 aide on the unit at night. He stated the nurse stayed at the nurse station outside of the unit and they would come to the unit about 2-3 times a night. Residents Affected - Some A phone call was attempted to LVN C on 7/11/2023 at 10:34 am and 4:43 pm with no answer and voicemail left. During an interview on 7/11/2023 at 11:01 am the DON stated she had started as the facility DON in February 2023. She stated that when she first started she was told that resident to resident altercations was not abuse if it occurred between residents on the secured unit that had cognitive delays and did not have to be investigated or reported to the state unless the other resident suffered a significant injury. She stated she had knowledge of the altercations regarding Resident #2 and the nurse had notified her with each incident but had missed that the altercations were abuse. She stated the administrator was aware and he did not treat the altercations as abuse either. She stated that with each incident the aide separated the residents, the nurse was notified, and the victim was assessed. She stated she knew the facilities policy on abuse and the process of investigation and reporting but with the incidents that occurred since she had been DON with Resident #2 were missed. She stated in April her regional nurse notified her that all resident-to-resident altercations were to be investigated, reported and followed through to prevent further abuse. She stated by not following the abuse program the risk to the residents could be significant. During an interview on 7/12/23 at 7:32 am CNA D stated she had been a CNA 6 years and employed at the facility 2 months. She stated she worked all units and shifts. She stated on the night shift there was only 1 CNA and the nurse came back and forth as needed. She stated if a resident-to-resident altercation occurred on her shift she would report it to the nurse and separate the residents. She stated she was aware of each resident and their moods and Resident #2 prefers to stay to himself and no one be in his space. She stated at night when she worked on the unit by herself, if she was in another resident's room, she just tried to listen for any noise indicating a resident had gotten up or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675940 If continuation sheet Page 21 of 63 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 675940 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hemphill Care Center 2000 Worth St Hemphill, TX 75948 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 0607 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some needed help. She stated she had not had any issues with any residents on the unit since starting to work at the facility. During an interview on 7/12/2023 at 7:48 am Resident #2 stated he did not remember any incidents occurring between him and another resident. He stated he was not sure how long he had been at the facility but there were a lot of people who lived there. He stated if someone were to come in his room that would be just fine but if they messed with him or his stuff he was not sure what he would do. He stated he was not a mean person and tried to get alone with everyone. He stated he stayed in his room and kept to himself. During an interview on 7/12/2023 at 7:53 am CNA E stated she had been a CNA for 21 years and employed at the facility 6 months. She stated she was not working during any of the incidents with Resident # 2. She stated when she was hired she had to go through a full training program through the facilities computer-based training program before she could start to work. She stated the training included signs of abuse, types of abuse and reporting abuse to the administrator. She stated there was training on behavior monitoring and if there was an altercation between residents that they were to be separated and monitored to make sure the incident did not occur again. She stated the nurse was informed and the nurse did a report. She stated when she had worked the unit there were 2 CNA's working during the day. She stated if she and the other CNA were busy she would ask the nurse to come to the unit and help supervise if it was needed. She stated that if residents are not properly supervised and the abuse program was not followed a resident could get hurt. During an interview on 07/12/2023 at 8:01 am RN F stated she was new to the facility as of 2 weeks but had worked in long term care for over 20 years. She stated abuse training was completed when she was hired through the facilities Relias training program. She stated resident to resident altercations are to be reported to the abuse coordinator. The residents were to be separated, the victim assessed, and the perpetrator should be monitored 1 on 1 if needed. She stated she worked the secured unit and was on and off the unit throughout her shift and as needed by the CNA. During an interview on 7/12/2023 at 9:44 am the psychiatrist stated that residents that receive hospice services are not typically seen by psychiatric services but he did follow them if it was requested by the doctor or hospice. He stated he did complete an evaluation on Resident #2 7/11/2023 and with coordination of the son was able to develop a past history and adjust his diagnosis. He stated he did a medication review and made some adjustments with dose times of his antipsychotic and anxiety medications. He stated he will continue to monitor for any symptoms and make other adjustments if needed. He stated the facility has put in place 1 on 1 monitoring to monitor for any negative outcomes to his interventions. He stated he was going to provide the facility staff with more in-depth training today 7/12/2023 on how to care for aggressive residents, behavior monitoring and interventions, pharmacological interventions, and regulations for abuse. During an interview on 7/12/2023 at 10:05 am the administrator stated he had been at the facility since mid-December 2022 and was aware of each incident regarding Resident #2. He stated he monitors all incidents that occur in the facility through the morning meeting. He stated he did not recognize that the incidents were abuse and because of that did not follow the facility abuse program in all aspects . At the time he did not see any risk to the residents but looking back now he could see the risk of injury to the other residents on the unit. He stated going forward he would follow the abuse program. During a phone interview on 7/12/2023 at 3:08 pm LVN C stated she had been employed at the facility (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675940 If continuation sheet Page 22 of 63 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 675940 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hemphill Care Center 2000 Worth St Hemphill, TX 75948 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 0607 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some about 9 months but no longer was working at the facility. She stated she remembered the incidents between Resident #2 and Resident #184 and Resident #12. She stated Resident #2 was territorial and the staff tried to keep other residents out of Resident #2's room but at times she and the aides were busy with other task and could not keep their eyes on him all the time. She stated when Resident #2 hit Resident #184 she was notified by the CNA working the hall and she assessed both residents and there were no injuries. She stated she called the doctor, DON and each residents responsible person and notified them of the incident but did not do any special monitoring. She stated when Resident #2 grabbed and pulled Resident #12 to the ground, the CNA got her that time as well. She stated she assessed each resident and called the doctor, DON, and each residents responsible person. She stated Resident #2 and Resident #12 were separated and no other special monitoring was done. She stated the nights she worked at the facility there was only 1 CNA on the secured unit and she would go to the unit if needed. She stated she knew the types of abuse and resident to resident altercations was abuse. She stated when she was hired she was trained on abuse and to report abuse to the DON or abuse coordinator. Record review of facility in-service sign in sheet dated 1/15/2023 indicated a training on abuse and neglect and on 3/6/2023 training on abuse and neglect, types, reporting, policy, and abuse coordinator. Record review of facility policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program dated indicated, .Residents have the right to be free from abuse. 1. protect residents from abuse, 2. develop and implement policies and protocols to prevent and identify abuse, 3. ensure adequate staffing, 8. identify and investigate all possible incidents of abuse, 9. Investigate and report any allegations within timeframe required by federal requirements, 10. protect residents from any further harm. Record review of facility policy titled Protection of Residents During Abuse Investigations dated April 2021 indicated, .3. if the alleged abuse involves another resident, there may be restrictions on the accused resident's freedom to visit other resident rooms unattended, 5. The victim is evaluated for safety, measures are taken such as more supervision. Record review of facility policy titled Identifying Types of Abuse dated April 2021 indicated, .5. Physical abuse includes but is not limited to hitting, slapping, punching. Record review of facility policy titled Abuse and Neglect Clinical Protocol dated March 2018 indicated, .The staff will investigate alleged abuse, the facility management will institute measures to address the needs of residents and minimize the possibility of abuse, the management will address situations of suspected or identified abuse and report them in a timely manner, and the staff and physician will monitor individuals who have been abused to address any issues regarding their medical condition, mood and function. Record review of facility policy titled Coordinating/Implementing Abuse, Neglect and Exploitation indicated, .the administrator is responsible for the overall coordination and implementation of the facility's policies and procedures against abuse. 1. Policies are in place that: a. prohibit and prevent resident abuse, b. establish processes to investigate such allegations, 2. policies address the following as part of abuse: c. prevention, d. identification of violations, e. investigative processes, f. protection of residents during investigations, g. reporting of and response to investigations, 3. the administrator has the overall responsibility for the coordination and implementation for facility's policies and procedures. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675940 If continuation sheet Page 23 of 63 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 675940 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hemphill Care Center 2000 Worth St Hemphill, TX 75948 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 0607 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Record review of facility policy titled Resident-to-Resident Altercations dated September 2022 indicated, .1.facility staff monitor residents for aggressive behaviors towards other residents, 3. Occurrences of such incidents are promptly reported to the nurse supervisor, DON, and administrator. The administrator will report the incident in accordance with the criteria established under Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, 4. If two residents are involved in an altercation staff: a. separate the residents b. identify what happened c. notify each resident's representative and the attending physician d. review the event with the DON e. consult the attending physician f. make changes to care plan if necessary g. document in the resident's clinical record h. consult psychiatric services as needed i. complete a report of Incident/Accident form j. report the incident, findings and corrective actions to appropriate agencies.5. Inquiries concerning resident-to resident altercations are referred to the DON or the administrator. Record review of facility policy titled Abuse, Neglect, Exploitation or misappropriation - Reporting and Investigating dated April 2021 indicated .All reports of resident abuse are reported to local, state and federal agencies and thoroughly investigated by facility management. 1. Resident abuse must be reported immediately to the administrator and to other officials according to state law, 3. Immediately is defined as within 2 hours of allegation involving abuse, 6. Upon receiving any abuse allegation the administrator is responsible for determining what actions are needed for the protection of residents. The facility Administrator was notified on 07/11/2022 at 4:13 PM that an Immediate Jeopardy situation had been identified due to the above failures and the IJ template was given at that time. The facility's plan of removal was accepted on 07/13/2022 at 03:35 PM and included: The facility will in-service all staff on abuse policy and procedure. To include types of abuse, reporting abuse, prevention of abuse, resident protection during abuse allegations and incidents, and signs and symptoms of abuse. Staff were trained in de-escalation techniques and interventions to prevent resident to resident altercations. The RDO will in-service facility administrator regarding reporting abuse and neglect according to Provider Letter 19-17 and federal regulations. The facility will assess all residents on the secured unit for changes in their behavior monitoring or notations of emotional distress. The RDO will in-service all administrative staff regarding reporting guidelines. The facility will in-service all staff on providing an environment free of hazards. The facility will have psychiatric service provider in-service the DON/ADON/RDC (regional director of clinical) on de-escalation techniques and protecting residents to provide to all staff. The facility will in-service any agency staff on all related in-services before being permitted to work. The facility will complete an elopement assessment on Resident #2 to ensure that the resident still needed a secure unit. Resident #2 will be placed on Q15 monitoring until psychiatric telehealth review could be achieved. Resident #2 will be assessed via psychiatric telehealth services and placed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675940 If continuation sheet Page 24 of 63 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 675940 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hemphill Care Center 2000 Worth St Hemphill, TX 75948 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 0607 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some on 1:1 to initiate nursing assessment review of psychiatric medication changes regarding behavior changes or safety measures because of these changes. A 30-day discharge will be initiated due to IDT determination. The facility will assign 1:1 designated staff to Resident #2 x 3 days following psychiatric evaluation. The facility will adjust staffing with the day shift having 2 nurse aides assigned to the secured unit and night shift having 1 nurse aide and 1 nurse assigned to the secured unit. The RDC (regional director of clinical) will in-service all licensed nursing staff over accidents and incident policy and procedure including investigating and documentation of events per facility protocol. All IDT members will be in-serviced on 24-hour report required review during stand-up meeting. The administrator, DON and ADON will review every incident report during the stand-up to ensure investigation, interventions and documentation is appropriate for resident safety and resident needs as applicable to prevent re-occurrence and provide protection. The facility will complete weekly QAPI review pertaining to abuse/neglect and accident and incidents. The facility administrator or designee will monitor and review all Accident/Incident reports and follow up accordingly. The IDT will review and assess each Accident/incident to determine any further actions needed. IDT members to include the administrator, DON, ADON, MDS coordinator, Social Worker, and therapy representative. The corporate staff will review all incident/accidents daily for 6 months and reevaluate the need for continued review. On 07/13/2023, the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy by: During an observation on 7/12/2023 at 7:40 am Resident #2 was up in his wheelchair eating breakfast with a facility staff present in room for 1 on 1 monitoring. During an interview on 7/12/2023 at 7:43 am laundry aide stated she worked at the facility in laundry but was asked to sit and provide 1 on 1 supervision to Resident #2 to prevent any altercations with other residents. During an observation on 7/12/23 at 3:10 pm 1:1 sitter present with Resident #2 in his room. During an observation on 7/13/23 at 7:25 am and 1:10 pm 1:1 sitter present with Resident #2 in his room. Staff interviews on 7/13/2023 10:45-2:50 pm completed with Administrator, DON, ADON, BOM, Activity Director, Housekeeping Supervisor, MDS coordinator, Maintenance supervisor, DM, dietary cook, CNA A, CNA E, CNA I, CNA N, Restorative aide, transportation aide, LVN J, LVN M, RN F, HSK K, and laundry aide H was able to verbalize the abuse policy and procedure, de-escalation techniques, interventions to prevent resident to resident altercations, providing environment free of hazards, protecting residents and recognizing patterns of behaviors. The DON and administrator verbalized abuse policy, reporting and investigating per facility policies, and agency staff permitted to work after in-services received. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675940 If continuation sheet Page 25 of 63 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 675940 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hemphill Care Center 2000 Worth St Hemphill, TX 75948 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 0607 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some During a phone interview on 7/13/2023 at 2:35 pm LVN M stated she worked the night shift and verbalized 1 CNA and 1 nurse were to reside on the unit at night. LVN M stated the other LVN was to cover the secured unit if she were to need to come off unit for a break. Record review of Resident #2's electronic health record indicated Resident #2 had an updated elopement risk completed, Q15 min checks were completed from 7/11/2023 at 4:30 pm until 7:00 pm and was seen by psychiatrist for evaluation on 7/11/23. Resident #2's medications were adjusted and 1 on 1 started 7/11/2023 at 7:15 pm to evaluate changes in behaviors and safety x 3 days. 1 on 1 to complete 7/15/23 with a reevaluation. Record review of psychiatric note dated 7/11/2023 indicated Resident #2 was evaluated[TRUNCATED] FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675940 If continuation sheet Page 26 of 63 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 675940 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hemphill Care Center 2000 Worth St Hemphill, TX 75948 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 - Some 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 interview and record review, the facility failed to ensure all alleged violations involving abuse, neglect, exploitation, or mistreatment were 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 for 4 of 10 residents (Resident #12, Resident #184, Resident #185, and Resident #186) reviewed for abuse and neglect. 1. On 11/22/2022 Resident #185 wandered by Resident #2's door on the secured unit, and Resident #2 grabbed Resident #185's arm and struck her in the upper chest. The incident was not reported to the state agency as required. 2. On 12/05/2022 Resident #185 wandered into Resident #2's room on the secured unit, and Resident #2 punched Resident #185 in the face causing an abrasion to her left check. The incident was not reported to the state agency as required. 3. On 01/15/2023 Resident #2 grabbed and yanked Resident #186's arm backwards. The incident was not reported to the state agency as required 4. On 03/04/2023 Resident #2 hit Resident #184 with an open hand on the left side of his face. The incident was not reported to the state agency as required 5. On 03/09/2023 Resident #12 wandered by Resident #2's door on the secured unit. and Resident #2 grabbed Resident #12's right arm pulling her to the floor. The incident was not reported to the state agency as required. This failure could place all residents at risk of emotional, physical, mental abuse and neglect. Findings included: 1. Record review of facility face sheet dated 7/11/2023 indicated Resident #2 was a [AGE] year-old male admitted to the facility on [DATE] with a primary diagnosis of bipolar disorder (mood disorder), psychosis (mental disorder), and anxiety. Record review of comprehensive MDS dated [DATE] indicated Resident #2 had a BIMS of 99 indicating Resident #2 was unable to complete interview. Section C for cognition indicated Resident #2 had disorganized thinking. Section E for behaviors indicated Resident #2 had verbal behaviors directed toward others and resident had wandered. Record review of care plan dated 05/08/2023 indicated Resident #2 required psychotropic medications for diagnosis of behavior management, bipolar disorder, and psychosis. Resident #2 had impaired cognitive function and dementia or impaired thought processes related to dementia and psychosis and required the secured unit due to risk of elopement and wandering. Resident #2 had physical behaviors towards residents and staff with interventions added on 03/04/2023 to separate from resident and redirect to room, 3/09/2023 Seroquel increased, and 4/27/2023 resident #2 was sent to a Behavioral Hospital for evaluation and treatment. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675940 If continuation sheet Page 27 of 63 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 675940 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hemphill Care Center 2000 Worth St Hemphill, TX 75948 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 - Some Record review of physician orders dated 7/11/2023 indicated Resident #2 had order for behavior monitoring, lorazepam 1 mg by mouth as needed for anxiety and Seroquel 100mg by mouth at bedtime. Record review of facility incident report dated 11/23/2022 revealed a resident-to-resident altercation that occurred between Resident # 2 and Resident #185. Resident #185 wandered by Resident #2's door on the secured unit, and Resident #2 grabbed Resident #185's arm and struck her in the upper chest. Resident #185 was removed from area, the responsible parties, physician, and administrator was notified. Record review of facility progress note dated 11/22/2023 LVN P stated the nurse was called to Resident #2's room by the aide working on the unit and the aide reported Resident #185 was walking by Resident #2's room when he grabbed Resident #185's arm and hit her in the chest before the aide was able to intervene. The aide separated the resident's and nurse notified the administrator. The administrator said an incident report was not needed due to resident's mental status. Record review of a facility progress note dated 12/05/2022 LVN L stated Resident #185 entered Resident #2's room, stooped down towards his face and Resident#2 punched Resident #185 on the left side of the face. Resident #185 was redirected and continue to monitor for behaviors. Record review of incident report log and no incident recorded on 12/05/2022 regarding incident between Resident #2 and Resident #185. Record review of incident report dated 01/15/2023 stated Resident #2 rolled up to Resident #186 at the dining table and Resident #2 pulled, twisted, and yanked Resident #186's right arm. CNA A attempted to separate the residents and Resident #2 punched CNA A in the jaw. Administrator and physician were notified. Record review facility progress note dated 01/15/2023 LVN P stated upon entering the unit, was notified Resident #2 had attacked Resident #186 and CNA A. Record review of incident report dated 03/04/2023 stated Resident #2 hit Resident#184 with an open hand on the left side of the face. Residents were separated and head to toe assessment completed. DON, physician, and families notified. Record review of progress note dated 03/05/2023 LVN C stated was notified by RA assigned to the unit; Resident #2 had hit Resident #184 with an open hand to the left side of the face when Resident #184 had gotten to close to Resident #2. RA was advised to do frequent monitoring and hallway checks. Record review of incident report dated 03/09/2023 stated resident #2 grabbed Resident #12 by the right arm and pulled her to the floor in the hallway. Head to toe assessment complete, physician, DON, and families notified. Record review of progress note dated 03/09/2023 LVN C stated was notified by RA assigned to the unit resident #12 was on the floor. RA reported that Resident #2 was sitting in the hallway when Resident #12 attempted to wander into Resident #2's room. Resident #2 grabbed Resident #12 by the right forearm pulling her to the floor. Head to toe assessment completed with no injuries noted to Resident #12. Resident #2 was redirected into his room and assisted to bed. 2. Record review of facility face sheet dated 7/11/2023 indicated Resident #12 was a [AGE] year-old (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675940 If continuation sheet Page 28 of 63 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 675940 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hemphill Care Center 2000 Worth St Hemphill, TX 75948 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 female admitted to the facility 9/19/2020 with the diagnosis of Alzheimer's disease. Level of Harm - Minimal harm or potential for actual harm Record review of quarterly MDS dated [DATE] indicated Resident #12 had a BIMS of 99 indicating Resident #12 was unable to complete the interview. Section E for behaviors indicated Resident #12 wandered daily. Residents Affected - Some Record review of comprehensive care plan dated 4/25/2023 indicated Resident #12 required secured unit placement due to elopement risk and Resident #12 had potential to demonstrate physical behaviors with interventions to analyze what deescalates behavior and document and intervene before agitation escalates. Record review of incident report dated 03/09/2023 stated resident #12 was grabbed by the right arm and pulled to the floor by Resident #2 in the hallway. Head to toe assessment complete, physician, DON, and families notified. Record review of progress note dated 03/09/2023 LVN C stated nurse was notified by RA assigned to the unit Resident #12 was on the floor. RA reported that Resident #12 attempted to wander into Resident #2's room. Resident #2 grabbed Resident #12 by the right forearm pulling her to the floor. Head to toe assessment completed with no injuries noted to Resident #12. 3.Record review of facility face sheet dated 7/12/2023 indicated Resident #184 was an [AGE] year-old male admitted to the facility on [DATE] with a diagnosis of Alzheimer's disease. Record review of admission MDS dated [DATE] indicated Resident #184 had a BIMS of 99 indicating Resident #184 was unable to complete the interview. Section E for behaviors indicated verbal behaviors directed towards others and wandered daily. Record review of comprehensive care plan dated 02/26/2023 indicated Resident # 184 had a potential to demonstrate physical behaviors with interventions to analyze triggers and what de-escalates behaviors and document and was an elopement risk requiring a secured unit. Record review of nurse progress note dated 3/05/2023 LVN C stated nurse was notified by RA assigned to the unit Resident #184 had been hit to the left side of the face with an open hand by Resident #2. RA was advised to do frequent checks on Resident #184 and monitor the hallway. Responsible parties , DON, ADON and physician notified. 4. Record review of facility face sheet dated 7/12/2023 indicated Resident #185 was a [AGE] year-old female admitted to the facility on [DATE] with diagnosis of Alzheimer's disease. Record review of admission MDS dated [DATE] indicated Resident #185 had a BIMS of 01 indicating severe cognitive deficit. Section E for behaviors indicated Resident # 185 had physical behavioral symptoms directed towards others and had wandered. Record review of comprehensive care plan dated 11/16/2022 indicated Resident #185 had potential for psychosocial problem and required secured unit and was an elopement risk for wandering. Record review of nurse progress note dated 11/23/22 LVN P stated on 11/22/2023 at 3:30 pm nurse was notified by the aide working the secured unit that Resident #185 was attempting to wander into Resident #2's room. Resident #2 grabbed Resident #185 by the arm and struck her in the chest twice (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675940 If continuation sheet Page 29 of 63 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 675940 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hemphill Care Center 2000 Worth St Hemphill, TX 75948 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 - Some before the aide could stop him. One on one care being provided to keep resident from wandering back into Resident #2's room until Resident #185 can be transferred to an all-female secured unit on Monday 11/28/2022. Record review of nurse progress note dated 12/2/2023 LVN Q indicated Resident #1185 was hit in the face by Resident #2 causing an abrasion to her left cheek. On review, the dates documented for the incident for Resident #185 and Resident #2 do not match. No record of incident report found in the electronic health record. 5. Record review of facility face sheet dated 7/12/2023 indicated Resident # 186 was a [AGE] year-old male admitted to the facility on [DATE] with diagnosis of hemiplegia following cerebral infarction (paralysis following a stroke). Record review of admission MDS 12/12/2022 indicated Resident #186 had moderately impaired cognition requiring supervision and wandered. Record review of comprehensive care plan dated 12/20/2022 indicated Resident # 186 had a communication problem and to provide a safe environment. Record review of Resident #186's electronic health record with no documentation related to altercation with Resident #2 on 01/15/2023. During an observation on 07/10/23 at 09:12 am CNA A and CNA B were present on the secured unit that housed 10 residents. During an observation on 7/10/2023 at 12:10 pm Resident #2 was up in his wheelchair in his room eating lunch. Resident #2 propels self in wheelchair and resides in a private room. During an interview on 07/10/2023 at 12:15 pm CNA A stated she had worked at the facility for 8 months and primarily was assigned to the secured unit. She stated the residents on the unit need supervision as they wander and get into things. She stated Resident #2 had been at the facility a long time and had a history of being aggressive if other residents entered his space. She stated she tried to keep everyone else away from him. She stated there was an incident when Resident #2 pulled another resident's arm in the dining room and when she intervened Resident #2 hit her. She stated the nurse was notified and Resident #2 returned to his room. She stated she had training on caring for residents with behaviors and incidents or abuse as to be reported to the nurse and administrator. During an interview on 07/10/20023 at 12:40 pm CNA B stated she had worked at the facility almost 2 years and worked the secured unit. She stated that during the day there are 2 CNAs on the unit and the nurse comes on and off the unit throughout the day. She stated that the residents on the unit have behaviors and she had been trained on how to control outburst but it does not always work. She stated Resident #2 did have issues a few months ago but in the last few months had been better. She stated as long as no one messes with him he is fine. She stated there had not been any special interventions for Resident #2 and she just tried to keep an eye on him and prevent the other residents from going around him. During an interview on 7/11/2023 at 10:11 am the RA stated he had been employed at the facility for 3 months part time. He said when he worked he worked all over the facility. He stated Resident #2 was on the secured unit and stayed in a wheelchair usually in his doorway of his room. He stated the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675940 If continuation sheet Page 30 of 63 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 675940 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hemphill Care Center 2000 Worth St Hemphill, TX 75948 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 - Some incident with Resident #2 and Resident #184 he had worked that night and witnessed the incident. He stated Resident #184 walked up to Resident #2's wheelchair and Resident #2 hit resident #184 in the face. He said he reported to the nurse LVN C and immediately separated both residents. He stated LVN C told him to write a witness statement and she called the hospice nurse. He stated he stayed in the hallway in the secured unit and put Resident #184 back to bed. He stated Resident #184 was a wanderer and he did not go back into the room of Resident #2. He stated LVN C checked on Resident #184 but could not recall any in-services or other interventions following that incident. He stated the incident with Resident #2 and Resident #12 was witnessed by him. He stated Resident #2 was sitting in the doorway of his room and Resident #12 went into his room but by the time he made it there, Resident #2 had already grabbed her by the arm and she fell to her knees. He stated Resident #12 jumped back up and he called to the nurse station to notify LVN C. He stated LVN C came and provided first aide to Resident 12's arm because she had a skin tear. He stated he was instructed by the nurse to write out a witness statement but no other special instructions were given. He said he had received training on abuse/neglect. He stated Resident #2 liked to sit in the doorway of his room and did not like other residents going in his room. He stated he was told by facility staff prior to working on the secured unit to monitor Resident #2 to ensure no residents entered his room. He stated at the time of both incidents, he was the only staff on the secured unit. He stated both incidents occurred on the night shift and usually there was only 1 aide on the unit at night. He stated the nurse stayed at the nurse station outside of the unit and they would come to the unit about 2-3 times a night. A phone call was attempted to LVN C on 7/11/2023 at 10:34 am and 4:43 pm with no answer and voicemail left. During an interview on 7/11/2023 at 11:01 am the DON stated she had started as the facility DON in February 2023. She stated that when she first started she was told that resident to resident altercations was not abuse if it occurred between residents on the secured unit that had cognitive delays and did not have to be investigated or reported to the state unless the other resident suffered a significant injury. She stated she had knowledge of the altercations regarding Resident #2 and the nurse had notified her with each incident but had missed that the altercations were abuse. She stated the administrator was aware and he did not treat the altercations as abuse either. She stated that with each incident the aide separated the residents, the nurse was notified, and the victim was assessed. She stated she knew the facilities policy on abuse and the process of investigation and reporting but with the incidents that occurred since she had been DON with Resident #2 were missed. She stated in April her regional nurse notified her that all resident-to-resident altercations were to be investigated, reported and followed through to prevent further abuse. She stated by not following the abuse program the risk to the residents could be significant. During an interview on 7/12/23 at 7:32 am CNA D stated she had been a CNA 6 years and employed at the facility 2 months. She stated she worked all units and shifts. She stated on the night shift there was only 1 CNA and the nurse came back and forth as needed. She stated if a resident-to-resident altercation occurred on her shift she would report it to the nurse and separate the residents. She stated she was aware of each resident and their moods and Resident #2 prefers to stay to himself and no one be in his space. She stated at night when she worked on the unit by herself, if she was in another resident's room, she just tried to listen for any noise indicating a resident had gotten up or needed help. She stated she had not had any issues with any residents on the unit since starting to work at the facility. During an interview on 7/12/2023 at 7:48 am Resident #2 stated he did not remember any incidents occurring between him and another resident. He stated he was not sure how long he had been at the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675940 If continuation sheet Page 31 of 63 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 675940 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hemphill Care Center 2000 Worth St Hemphill, TX 75948 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 - Some facility but there were a lot of people who lived there. He stated if someone were to come in his room that would be just fine but if they messed with him or his stuff he was not sure what he would do. He stated he was not a mean person and tried to get alone with everyone. He stated he stayed in his room and kept to himself. During an interview on 7/12/2023 at 7:53 am CNA E stated she had been a CNA for 21 years and employed at the facility 6 months. She stated she was not working during any of the incidents with Resident # 2. She stated when she was hired she had to go through a full training program on Relias before she could start to work. She stated the training included signs of abuse, types of abuse and reporting abuse to the administrator. She stated there was training on behavior monitoring and if there was an altercation between residents that they were to be separated and monitored to make sure the incident did not occur again. She stated the nurse was informed and the nurse did a report. She stated when she had worked the unit there were 2 CNA's working during the day. She stated if she and the other CNA were busy she would ask the nurse to come to the unit and help supervise if it was needed. She stated that if residents are not properly supervised and the abuse program was not followed a resident could get hurt. During an interview on 07/12/2023 at 8:01 am RN F stated she was new to the facility as of 2 weeks but had worked in long term care for over 20 years. She stated abuse training was completed when she was hired through the facilities Relias training program. She stated resident to resident altercations are to be reported to the abuse coordinator. The residents were to be separated, the victim assessed, and the perpetrator should be monitored 1 on 1 if needed. She stated she worked the secured unit and was on and off the unit throughout her shift and as needed by the CNA. During an interview on 7/12/2023 at 10:05 am the administrator stated he had been at the facility since mid-December 2022 and was aware of each incident regarding Resident #2. He stated he monitors all incidents that occur in the facility through the morning meeting. He stated he did not recognize that the incidents were abuse and because of that did not follow the facility abuse program in all aspects including reporting to the state agency. At the time he did not see any risk to the residents but looking back now he could see the risk of injury to the other residents on the unit. He stated going forward he would follow the abuse program. During a phone interview on 7/12/2023 at 3:08 pm LVN C stated she had been employed at the facility about 9 months but no longer was working at the facility. She stated she remembered the incidents between Resident #2 and Resident #184 and Resident #12. She stated Resident #2 was territorial and the staff tried to keep other residents out of Resident #2's room but at times she and the aides were busy with other task and could not keep their eyes on him all the time. She stated when Resident #2 hit Resident #184 she was notified by the CNA working the hall and she assessed both residents and there were no injuries. She stated she called the doctor, DON and each residents responsible person and notified them of the incident but did not do any special monitoring. She stated when Resident #2 grabbed and pulled Resident #12 to the ground, the CNA got her that time as well. She stated she assessed each resident and called the doctor, DON, and each residents responsible person. She stated Resident #2 and Resident #12 were separated and no other special monitoring was done. She stated the nights she worked at the facility there was only 1 CNA on the secured unit and she would go to the unit if needed. She stated she knew the types of abuse and resident to resident altercations was abuse. She stated when she was hired she was trained on abuse and to report abuse to the DON or abuse coordinator. Record review of facility in-service sign in sheet dated 1/15/2023 indicated a training on abuse (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675940 If continuation sheet Page 32 of 63 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 675940 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hemphill Care Center 2000 Worth St Hemphill, TX 75948 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 and neglect and on 3/6/2023 training on abuse and neglect, types, reporting, policy, and abuse coordinator. Level of Harm - Minimal harm or potential for actual harm Record review of facility policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program dated indicated, .Residents have the right to be free from abuse. 1. protect residents from abuse, 2. develop and implement policies and protocols to prevent and identify abuse, 3. ensure adequate staffing, 8. identify and investigate all possible incidents of abuse, 9. Investigate and report any allegations within timeframe required by federal requirements, 10. protect residents from any further harm. Residents Affected - Some Record review of facility policy titled Protection of Residents During Abuse Investigations dated April 2021 indicated, .3. if the alleged abuse involves another resident, there may be restrictions on the accused resident's freedom to visit other resident rooms unattended, 5. The victim is evaluated for safety, measures are taken such as more supervision. Record review of facility policy titled Identifying Types of Abuse dated April 2021 indicated, .5. Physical abuse includes but is not limited to hitting, slapping, punching. Record review of facility policy titled Abuse and Neglect Clinical Protocol dated March 2018 indicated, .The staff will investigate alleged abuse, the facility management will institute measures to address the needs of residents and minimize the possibility of abuse, the management will address situations of suspected or identified abuse and report them in a timely manner, and the staff and physician will monitor individuals who have been abused to address any issues regarding their medical condition, mood and function. Record review of facility policy titled Coordinating/Implementing Abuse, Neglect and Exploitation indicated, .the administrator is responsible for the overall coordination and implementation of the facility's policies and procedures against abuse. 1. Policies are in place that: a. prohibit and prevent resident abuse, b. establish processes to investigate such allegations, 2. policies address the following as part of abuse: c. prevention, d. identification of violations, e. investigative processes, f. protection of residents during investigations, g. reporting of and response to investigations, 3. the administrator has the overall responsibility for the coordination and implementation for facility's policies and procedures. Record review of facility policy titled Abuse, Neglect, Exploitation or misappropriation - Reporting and Investigating dated April 2021 indicated .All reports of resident abuse are reported to local, state and federal agencies and thoroughly investigated by facility management. 1. Resident abuse must be reported immediately to the administrator and to other officials according to state law, 3. Immediately is defined as within 2 hours of allegation involving abuse, 6. Upon receiving any abuse allegation the administrator is responsible for determining what actions are needed for the protection of residents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675940 If continuation sheet Page 33 of 63 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 675940 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hemphill Care Center 2000 Worth St Hemphill, TX 75948 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 0610 Respond appropriately to all alleged violations. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to thoroughly investigate and take measures to prevent further potential abuse, neglect, exploitation or mistreatment while the investigation is in process, and failed to ensure corrective action was taken for 4 of 10 residents (Resident #12, Resident #184, Resident #185, and Resident #186) reviewed for abuse. Residents Affected - Some 1.The facility failed to investigate allegations of abuse and ensure corrective actions were in place when Resident #2 hit Resident #185 in the chest on 11/22/2022. 2.The facility failed to investigate allegations of abuse and ensure corrective actions were in place when Resident #2 hit Resident #185 in the face causing an abrasion to her cheek on 12/05/2022. 3.The facility failed to investigate allegations of abuse and ensure corrective actions were in place when Resident #2 grabbed and yanked Resident #186's arm backwards on 01/15/2023. 4.The facility failed to investigate allegations of abuse and ensure corrective actions were in place when Resident #2 hit Resident #184 with an open hand on the left side of his face on 03/04/2023. 5.The facility failed to investigate allegations of abuse and ensure corrective actions were in place when Resident #2 grabbed Resident #12's right arm pulling her to the floor on 03/09/2023. An IJ was identified on 07/11/2023 at 4:13 PM. The IJ template was provided to the facility on [DATE] at 4:13 PM. While the IJ was removed on 07/13/2023 at 3:35 PM, the facility remained out of compliance at a scope of pattern and a severity level of actual harm that is not immediate with a scope of pattern due to the facility's need to monitor and evaluate the effectiveness of their plan of removal and corrective actions. These failures placed all residents at risk of increased abuse, major injury and decreased quality of life. Findings included: 1. Record review of facility face sheet dated 7/11/2023 indicated Resident #2 was a [AGE] year-old male admitted to the facility on [DATE] with a primary diagnosis of bipolar disorder (mood disorder), psychosis (mental disorder), and anxiety. Record review of comprehensive MDS dated [DATE] indicated Resident #2 had a BIMS of 99 indicating Resident #2 was unable to complete interview. Section C for cognition indicated Resident #2 had disorganized thinking. Section E for behaviors indicated Resident #2 had verbal behaviors directed toward others and resident had wandered. Record review of care plan dated 05/08/2023 indicated Resident #2 required psychotropic medications for diagnosis of behavior management, bipolar disorder, and psychosis. Resident #2 had impaired cognitive function and dementia or impaired thought processes related to dementia and psychosis and required the secured unit due to risk of elopement and wandering. Resident #2 had physical behaviors towards residents and staff with interventions added on 03/04/2023 to separate from resident and redirect to room, 3/09/2023 Seroquel increased, and 4/27/2023 resident #2 was sent to a Behavioral (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675940 If continuation sheet Page 34 of 63 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 675940 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hemphill Care Center 2000 Worth St Hemphill, TX 75948 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 0610 Hospital for evaluation and treatment. Level of Harm - Immediate jeopardy to resident health or safety Record review of physician orders dated 7/11/2023 indicated Resident #2 had order for behavior monitoring, lorazepam 1 mg by mouth as needed for anxiety and Seroquel 100mg by mouth at bedtime. Residents Affected - Some Record review of facility incident report dated 11/23/2022 revealed a resident-to-resident altercation that occurred between Resident # 2 and Resident #185. Resident #185 wandered by Resident #2's door on the secured unit, and Resident #2 grabbed Resident #185's arm and struck her in the upper chest. Resident #185 was removed from area, the responsible parties, physician, and administrator was notified. Record review of facility progress note dated 11/22/2023 at 6:18 pm LVN P stated the nurse was called to Resident #2's room by the aide working on the unit and the aide reported Resident #185 was walking by Resident #2's room when he grabbed Resident #185's arm and hit her in the chest before the aide was able to intervene. The aide separated the resident's and nurse notified the administrator. The administrator said an incident report was not needed due to resident's mental status. Record review of a facility progress note dated 12/05/2022 at 3:14 pm LVN L stated Resident #185 entered Resident #2's room, stooped down towards his face and Resident#2 punched Resident #185 on the left side of the face. Resident #185 was redirected and continue to monitor for behaviors. Record review of incident report log and no incident recorded on 12/05/2022 regarding incident between Resident #2 and Resident #185. Record review of incident report dated 01/15/2023 stated Resident #2 rolled up to Resident #186 at the dining table and Resident #2 pulled, twisted, and yanked Resident #186's right arm. CNA A attempted to separate the residents and Resident #2 punched CNA A in the jaw. Administrator and physician were notified. Record review facility progress note dated 01/15/2023 at 11:33 am LVN P stated upon entering the unit, was notified Resident #2 had attacked Resident #186 and CNA A. Record review of incident report dated 03/04/2023 stated Resident #2 hit Resident#184 with an open hand on the left side of the face. Residents were separated and head to toe assessment completed. DON, physician, and families notified. Record review of progress note dated 03/05/2023 at 2:54 am LVN C stated nurse was notified by RA assigned to the unit; Resident #2 had hit Resident #184 with an open hand to the left side of the face when Resident #184 had gotten to close to Resident #2. RA was advised to do frequent monitoring and hallway checks. Record review of incident report dated 03/09/2023 stated resident #2 grabbed Resident #12 by the right arm and pulled her to the floor in the hallway. Head to toe assessment complete, physician, DON, and families notified. Record review of progress note dated 03/09/2023 at 4:36 am LVN C stated nurse was notified by RA assigned to the unit resident #12 was on the floor. RA reported that Resident #2 was sitting in the hallway when Resident #12 attempted to wander into Resident #2's room. Resident #2 grabbed Resident #12 by the right forearm pulling her to the floor. Head to toe assessment completed with no injuries (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675940 If continuation sheet Page 35 of 63 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 675940 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hemphill Care Center 2000 Worth St Hemphill, TX 75948 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 0610 noted to Resident #12. Resident #2 was redirected into his room and assisted to bed. Level of Harm - Immediate jeopardy to resident health or safety 2. Record review of facility face sheet dated 7/11/2023 indicated Resident #12 was a [AGE] year-old female admitted to the facility 9/19/2020 with the diagnosis of Alzheimer's disease. Residents Affected - Some Record review of quarterly MDS dated [DATE] indicated Resident #12 had a BIMS of 99 indicating Resident #12 was unable to complete the interview. Section E for behaviors indicated Resident #12 wandered daily. Record review of comprehensive care plan dated 4/25/2023 indicated Resident #12 required secured unit placement due to elopement risk and Resident #12 had potential to demonstrate physical behaviors with interventions to analyze what deescalates behavior and document and intervene before agitation escalates. Record review of incident report dated 03/09/2023 stated resident #12 was grabbed by the right arm and pulled to the floor by Resident #2 in the hallway. Head to toe assessment complete, physician, DON, and families notified. Record review of progress note dated 03/09/2023 at 5:20 am LVN C stated nurse was notified by RA assigned to the unit Resident #12 was on the floor. RA reported that Resident #12 attempted to wander into Resident #2's room. Resident #2 grabbed Resident #12 by the right forearm pulling her to the floor. Head to toe assessment completed with no injuries noted to Resident #12. 3.Record review of facility face sheet dated 7/12/2023 indicated Resident #184 was a [AGE] year-old male admitted to the facility on [DATE] with a diagnosis of Alzheimer's disease. Record review of admission MDS dated [DATE] indicated Resident #184 had a BIMS of 99 indicating Resident #184 was unable to complete the interview. Section E for behaviors indicated verbal behaviors directed towards others and wandered daily. Record review of comprehensive care plan dated 02/26/2023 indicated Resident # 184 had a potential to demonstrate physical behaviors with interventions to analyze triggers and what de-escalates behaviors and document and was an elopement risk requiring a secured unit. Record review of nurse progress note dated 3/05/2023 at 2:15 am LVN C stated nurse was notified by RA assigned to the unit Resident #184 had been hit to the left side of the face with an open hand by Resident #2. RA was advised to do frequent checks on Resident #184 and monitor the hallway. Responsible parties , DON, ADON and physician notified. 4. Record review of facility face sheet dated 7/12/2023 indicated Resident #185 was a [AGE] year-old female admitted to the facility on [DATE] with diagnosis of Alzheimer's disease. Record review of admission MDS dated [DATE] indicated Resident #185 had a BIMS of 01 indicating severe cognitive deficit. Section E for behaviors indicated Resident # 185 had physical behavioral symptoms directed towards others and had wandered. Record review of comprehensive care plan dated 11/16/2022 indicated Resident #185 had potential for psychosocial problem and required secured unit and was an elopement risk for wandering. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675940 If continuation sheet Page 36 of 63 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 675940 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hemphill Care Center 2000 Worth St Hemphill, TX 75948 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 0610 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Record review of nurse progress note dated 11/23/22 at 8:28 pm LVN P stated on 11/22/2023 nurse was notified by the aide working the secured unit that Resident #185 was attempting to wander into Resident #2's room. Resident #2 grabbed Resident #185 by the arm and struck her in the chest twice before the aide could stop him. One on one care being provided to keep resident from wandering back into Resident #2's room until Resident #185 can be transferred to an all-female secured unit on Monday 11/28/2022. Record review of electronic health record for Resident #185 indicated no documentation of one-on-one monitoring initiated after incident on 11/22/2022. Record review of nurse progress note dated 12/2/2023 at 5:09 pm LVN Q indicated Resident #185 was hit in the face by Resident #2 causing an abrasion to her left cheek. On review, the dates documented for the incident for Resident #185 and Resident #2 do not match. No record of incident report found in the electronic health record. 5. Record review of facility face sheet dated 7/12/2023 indicated Resident # 186 was a [AGE] year-old male admitted to the facility on [DATE] with diagnosis of hemiplegia following cerebral infarction (paralysis following a stroke). Record review of admission MDS 12/12/2022 indicated Resident #186 had moderately impaired cognition requiring supervision and wandered. Record review of comprehensive care plan dated 12/20/2022 indicated Resident # 186 had a communication problem and to provide a safe environment. Record review of Resident #186's electronic health record with no documentation related to altercation with Resident #2 on 01/15/2023. During an observation on 07/10/23 at 09:12 AM CNA A and CNA B were present on the secured unit that housed 10 residents. During an observation on 7/10/2023 at 12:10 pm Resident #2 was up in his wheelchair in his room eating lunch. Resident #2 propels self in wheelchair and resides in a private room. During an interview on 07/10/2023 at 12:15 pm CNA A stated she had worked at the facility for 8 months and primarily was assigned to the secured unit. She stated the residents on the unit need supervision as they wander and get into things. She stated Resident #2 had been at the facility a long time and had a history of being aggressive if other residents entered his space. She stated she tried to keep everyone else away from him because of his behaviors. She stated there was an incident when Resident #2 pulled another resident's arm in the dining room and when she intervened Resident #2 hit her. She stated the nurse was notified and Resident #2 returned to his room. She stated she had training on caring for residents with behaviors and incidents or abuse as to be reported to the nurse and administrator. During an interview on 07/10/20023 at 12:40 pm CNA B stated she had worked at the facility almost 2 years and worked the secured unit. She stated that during the day there are 2 CNAs on the unit and the nurse comes on and off the unit throughout the day. She stated that the residents on the unit have behaviors and she had been trained on how to control outburst but it does not always work. She stated Resident #2 did have some issues a few months ago but in the last few months had been better. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675940 If continuation sheet Page 37 of 63 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 675940 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hemphill Care Center 2000 Worth St Hemphill, TX 75948 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 0610 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some She stated as long as no one messes with him he is fine. She stated there had not been any special interventions for Resident #2 and she just tried to keep an eye on him and prevent the other residents from going around him. During an interview on 7/11/2023 at 10:11 AM the RA stated he had been employed at the facility for 3 months part time. He said when he worked he worked all over the facility. He stated Resident #2 was on the secured unit and stayed in a wheelchair usually in his doorway of his room. He stated the incident with Resident #2 and Resident #184 he had worked that night and witnessed the incident. He stated Resident #184 walked up to Resident #2's wheelchair and Resident #2 hit resident #184 in the face. He said he reported to the nurse LVN C and immediately separated both residents. He stated LVN C told him to write a witness statement and she called the hospice nurse. He stated he stayed in the hallway in the secured unit and put Resident #184 back to bed. He stated Resident #184 was a wanderer and he did not go back into the room of Resident #2. He stated LVN C checked on Resident #184 but could not recall any in-services or other interventions following that incident. He stated the incident with Resident #2 and Resident #12 was witnessed by him. He stated Resident #2 was sitting in the doorway of his room and Resident #12 went into his room but by the time he made it there, Resident #2 had already grabbed her by the arm and she fell to her knees. He stated Resident #12 jumped back up and he called to the nurse station to notify LVN C. He stated LVN C came and provided first aide to Resident 12's arm because she had a skin tear. He stated he was instructed by the nurse to write out a witness statement but no other special instructions were given to him regarding preventing Resident #2 from further harming any other resident on the unit. He said he had received training on abuse/neglect. He stated Resident #2 liked to sit in the doorway of his room and did not like other residents going in his room. He stated he was told by facility staff prior to working on the secured unit to monitor Resident #2 to ensure no residents entered his room. He stated at the time of both incidents, he was the only staff on the secured unit. He stated both incidents occurred on the night shift and usually there was only 1 aide on the unit at night. He stated the nurse stayed at the nurse station outside of the unit and they would come to the unit about 2-3 times a night. A phone call was attempted to LVN C on 7/11/2023 at 10:34 am and 4:43 pm with no answer and voicemail left. During an interview on 7/11/2023 at 11:01 am the DON stated she had started as the facility DON in February 2023. She stated that when she first started she was told that resident to resident altercations was not abuse if it occurred between residents on the secured unit that had cognitive delays and did not have to be investigated or reported to the state unless the other resident suffered a significant injury. She stated no actual measures or corrective actions had been in place to prevent Resident #2 for further harming the other residents on the unit until April when the regional nurse notified her that all resident-to-resident altercations are treated as abuse and had to be investigated. She stated the administrator was aware and he did not treat the altercations as abuse either. She stated that with each incident the aide separated the residents, the nurse was notified, and the victim was assessed. She stated she knew the facilities policy on abuse and the process of investigation and reporting but with the incidents that occurred before April 2023 the abuse policy was not followed. She stated by not following the abuse program the risk to the residents could be significant. During an interview on 7/12/23 at 7:32 am CNA D stated she had been a CNA 6 years and employed at the facility 2 months. She stated she worked all units and shifts. She stated on the night shift there was only 1 CNA and the nurse came back and forth as needed. She stated if a resident-to-resident altercation occurred on her shift she would report it to the nurse and separate the residents. She (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675940 If continuation sheet Page 38 of 63 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 675940 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hemphill Care Center 2000 Worth St Hemphill, TX 75948 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 0610 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some stated she was aware of each resident and their moods and Resident #2 prefers to stay to himself and no one be in his space. She stated at night when she worked on the unit by herself, if she was in another resident's room, she just tried to listen for any noise indicating a resident had gotten up or needed help. She stated she had not had any issues with any residents on the unit since starting to work at the facility. During an interview on 7/12/2023 at 7:48 am Resident #2 stated he did not remember any incidents occurring between him and another resident. He stated he was not sure how long he had been at the facility but there were a lot of people who lived there. He stated if someone were to come in his room that would be just fine but if they messed with him or his stuff he was not sure what he would do. He stated he was not a mean person and tried to get alone with everyone. He stated he stayed in his room and kept to himself. During an interview on 7/12/2023 at 7:53 am CNA E stated she had been a CNA for 21 years and employed at the facility 6 months. She stated she was not working during any of the incidents with Resident # 2. She stated when she was hired she had to go through a full training program on Relias before she could start to work. She stated the training included signs of abuse, types of abuse and reporting abuse to the administrator. She stated there was training on behavior monitoring and if there was an altercation between residents that they were to be separated and monitored to make sure the incident did not occur again. She stated the nurse was informed and the nurse did a report. She stated when she had worked the unit there were 2 CNA's working during the day. She stated if she and the other CNA were busy she would ask the nurse to come to the unit and help supervise if it was needed. She stated that if residents are not properly supervised and the abuse program was not followed a resident could get hurt. During an interview on 07/12/2023 at 8:01 am RN F stated she was new to the facility as of 2 weeks but had worked in long term care for over 20 years. She stated abuse training was completed when she was hired through the facilities Relias training program. She stated resident to resident altercations are to be reported to the abuse coordinator. The residents were to be separated, the victim assessed, and the perpetrator should be monitored 1 on 1 if needed. She stated she worked the secured unit and was on and off the unit throughout her shift and as needed by the CNA. During an interview on 7/12/2023 at 9:44 am the psychiatrist stated that residents that receive hospice services are not typically seen by psychiatric services but he did follow them if it was requested by the doctor or hospice. He stated he did complete an evaluation on Resident #2 7/11/2023 and with coordination of the son was able to develop a past history and adjust his diagnosis. He stated he did a medication review and made some adjustments with dose times of his antipsychotic and anxiety medications. He stated he will continue to monitor for any symptoms and make other adjustments if needed. He stated the facility has put in place 1 on 1 monitoring to monitor for any negative outcomes to his interventions. He stated he was going to provide the facility staff with more in-depth training today 7/12/2023 on how to care for aggressive residents, behavior monitoring and interventions, pharmacological interventions, and regulations for abuse. During an interview on 7/12/2023 at 10:05 am the administrator stated he had been at the facility since mid-December 2022 and was aware of each incident regarding Resident #2. He stated he monitors all incidents that occur in the facility through the morning meeting. He stated he did not recognize that the incidents were abuse and because of that did not follow the facility abuse program in all aspects. At the time he did not see any risk to the residents but looking back now he could see the risk of injury to the other residents on the unit. He stated going forward he would follow the abuse (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675940 If continuation sheet Page 39 of 63 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 675940 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hemphill Care Center 2000 Worth St Hemphill, TX 75948 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 0610 program. Level of Harm - Immediate jeopardy to resident health or safety During a phone interview on 7/12/2023 at 3:08 pm LVN C stated she had been employed at the facility about 9 months but no longer was working at the facility. She stated she remembered the incidents between Resident #2 and Resident #184 and Resident #12. She stated Resident #2 was territorial and the staff tried to keep other residents out of Resident #2's room but at times she and the aides were busy with other task and could not keep their eyes on him all the time. She stated when Resident #2 hit Resident #184 she was notified by the CNA working the hall and she assessed both residents and there were no injuries. She stated she called the doctor, DON and each residents responsible person and notified them of the incident but did not do any special monitoring. She stated when Resident #2 grabbed and pulled Resident #12 to the ground, the CNA got her that time as well. She stated she assessed each resident and called the doctor, DON, and each residents responsible person. She stated Resident #2 and Resident #12 were separated and no other special monitoring was done. She stated the nights she worked at the facility there was only 1 CNA on the secured unit and she would go to the unit if needed. She stated she knew the types of abuse and resident to resident altercations was abuse. She stated when she was hired she was trained on abuse and to report abuse to the DON or abuse coordinator. Residents Affected - Some Record review of facility in-service sign in sheet dated 1/15/2023 indicated a training on abuse and neglect and on 3/6/2023 training on abuse and neglect, types, reporting, policy, and abuse coordinator. Record review of facility policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program dated indicated, .Residents have the right to be free from abuse. 1. protect residents from abuse, 2. develop and implement policies and protocols to prevent and identify abuse, 3. ensure adequate staffing, 8. identify and investigate all possible incidents of abuse, 9. Investigate and report any allegations within timeframe required by federal requirements, 10. protect residents from any further harm. Record review of facility policy titled Protection of Residents During Abuse Investigations dated April 2021 indicated, .3. if the alleged abuse involves another resident, there may be restrictions on the accused resident's freedom to visit other resident rooms unattended, 5. The victim is evaluated for safety, measures are taken such as more supervision. Record review of facility policy titled Identifying Types of Abuse dated April 2021 indicated, .5. Physical abuse includes but is not limited to hitting, slapping, punching. Record review of facility policy titled Abuse and Neglect Clinical Protocol dated March 2018 indicated, .The staff will investigate alleged abuse, the facility management will institute measures to address the needs of residents and minimize the possibility of abuse, the management will address situations of suspected or identified abuse and report them in a timely manner, and the staff and physician will monitor individuals who have been abused to address any issues regarding their medical condition, mood and function. Record review of facility policy titled Coordinating/Implementing Abuse, Neglect and Exploitation indicated, .the administrator is responsible for the overall coordination and implementation of the facility's policies and procedures against abuse. 1. Policies are in place that: a. prohibit and prevent resident abuse, b. establish processes to investigate such allegations, 2. policies address the following as part of abuse: c. prevention, d. identification of violations, e. investigative (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675940 If continuation sheet Page 40 of 63 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 675940 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hemphill Care Center 2000 Worth St Hemphill, TX 75948 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 0610 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some processes, f. protection of residents during investigations, g. reporting of and response to investigations, 3. the administrator has the overall responsibility for the coordination and implementation for facility's policies and procedures. Record review of facility policy titled Resident-to-Resident Altercations dated September 2022 indicated, .1.facility staff monitor residents for aggressive behaviors towards other residents, 3. Occurrences of such incidents are promptly reported to the nurse supervisor, DON, and administrator. The administrator will report the incident in accordance with the criteria established under Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, 4. If two residents are involved in an altercation staff: a. separate the residents b. identify what happened c. notify each resident's representative and the attending physician d. review the event with the DON e. consult the attending physician f. make changes to care plan if necessary g. document in the resident's clinical record h. consult psychiatric services as needed i. complete a report of Incident/Accident form j. report the incident, findings and corrective actions to appropriate agencies.5. Inquiries concerning resident-to resident altercations are referred to the DON or the administrator. Record review of facility policy titled Abuse, Neglect, Exploitation or misappropriation - Reporting and Investigating dated April 2021 indicated .All reports of resident abuse are reported to local, state and federal agencies and thoroughly investigated by facility management. 1. Resident abuse must be reported immediately to the administrator and to other officials according to state law, 3. Immediately is defined as within 2 hours of allegation involving abuse, 6. Upon receiving any abuse allegation the administrator is responsible for determining what actions are needed for the protection of residents. The facility Administrator was notified on 07/11/2022 at 4:13 PM that an Immediate Jeopardy situation had been identified due to the above failures and the IJ template was given at that time. The facility's plan of removal was accepted on 07/13/2022 at 03:35 PM and included: The facility will in-service all staff on abuse policy and procedure. To include types of abuse, reporting abuse, prevention of abuse, resident protection during abuse allegations and incidents, and signs and symptoms of abuse. Staff were trained in de-escalation techniques and interventions to prevent resident to resident altercations. The facility will assess all residents on the secured unit for changes in their behavior monitoring or notations of emotional distress. The facility will in-service all staff on abuse policy-protection, protecting residents from abuse from residents with history of multiple physical incidents and recognizing patterns of behaviors. The facility will in-service any agency staff on all related in-services before being permitted to work. The facility will in-service all nursing staff over accident/incident policy and procedure including documentation of events per facility protocol with investigation and intervention review. All IDT members will be in-serviced on 24-hour report required review during stand-up meeting. The administrator, DON and ADON will review every incident report during the stand-up to ensure (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675940 If continuation sheet Page 41 of 63 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 675940 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hemphill Care Center 2000 Worth St Hemphill, TX 75948 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 0610 investigation, interventions and documentation is appropriate for resident safety and resident needs as applicable to prevent re-occurrence and provide protection. Level of Harm - Immediate jeopardy to resident health or safety Facility will complete weekly QAPI review pertaining to abuse/neglect and accident and incidents. Residents Affected - Some The RDO (regional director of operations) will complete an in-service with the administrator and DON regarding abuse policy and procedure for types of abuse, reporting and investigating according to facility policies. The facility administrator or designee will monitor and review all Accident/Incident reports and follow up accordingly. The IDT will review and assess each Accident/incident to determine any further actions needed. IDT members to include the administrator, DON, ADON, MDS coordinator, Social Worker, and therapy representative. The corporate staff will review all incident/accidents daily for 6 months and reevaluate the need for continued review. On 07/13/2023, the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy by: Staff interviews on 7/13/2023 10:45-2:50 pm completed with Administrator, DON, ADON, BOM, Activity Director, Housekeeping Supervisor, MDS coordinator, Maintenance supervisor, DM, dietary cook, CNA A, CNA E, CNA I, CNA N, Restorative aide, transportation aide, LVN J, LVN M, RN F, HSK K, and laundry aide H was able to verbalize the abuse policy and procedure, de-escalation techniques, interventions to prevent resident to resident altercations, providing environment free of hazards, protecting residents and recognizing patterns of behaviors. The DON and administrator verbalized abuse policy, reporting and investigating per facility policies, and agency staff permitted to work after in-services received. Record review of in-service dated 7/11/2023 presented by DON revealed topic of Abuse/Neglect, resident to resident altercations and reporting, emotional assessments, abuse/neglect policy and procedures. The attendees included management staff, nurses, nurse aides, dietary staff, activity director, and BOM (business office manager). Record review of in-service dated 7/11/2023 and 7/12/2023 presented by RDO revealed topic of reporting and investigating incidents of abuse. The attendees included administrator, DON, management staff, nurses, CNA's, housekeeping, activity director, laundry staff, dietary staff, and maintenance. Record review of in-service dated 7/11/2023 and 7/12/2023 presented by RDO revealed topic of environment free of hazards, accident and incident policy, and investigating and documentation. The attendees included management staff, nurses, aides, dietary staff, laundry staff, activity director, housekeeping staff, and BOM. Record review of in-service dated 7/11/2023 and 7/12/2023 presented by RDC revealed topic of 24-hour report review during morning meeting. The attendees included IDT members. Record review of in-service dated 7/11/2023 and 7/12/2023 presented by RDO revealed topic of investigating and protecting residents from abuse. The attendees included administrator, DON, management staff, nurses, CNA's, housekeeping, activity director, laundry staff, dietary staff, and maintenance. Record review of in-service dated 7/12/2023 presented by RDC (regional director of clinical) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675940 If continuation sheet Page 42 of 63 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 675940 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hemphill Care Center 2000 Worth St Hemphill, TX 75948 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 0610 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some revealed topic of incidents and accidents are to be reviewed daily. The attendees included DON, ADON, and administrator. Record review of communication note dated 7/11/2023 indicated the medical director was notified of IJ and participated in plan of removal. Record review of quality assurance meeting sign in sheet indicated meeting was held 7/12/2023 with the medical director and IDT (interdisciplinary team) members. Record review of electronic health record indicated 11 of 11 residents residing on the secured unit were assessed for changes in their behaviors and monitoring. On 07/13/2023 at 03:35 PM, the facility was informed the IJ was removed. However, the facility remained out of compliance at severity level of actual harm [TRUNCATED] FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675940 If continuation sheet Page 43 of 63 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 675940 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hemphill Care Center 2000 Worth St Hemphill, TX 75948 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for 1 of 1 resident (Resident #186), reviewed for quality of care. Residents Affected - Few The facility failed to promptly identify and intervene for an acute change in Resident #186 following a fall resulting in him being transported to the hospital with bilateral subdural hematomas, which resulted in his death. An Immediate Jeopardy (IJ) situation was identified on 07/12/23 at 11:15 am. The IJ template was provided to the facility on [DATE] at 11:30 am. While the IJ was removed on 07/13/23, the facility remained out of compliance at a severity level of actual harm that is not immediate with a scope of isolated due to the facility's need to monitor and evaluate the effectiveness of their plan of removal and corrective actions. This failure could place residents at the risk of not receiving appropriate medical interventions timely and effectively, which could result in severe illness, hospitalization or even death. Findings include: Record review of facility face sheet dated 7/12/23 for Resident #186 indicated that he was a [AGE] year-old male admitted to the facility on [DATE] with subsequent readmission on [DATE] with diagnoses including: right sided hemiplegia and hemiparesis following cerebral infarction (right sided weakness/paralysis due to a stroke), aphasia (problems speaking), dysphagia (trouble swallowing), and type 2 diabetes. Record review of a comprehensive MDS dated [DATE] for Resident #186 indicated that BIMS was not done due to resident being rarely/never understood. Also indicated that he required supervision of 1 person for transfers, and extensive assist of 1 person for toileting. Record review of physician orders dated 7/12/23 for Resident #186 indicated that resident was receiving Aspirin 81mg 1 tablet 1 time per day and Clopidogrel Bisulfate 75mg 1 tablet 1 time per day (medications that can thin the blood causing easy bleeding and increasing risk for internal bleeding). Record review of electronic medical record for Resident #186 indicated that he was a DNR and had been receiving hospice services since 11/2/2022 for diagnosis of CVA (stroke). Record review of incident report dated 1/16/23 for Resident #186 indicated that he had suffered an unwitnessed fall resulting in large gash above right eye and swelling and bruising to right eye. Record review of a care plan, undated, for Resident #186 indicated he was at risk for bleeding and injury associated with daily use of anti-platelet (blood-thinning) medications (Clopidogrel). Record review of a facility 24-hour report dated 7/12/23 for the dates of 1/16/23 through 1/17/23 indicated that resident had fallen on 1/16/23 and neurological assessments were initiated immediately after fall. 24-hour report indicated that Resident #186's neurological assessment on 1/16/23 at 5:41 pm his CGS was 15 indicating mild head injury. At 6:12 pm on 1/16/23, his score was a 10, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675940 If continuation sheet Page 44 of 63 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 675940 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hemphill Care Center 2000 Worth St Hemphill, TX 75948 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 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few indicating a moderate head injury. There was no documentation of physician notification regarding this decline. Resident remained in facility and received no interventions. Record review of hospital paperwork in Resident #186's electronic medical record indicated that Resident #186 was admitted to ICU on 1/17/23 at 5:40 pm. Record review of progress note dated 1/19/23 indicated that resident readmitted to facility with diagnoses: right frontal intraparenchymal hemorrhage (a bleed that occurs within the brain parenchyma, the functional tissue in the brain); right temporal horn IVH (a bleeding into the brain's ventricular system, where the cerebrospinal fluid is produced and circulates through towards the subarachnoid space. It can result from physical trauma); bilateral subdural hematomas (a dangerous condition where blood collects under the skull, putting pressure on the brain and causing damage or death); left temporal horn IVH (a bleeding into the brain's ventricular system, where the cerebrospinal fluid is produced and circulates through towards the subarachnoid space. It can result from physical trauma). Record review of a progress note dated 1/21/23 for Resident #186 indicated that he passed away on 1/21/23 at 9:23 am. During an interview with DON on 7/11/23 at 4:00 pm, she said that she was not employed by this facility at that time but that she was employed by hospice services on 1/16/23. She said she had started as the facility DON in February 2023. She said she had come to the facility to assess Resident #186 on 1/16/23 and she noticed a change from his baseline, and he was unresponsive. She said she was unable to reach a family member to see what they wanted to do, so she had him sent out to the emergency room. She said in cases where she could not reach family members regarding hospice residents, she would use nursing judgement and sent out for evaluation. She said that any resident that suffered a fall with possible head injury should be sent out for evaluation. During an interview with Resident #186's family member on 7/11/23 at 4:34 pm, she said that the facility did notify her of the fall on 1/16/23 and that she had told them to send him to the ER if they thought he needed to go. She said she was under the impression that the nurse would use her judgement to decide if he needed to go. She said if she had known the severity of the situation, she would have insisted they send him out. She said once he was in the ICU at the hospital, the doctors there told her that he had five brain bleeds and there was nothing they could do. She said before the fall, he had been active and alert, he just was unable to speak due to a stroke. She said she had him sent back to the nursing facility because the hospital said they could not do anything for the bleeding on his brain. During an interview with physician office staff on 7/12/23 at 9:00 am, surveyor was informed that physician was not currently in office, but staff could take a message. Message left with return phone number for physician to call regarding incident on 1/16/23. No return call received from physician before exit from facility. During an interview with LVN L on 7/12/23 at 10:18 am, she said she had worked for the facility from November of 2022 to March of 2023. She said she had worked days in the unit and was working the day of the fall. She said she had been at the nurse's station and was notified by a CNA of the resident's fall. She said she did an assessment and took vital signs on Resident #186. She said around 3:30 pm, he was found laying on the floor and had been trying to get up on his own without assistance. She said that he fell in his room while ambulating unassisted, and he pointed to the bathroom to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675940 If continuation sheet Page 45 of 63 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 675940 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hemphill Care Center 2000 Worth St Hemphill, TX 75948 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 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few indicate he was trying to go to the bathroom. She said he had a gash on his forehead on the right side. She said she called the hospice nurse, and the DON at the time. She said the DON at that time came back to the unit and assessed the resident, cleaned his wound, and put steri-strips in place. She said he was not sent to the hospital. She said she was monitoring him every 30 minutes and the wound was still bleeding. She said she notified hospice again about the bleeding. She said she was doing neurological checks, checking pupils with her penlight, and checking his grips. She said his grips were strong. She said his pupils were not dilated; they were normal at 2mm. She said he was moving around a lot, acting restless, moaning, and groaning. She said she worked until 6 pm that evening. She said she had called and spoke to his wife and explained about the fall. She said their protocol was to notify hospice regarding incidents with any hospice residents and hospice would instruct on what to do. She said there were no in services done regarding the incident. During an interview with LVN C on 7/12/23 at 3:00 pm, she said she had called the hospice the night Resident #186 fell because she had wanted to send him to the emergency room due to the wound continuing to bleed, but hospice said that they were against sending him out unless the wife wanted to send him out. She said she spoke to a family member and notified them of his condition regarding the contusion and that it continued to bleed, but she said to just monitor him for now. She said she did not notify the physician because it was their policy to just notify hospice for hospice residents. Record review of a facility policy titled Falls - Clinical Protocol dated 2001, with revision date of March, 2018, indicated .the nurse shall assess and document/report the following: .recent injury, especially fracture or head injury .neurological status . and .the physician will identify medical conditions .and the risk for significant complications of falls (for example .increased risk of bleeding in someone taking an anticoagulant) . and .The staff, along with the physician's guidance, will follow up on any fall with associated injury until the resident is stable and delayed complications such as .subdural hematoma have been ruled out or resolved . Record review of a facility policy titled Change in a Resident's Condition or Status dated 2001, with revision date of February 2021 indicated .the nurse will notify the resident's attending physician or physician on call when there has been a(an): .need to transfer the resident to a hospital/treatment center . This was determined to be an Immediate Jeopardy (IJ) on 07/12/23 at 11:15 am. The Administrator was notified. The Administrator was provided with the IJ template on 07/12/23 at 11:30 am. On 7/13/23 at 3:35 pm, the facility was informed the IJ was removed. However, the facility remained out of compliance at a severity level of actual harm with a scope of isolated due to the facility's need to monitor and evaluate the effectiveness of their plan of removal and corrective actions. The facility's plan of removal was accepted on 7/13/23 at 9:05 am and included: 1) MDS and Corporate MDS completed a review all residents fall assessments completed in the last quarter for current interventions and effectiveness with completion date 7/12/23 at 8:00 pm. 2) The in-services are as follows completed by RDC (regional director of clinical) and/or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675940 If continuation sheet Page 46 of 63 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 675940 B. Wing (X3) DATE SURVEY COMPLETED A. Building 07/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hemphill Care Center 2000 Worth St Hemphill, TX 75948 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 0684 administrative nursing designee once trained. Level of Harm - Immediate jeopardy to resident health or safety Falls/Interventions/Documentation Residents Affected - Few Documentation of incident must be charted in the incident report, and must contain investigation of cause of fall, interventions to prevent further falls, assessment summary including injuries, vitals, and initiation of neuros indicated. Neuro checks must follow any unwitnessed fall or evidence of head trauma. Notification to physician regarding fall with or without injury. Notification to physician regarding blood thinners as applicable on active orders or medications with anticoagulant similarities on active orders. Specific interventions will be determined by the Charge Nurse and IDT team. These interventions will be reviewed, and the Care plan will be updated to reflect changes by MDS Nurse. The Administrator and IDT will review each fall, possible cause, and interventions for effectiveness-and change accordingly if not effectual. Nurse to monitor and document resident response to interventions on the Incident Report, and the MDS Nurse will update the Care Plan. Changes to be reported to Medical Director, Director of Nursing, Assistant Director of Nursing, Administrator, and Responsible Representative/Emergency Contact. Intervention review occurs daily in the morning Stand Up Meeting; and weekly in Standards of Care (SOC) with IDT. Changes will be noted in the progress note by the nurse; as well as the Stands of Care document. Residents at risk for fall will be identified utilizing the Fall Risk Assessment tool in Point Click Care (PCC) that is completed after any fall occurs, and quarterly. Resident Assessment - in service completed by RDC (regional director of clinical) and/or nursing administration once trained After all incidents the licensed nurse will completely fill out the incident report to include all portions of areas completed: o Nursing Description o Resident Description if applicable o (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675940 If continuation sheet Page 47 of 63 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 675940 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hemphill Care Center 2000 Worth St Hemphill, TX 75948 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 0684 Description of immediate action taken Level of Harm - Immediate jeopardy to resident health or safety o Residents Affected - Few o Injuries observed Pain Assessment o Mental status, o Mobility status, o Environmental factors, o Predisposing physiological factors, o Witness statements if applicable, o Agencies and people notified o Fall nurses note, o Fall risk assessment, o Neuros if applicable, o Administration of blood thinners review (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675940 If continuation sheet Page 48 of 63 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 675940 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hemphill Care Center 2000 Worth St Hemphill, TX 75948 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 0684 o Level of Harm - Immediate jeopardy to resident health or safety Complete set of Vital Signs in the fall nurse note Residents Affected - Few Administer first aid if applicable. Change of Condition o All abnormal findings including change of vital signs, change of mobility, change of mental status, and/or decline in ADL's must be reported to the Medical Director, Director of Nursing, Assistant Director of Nursing, Administrator, and Responsible Representative/Emergency Contact immediately. To assess baseline, the Charge Nurse may utilize previous assessment and/or the comprehensive care plan in Point Click Care. Progress notes must reflect the changes observed, interventions, and notification. Neuro Checks Post fall neuros must be conducted for 30 hours. ? Q 15 minutes for a duration of 1 hour ? Q 30 minutes for a duration of 1 hour ? Q 1 hour for a duration of 4 hours ? Q 4 hours for a duration of 24 hours All neuros MUST be completed for falls with head injury and unwitnessed fall. Abnormal findings will be reported to Medical Director (regardless of hospice physician notification), Director of Nursing, and Assistant Director of Nursing; and will be extended for an additional 24 hours to be monitored Q 4 hours (unless otherwise directed by physician). Review & Reporting-in-service completed by RDC (regional director of clinical) on 8/12/23. The Administrator and DON, along with IDT will review each incident in the Stand-Up meeting to determine possible cause, interventions, documentation, follow-up, and reporting status according to HHSC reporting guidelines. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675940 If continuation sheet Page 49 of 63 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 675940 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hemphill Care Center 2000 Worth St Hemphill, TX 75948 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 0684 All residents have the potential to be affected by this alleged deficient practice. Level of Harm - Immediate jeopardy to resident health or safety The Medical Director was initially made aware of the immediate jeopardy 7/12/23 and has been involved in the development of the plan to removal. These conversations are considered a part of the QA process. Residents Affected - Few To monitor for compliance the Administrator and/or designee will review all Accident/Incident reports and follow up accordingly. The IDT will review and assess the Accident/Incident to determine what further actions if needed are necessary. Members of this meeting are to include the Administrator, Director of Nursing, Assistant Director of Nursing, MDS Coordinator, Social Worker, and Therapy Representative. In addition, designated members of the corporate staff will review all Accident/Incidents daily for 6 months and reevaluate the need for continued review. Any negative findings will be forwarded to the Administrator and the QA committee. This plan was initially implemented 7/12/23 and will be monitored through completion by corporate and regional staff. Plan of Removal completion date is 7/12/23 8:00 pm with continued follow up for oncoming staff. Verification of POR: Verified MDS and Corporate MDS completed a review of all residents fall assessments completed in the last quarter for current interventions and effectiveness with completion date 7/12/23 at 8:00 pm Staff interviews 7/13/23 10:45 am-2:50 pm completed with DON, ADON, and RN F were able to verbalize the Fall/Interventions/Documentation policy including neuro checks, documentation of incident, notification to physician, specific interventions, and monitoring or resident condition; Resident assessment and fall documentation policy and procedure; Neuro checks policy including must be conducted for 30 hours, Q 15 minutes for 1 hour, Q 30 minutes for 1 hour, Q 1 hour for 4 hours, and Q 4 hours for 24 hours, abnormal findings will be reported to physician (regardless of hospice notification), DON, ADON, and will be monitored for an extended 24 hours; Notification of Change in residents condition to be reported to physician; notification to physician regarding blood thinners/anticoagulants as applicable. Admin, DON, ADON verbalized review and reporting procedures for daily stand-up meetings. Verified Medical director was notified of IJ and participated in POR. 7/12/23 QA meeting held with medical director and IDT members. On 7/13/23 at 3:35 pm, the facility was informed the IJ was removed. However, the facility remained out of compliance at a severity level of actual harm that is not immediate with a scope of isolated due to the facility's need to monitor and evaluate the effectiveness of their plan of removal and corrective actions. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675940 If continuation sheet Page 50 of 63 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 675940 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hemphill Care Center 2000 Worth St Hemphill, TX 75948 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 0727 Level of Harm - Minimal harm or potential for actual harm Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on interview and record review, the facility failed to use the services of a registered nurse for at least eight consecutive hours a day, 7 days a week for 2 of 3 months reviewed. (February 2023 and March 2023) Residents Affected - Many The facility did not have RN coverage for 1 day in February 2023. The facility did not have RN coverage for 3 days in March 2023. This failure could place residents at risk by leaving staff without supervisory coverage for RN specific nursing activities and for coordination of events such as an emergency care and disasters. Findings included: Record review of the RN punch detail hour report for February 2023 indicated there were no RN hours worked on the following date: 2/12/2023. Record review of the RN punch detail hour report for March 2023 indicated there were no RN hours worked on the following dates: 3/18/2023, 3/25/2203, and 3/26/2023. Record review of the CMS Payroll Based Journal (PBJ) report for the second quarter of 2023 (January 1, 2023, through March 31, 2023) indicated there were no RN hours for the following dates: 02/11 (SA); 02/12 (SU); 02/13 (MO) 03/16 (TH); 03/17 (FR); 03/18 (SA); 03/20 (MO); 03/21 (TU); 03/22 (WE); 03/23 (TH); 03/24 (FR); 03/25; (SA); 03/26 (SU); 03/27 (MO); 03/28 (TU); 03/29 (WE); 03/30 (TH); 03/31 (FR) During an interview on 7/11/2023 at 12:10 PM, the BOM said she had been employed at the facility since 11/8/2021. She said the ADON was responsible for staffing. She said the previous DON last day at the facility was on 1/28/2023 and the Regional Nurse was coming to the facility during that time. She said the current DON started at the facility as a weekend RN on 11/4/2022 and did not become the DON of the facility until the beginning of February 2023. She said the DON did not clock in or out when she worked. The BOM said she would enter in time of 8 hours on the days the DON worked in the payroll time system. During an interview on 7/12/2023 at 1:30 PM, the ADON said she had been employed at the facility since January 30, 2023. She said she was responsible for staffing. She said in February 2023 the facility had 2 RN's that worked the weekends and the DON at that time worked some weekends also. She said on 2/12/2023 the DON was scheduled on her calendar. She said in March 2023 the facility had a nurse who worked the weekends but did not have record of who was scheduled to work on 3/18/2023, 3/25/2203, and 3/26/2023. She said her schedules only indicated who was on call for those days and it was not a RN. During an interview on 7/13/2023 at 8:39 AM, the Accounts Payable Manager said the RN hours for the facilities was automatically entered into the PBJ reporting data. She said salaried RN hours were entered into the payroll system manually by the BOM, but she was not sure why the hours were not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675940 If continuation sheet Page 51 of 63 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 675940 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hemphill Care Center 2000 Worth St Hemphill, TX 75948 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 0727 reported to the PBJ system. She said she was not aware of the missing RN hours for the second quarter. Level of Harm - Minimal harm or potential for actual harm During an interview on 7/13/2023 at 2:00 PM, the Regional Nurse said the facility should have an RN in the facility 8 hours a day, 7 days a week. She said if there was not a RN scheduled, then she would come to the facility and if she was not available, she would get agency staff to cover the hours. She said the facility also had access to a RN via phone if needed. She said she could not think of any risk that could affect the residents by not having a RN in the facility daily. She said going forward she would have RN coverage daily and would have documentation for the RN's who cover the weekends. Residents Affected - Many During an interview on 7/13/2023 at 4:35 PM, the Corporate Director of Nursing said there was a system error with how payroll was entering the hours for RN coverage and how it was being submitted to CMS. Record review of a facility policy dated June 2022 titled Electronic Staffing Data Submission Payroll-Based Journal indicated. Accuracy: Staffing information is required to be an accurate and complete submission of a facility's staffing records . Record review of a facility policy undated titled Staffing indicated, .Our facility provides sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with resident care plans and the facility assessment. An RN is available for coverage 8 hours a day, 7 days a week . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675940 If continuation sheet Page 52 of 63 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 675940 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hemphill Care Center 2000 Worth St Hemphill, TX 75948 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interview, and record review, the facility failed to provide pharmaceutical services, including procedures that assures the accurate acquiring, receiving, dispensing and administering of medications for 1 of 1 medication storage room reviewed for pharmacy services. The facility failed to properly date tuberculin PPD (purified protein derivative) Mantoux testing solution in the medication storage refrigerator with an open date. The facility failed to remove 3 vials of Flucelvax from the medication storage room refrigerator that had expired on 06/30/2023. These failures could place residents who receive medications at risk of not receiving the intended therapeutic benefit of the medications. Findings included: During an observation on 07/10/23 at 10:30 AM with LVN G the medication room refrigerator had 1 vial of Tubersol PPD with no open date and instructions to dispose of 30 days after opening and 3 vials of Flucelvax (influenza vaccine) with expiration date of June 30, 2023. During an interview on 07/10/2023 at 10:45 am LVN G stated that Tuberculosis skin test and Influenza vaccines were given by the nurses and it was each nurses responsibility to check the expiration date on all medicine before it was given. She stated multi-use vials were to be dated and they were usually only good for 30 days. She stated she had received training on multi use vials use by dates. She stated the risk could be ineffective medication. During an interview on 07/10/2023 at 10:55 am 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 have had training and there was a book they could reference on the medication cart. She stated it was her responsibility to provide oversight but had not gotten around to checking the medication storage room. She stated the risk could be ineffective medication. During an interview on 07/10/2023 at 11:15 am the administrator stated the DON and ADON were responsible for medication storage and removing expired medications for destruction. He stated he 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 nurse tool undated and titled List of Medications with Shortened Expiration Dates indicated, Tubersol beyond use date, 30 days after opening. Record Review of policy and procedure titled Storage of medications indicated, .4.Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675940 If continuation sheet Page 53 of 63 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 675940 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hemphill Care Center 2000 Worth St Hemphill, TX 75948 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 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen in that: Residents Affected - Many The facility failed to ensure an opened items in the reach in refrigerators were labeled and dated correctly. The facility failed to ensure all food items were discarded by the expiration date. This deficient practice could place residents who ate food from the kitchen at risk for foodborne illness. The findings included: During an observation, in the main refrigerator, on 07/10/2023 at 09:00 a.m., revealed on the top shelf a clear plastic container with a green lid of au gratin potatoes with no label or date on main container or individual containers, on the top shelf clear container of condiments of mayonnaise and pickle relish in individual containers with no label or date, on top shelf a bottle of chocolate syrup with the expiration date of 05/2023, on the top shelf an open box of baking soda with a expiration date of 06/28/2023, on the second shelf a plastic grocery bag of personal employee items that contained pomegranate juice, jalapenos, cilantro, and garlic paste, on the bottom shelf two plastic zip lock bags that contained raw hamburger meat with no label, received or expiration date. During an observation, in the milk cooler, on 07/10/2023 at 09:00 a.m., revealed in one of the milk crates two 236ml Dairy Pure 2% reduced fat milk with the expiration date of 07/09/2023. During an Interview 07/10/23 09:50 AM the DM said she has worked here for 6 years and has never had any expired items. Said she is currently an administrator in training and the person who would be taking her place is on her way to the facility. Said she is ultimately responsible for the dietary department at this time. She said all food is to be labeled with the received date or expiration date. She said she does not know why the expired items were not pulled from the refrigerator and discarded. She said staff knows they are not supposed to have personal items in the facility refrigerators. She said the food in the clear container with the green lid is au gratin potatoes left over from Fridays dinner meal. Said the expired foods and personal food in the fridge puts the residents at risk for food borne illnesses and cross contamination. During an interview on 07/10/2023 at 5:29 p.m., the administrator said that he was checking the kitchen periodically however he was out of town last week and that is when the expired foods happened. He said everything in the refrigerator is supposed to be labeled and dated with no personal items in the fridge. He said the water that was leaking from the top of the fridge is coming from ice that had accumulated on the top of the fridge and is melting. He said the potential harm to resident is cross contamination and the possibility of food borne illnesses. During an interview 07/11/23 at 12:30 PM the Dietary aide said she was currently taking classes for her dietary managers certification and once it is complete, she will officially be the dietary manager in the kitchen. She said all items that are put in the fridge must be labeled and dated and no (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675940 If continuation sheet Page 54 of 63 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 675940 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hemphill Care Center 2000 Worth St Hemphill, TX 75948 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 - Many personal items are to be put in the fridge. She said if a resident was to consume expired foods it could cause the resident to become sick. She said personal items in the fridge is cross contamination and could also cause residents to become sick. Record Review 07/13/23 at 08:24 AM of policy titled Refrigerated Storage revealed under dairy products: Milk, fluid-follow expiration date. Record Review 07/13/23 08:26 AM of policy titled Refrigerators and Freezers dated 2001 with a revised date of April 2006 revealed: 7. All food shall be appropriately dated to ensure proper rotation by expiration dates. Received dates (dates of delivery) will be marked on cases and on individual items removed from cases for storage. use by dates will be completed with expiration dates on all prepared food in refrigerators. Expiration dates on unopened food will be observed and use by dates indicated once food is opened. 8. Supervisors will be responsible for ensuring food items in pantry, refrigerators, and freezers are not expired or past perish dates. Supervisors should contact vendors or manufacturers when expiration dates are in question or to decipher codes. 9. Supervisors will inspect refrigerators and freezers monthly for gasket condition, fan condition, presence of rust, excess condensation, and any other damage or maintenance needs. Necessary repairs will be initiated immediately. Maintenance schedules per manufacturer guidelines will be scheduled and followed. 9. Refrigerators and freezers will be kept clean, free of debris, and mopped with sanitizing solution on a scheduled basis and more often as necessary. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675940 If continuation sheet Page 55 of 63 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 675940 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hemphill Care Center 2000 Worth St Hemphill, TX 75948 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 0813 Have a policy regarding use and storage of foods brought to residents by family and other visitors. 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 and ensure safe and sanitary storage of residents' food items for 1 of 3 resident personal refrigerators reviewed for food safety (Resident #14). Residents Affected - Few The facility failed to ensure the refrigerator for Resident #14 did not contain expired milk. This failure could place resident at risk for food borne illnesses. Findings include: Record review of Resident #14's face sheet dated 07/11/2023 revealed that he was a [AGE] year-old female admitted to the facility on [DATE] with the most recent readmission of 07/09/2023 with diagnoses including: chronic kidney disease (kidney problems), urinary tract infection (infection in the bladder), basal cell carcinoma of skin (skin cancer). Record review of a Quarterly MDS Assessment for Resident #14 dated 07/03/2023 indicated a BIMS score of 12 meaning mild cognitive impairment. She requires extensive assistance with bed mobility, transfers, dressing, toilet use and personal hygiene. Supervision with locomotion and eating. Balance during transitions and walking indicated he was not steady, but able to stabilize without staff assistance and required a wheelchair mobility device. Record review of a care plan for Resident #1 dated 04/06/2023 Resident #14 requires supervision setup by staff participation to eat. During an observation and interview on 07/10/2023 at 09:57 AM, Resident #14 said she gets food and drinks from her personal refrigerator herself when she wants. Her personal refrigerator had a unopened 236ml boxed container for Dairy Pure 2% reduced fat milk with the expiration date of 07/02/2023, also a ¾ full half gallon of milk with the expiration date of 07/06/2023. When asked if staff checked her refrigerator, she said the staff cleans and takes care of the refrigerator for her. During an interview on 07/12/2023 at 08:30 am, the Administrator said housekeeping was responsible for cleaning out the resident refrigerators and making sure there is no expired food. He said he does not think there is a facility policy for personal refrigerators but will look. During an interview on 07/12/2023 at 08:30 am, the Housekeeping Supervisor said she has worked at the facility for 5 years, she said housekeeping has always been responsible for cleaning the personal refrigerators. She said she has a folder on her cleaning cart that has the refrigerator temperature logs. She said she was not sure how Resident #14's refrigerator was missed. She said the facility had cut housekeeping hours about 6 months ago, so she has 1 fulltime housekeeper, and she works on the floor cleaning. She said personal refrigerators are to be cleaned daily when the resident's room is cleaned. Record Review 07/13/23 08:24 AM of policy titled Refrigerated Storage revealed under dairy products: Milk, fluid-follow expiration date. Record Review 07/13/23 08:26 AM of policy titled Refrigerators and Freezers dated 2001 with a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675940 If continuation sheet Page 56 of 63 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 675940 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hemphill Care Center 2000 Worth St Hemphill, TX 75948 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 0813 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few revised date of April 2006 revealed: 7. All food shall be appropriately dated to ensure proper rotation by expiration dates. Received dates (dates of delivery) will be marked on cases and on individual items removed from cases for storage. use by dates will be completed with expiration dates on all prepared food in refrigerators. Expiration dates on unopened food will be observed and use by dates indicated once food is opened. 8. Supervisors will be responsible for ensuring food items in pantry, refrigerators, and freezers are not expired or past perish dates. Supervisors should contact vendors or manufacturers when expiration dates are in question or to decipher codes. 9. Supervisors will inspect refrigerators and freezers monthly for gasket condition, fan condition, presence of rust, excess condensation, and any other damage or maintenance needs. Necessary repairs will be initiated immediately. Maintenance schedules per manufacturer guidelines will be scheduled and followed. 9. Refrigerators and freezers will be kept clean, free of debris, and mopped with sanitizing solution on a scheduled basis and more often as necessary. Record Review 07/13/23 08:48 AM of facility policy titled Nutritious Lifestyles potluck meals and foods from home dated 1/1/2018 revealed: Guidelines: 1. When outside foods are brought in to the facility by resident family or friends, it must be labeled to clearly distinguish it from the food purchased or prepared by the facility and stored separately from the facility's food by placing on a distinguished shelf, labeled bag, or in a bin labeled resident food with the resident name on the items. Foods must be dated with food safety guidelines followed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675940 If continuation sheet Page 57 of 63 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 675940 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hemphill Care Center 2000 Worth St Hemphill, TX 75948 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 0851 Level of Harm - Potential for minimal harm Residents Affected - Many Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. Based on interview and record review, the facility failed to electronically submit to CMS complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS reviewed for administration (Fiscal year 2023 for the second quarter January 1, 2023, to March 31, 2022) The facility failed to submit accurate RN hours for: 02/11 (SA); 02/12 (SU); 02/13 (MO) 03/16 (TH); 03/17 (FR); 03/18 (SA); 03/20 (MO); 03/21 (TU); 03/22 (WE); 03/23 (TH); 03/24 (FR); 03/25; (SA); 03/26 (SU); 03/27 (MO); 03/28 (TU); 03/29 (WE); 03/30 (TH); 03/31 (FR) These failures could place residents at risk for personal needs not being identified and met. The findings included: Record review of the CMS PBJ report for the second quarter of 2023 (January 1, 2023, through March 31, 2023) indicated there was no RN hours for the following dates: 02/11 (SA); 02/12 (SU); 02/13 (MO) 03/16 (TH); 03/17 (FR); 03/18 (SA); 03/20 (MO); 03/21 (TU); 03/22 (WE); 03/23 (TH); 03/24 (FR); 03/25 (SA); 03/26 (SU); 03/27 (MO); 03/28 (TU); 03/29 (WE); 03/30 (TH); 03/31 (FR) Record review of a RN punch detail report for February and March 2023 indicated RN hours on 2/11/2023, 2/13/2023, 3/16/2023, 3/17/2023, 3/20/2023, 3/21/2023, 3/22/2023, 3/23/2023, 3/24/2023, 3/27/2023, 3/28/2023, 3/29/2023, 3/30/2023 and 3/31/2023. During an interview on 7/11/2023 at 12:10 PM, BOM said she had been employed at the facility since 11/8/2021. She said the previous DON last day at the facility was on 1/28/2023 and the Regional Nurse was coming to the facility during that time. She said the current DON started at the facility as a weekend RN on 11/4/2022 and did not become the DON of the facility until the beginning of February 2023. She said the DON did not clock in or out when they worked but she would enter in time of 8 hours on the days they worked. During an interview on 7/13/2023 at 8:39 AM, the Accounts Payable Manager said the RN hours for the facilities was automatically entered into the PBJ reporting data. She said salaried RN's hours were entered into the payroll system manually by the BOM but was not sure why the hours were not reported to the PBJ system and thought it could be how the BOM was coding the hours in the payroll system. She said she was not aware of the missing RN hours for the second quarter. During an interview on 7/13/2023 at 4:35 PM, the Corporate Director of Nursing said there was a system error with how payroll was entering the hours for RN coverage and how it was being submitted to CMS. He said going forward they were going to review the payroll hours reported with accounts (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675940 If continuation sheet Page 58 of 63 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 675940 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hemphill Care Center 2000 Worth St Hemphill, TX 75948 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 0851 payable every 7 days to ensure it was getting accurate information to be submitted to CMS. Level of Harm - Potential for minimal harm Record review of a facility policy dated June 2022 titled Electronic Staffing Data Submission Payroll-Based Journal indicated. Accuracy: Staffing information is required to be an accurate and complete submission of a facility's staffing records . Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675940 If continuation sheet Page 59 of 63 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 675940 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hemphill Care Center 2000 Worth St Hemphill, TX 75948 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 infections for 2 of 6 residents (Resident # 1 and Resident #17) reviewed for infection control. Residents Affected - Some LVN J failed to clean the scissors used to cut wound care dressings for Resident #1 and she stored the scissors in her pocket. CNA I failed to change her gloves when going from dirty to clean while providing incontinent care for Resident #17. These failures could place residents at risk of exposure to communicable diseases and infections. Findings included: 1. Record review of an admission Record for Resident #1 dated 7/13/2023 indicated he admitted to the facility on [DATE] and was [AGE] years old with diagnoses of paraplegia (paralyzed in lower half of body), COPD (a group of diseases that cause airflow blockage and breathing problems), and major depressive disorder (persistent depressed mood and loss of interest in life). Record review of a physician order dated 7/5/2023 for Resident #1 indicated an order to cleanse ulcer to right gluteal cleft (butt crack) with wound cleanser, pat dry with 4 x4's, apply Santyl (removes dead tissues from wounds) and collagen (dressing that contains proteins the promotes skin growth), apply zinc to peri-wound (tissue surrounds a wound) and cover with foam dressing daily until resolved or treatment changed one time a day. Record review of a Quarterly MDS assessment dated [DATE] for Resident #1 indicated he did not have any impairment in thinking with a BIMS score of 15. He did not have any unhealed pressure ulcers/injuries. Record review of a care plan undated for Resident #1 indicated he had actual skin impairment related to wound to sacrum (bone in the lower spine that forms part of the pelvis) with interventions to cleanse ulcer to right gluteal cleft with wound cleanser, pat dry with 4x4's, apply Santyl and collagen, apply zinc to peri-wound and cover with foam dressing. During an observation on 7/13/2023 at 9:00 AM, LVN J was in Resident #1's room. She removed the dressing from Resident #1's buttocks and placed in in the trash. She removed her gloves and placed them in the trash and went into the restroom and washed her hands. She applied gloves to both hands and cleaned Resident #1's gluteal area with the gauze soaked in wound cleanser and placed the gauze in the trash. She patted the area dry with dry gauze and placed the gauze in the trash. She removed her gloves and placed them in the trash and washed her hands. She applied gloves and removed a pair of scissors from her pocket and cut the collagen dressing and applied to the wound bed with Santyl ointment and zinc to peri-wound. She completed the care and exited the room. During an interview on 7/13/2023 at 9:20 AM, LVN J said she had been employed at the facility since January 2023 prn (as needed). She said she should have cleaned her scissors prior to providing (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675940 If continuation sheet Page 60 of 63 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 675940 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hemphill Care Center 2000 Worth St Hemphill, TX 75948 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 wound care treatment and placed them on the over bed table with the wound supplies. She said she should not have kept her scissors in her pocket. She said she had training on infection control. She said equipment should be cleaned before and after resident use and residents could be at risk of infections. 2. Record review of an admission Record for Resident #17 dated 7/13/2023 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of atherosclerotic heart disease (buildup of fats and cholesterol in the arteries), iron deficiency anemia (low red blood cells in the body which carry oxygen) and dementia (loss of thinking, remembering and reasoning that interferes with daily activities). Record review of a Quarterly MDS Assessment for Resident #17 dated 7/10/2023 indicated she was rarely/never understood and was always incontinent of bowel and bladder. Record review of a care plan for Resident #17 undated indicated she had an ADL self-care performance deficit related to dementia and was no longer able to toilet self. She needs total assist of one to toilet and for perineal hygiene. She had bowel and bladder continence related to cognitive factors with interventions to check the resident every two hours and as required for incontinence. During an observation on 7/13/2023 at 9:25 AM in Resident #17's room, CNA I and CNA E were present to provide incontinent care for Resident #17. CNA E positioned Resident #17 on her right side. CNA I removed wipes from the plastic bag and wiped Resident #17's rectal area with multiple wipes from front to back to remove fecal material until area was clean. CNA I removed the soiled brief and placed it in the trash. CNA I placed a clean under pad and then positioned a brief underneath Resident #17's buttocks without removing her dirty gloves. CNA I and CNA E repositioned Resident #17 on her back and secured the brief, linens pulled back up During an interview on 7/13/2023 at 9:40 AM, CNA I said she had been employed at the facility since 2019. She said she normally worked nights. She said during the incontinent care provided to Resident #17 she should have changed her gloves before she placed the clean brief and under pad. She said the facility did in-services with staff and trainings online that included infection control. She said she did not remember having a skills check off with staff who observed her perform incontinent care since she on hire. She said residents could be at risk of bacterial transfer if she did not change her gloves from dirty to clean. During an interview on 7/13/2023 at 9:45 AM, the ADON said she had been employed at the facility since January 30, 2023. She said she was responsible for training staff on infection control and completing competency check offs for the aides and nurses at the facility. She said the competency skills check offs were to be completed on hire and annually for staff. She said residents could be at risk of infection if staff did not change gloves when changing from dirty to clean. She said she could not find a competency skills check off for CNA I. She said she facility had a change in ownership a few months ago and was not sure where the skills check offs were stored. During an interview on 7/13/2023 at 1:50 PM, the DON said she had been employed at the facility as the DON since February 2023. She said staff should be washing their hands between glove changes or sanitizing their hands. She said equipment should be cleaned prior to each resident and before and after each use. She said residents could be at risk of infection. She said going forward staff would be in-serviced on proper technique on infection control. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675940 If continuation sheet Page 61 of 63 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 675940 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hemphill Care Center 2000 Worth St Hemphill, TX 75948 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 During an interview on 7/13/2023 at 2:00 PM, the Regional Nurse said CNA I should have changed her gloves going between clean and dirty. She said handwashing should be done prior to providing care to residents and between glove changes. She said a resident could be at risk for infection and cross contamination. Record review of a facility policy titled Cleaning and Disinfection of Resident-care Items and Equipment with a revised date of October 2018 indicated, .Resident-care equipment, including reusable and durable medical equipment will be cleaned and disinfected according to current CDC recommendations for disinfection, d. Reusable items are cleaned and disinfected or sterilized between residents (e.g., stethoscopes, durable medical equipment), 4. Reusable resident care equipment will be decontaminated and/or sterilized between residents according to manufacturers' instructions . Record review of a facility policy titled Handwashing/Hand Hygiene with a revised date of August 2019 indicated, .This facility considers hand hygiene the primary means to prevent the spread of infections. 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. 7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap and water for the following situations: g. Before handling clean or soiled dressings, gauze pads, etc.; h. Before moving from a contaminate body site to a clean body site during resident care . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675940 If continuation sheet Page 62 of 63 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 675940 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hemphill Care Center 2000 Worth St Hemphill, TX 75948 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 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for 1 of 1 refrigerator in the kitchen reviewed for essential equipment. Residents Affected - Many The facility did not ensure the refrigerator was in safe operating condition. The refrigerator had built up condensation in the top of the refrigerator that was melting and leaking water in food and storage containers within the refrigerator. This failure could place the residents at risk of food borne illnesses and not having safe operating equipment. Findings included: During an observation on 07/10/2023 at 09:00 AM the kitchen refrigerator was observed to have ice buildup in the top of the refrigerator that was melting and leaking into food and storage containers in the refrigerator. There was a clear plastic container half full of water with condiments mayonnaise and pickle relish containers floating. Water was standing on top of three containers of sour cream. Standing water was on top of the container of left over au gratin potatoes. During an interview on 07/10/23 at 09:50 AM the DM said she has worked here for 6 years. Said she told the maintenance man last week that the fridge was leaking and said there was a repair man that came, and they were currently waiting on the part to fix it. During an interview 07/10/23 at 10:15 AM the Maintenance man said the repair man came to work on the freezer and he also had them look at the fridge. He said they also cleaned the condenser to the fridge. During an interview 07/12/23 at 08:30 AM the administrator, he said the water that was leaking from the top of the fridge was coming from ice that had accumulated on the top of the fridge and is melting. He said the potential harm to resident is cross contamination and the possibility of food borne illnesses. Record review 07/10/23 10:15 AM of a work order estimate with [company name] Restaurant and chemical supply certified service center dated 6/13/23 said the following were reasons for the service call 1. 5/30/23 freezer was not the correct temp. 2. 6/2/23 Fans for the evaporator not working for the freezer. 3. 6/9/23 Freezer not at temp. Record Review 07/13/23 08:26 AM of policy titled Refrigerators and Freezers dated 2001 with a revised date of April 2006 revealed: 9. Supervisors will inspect refrigerators and freezers monthly for gasket condition, fan condition, presence of rust, excess condensation, and any other damage or maintenance needs. Necessary repairs will be initiated immediately. Maintenance schedules per manufacturer guidelines will be scheduled and followed. 9. Refrigerators and freezers will be kept clean, free of debris, and mopped with sanitizing solution on a scheduled basis and more often as necessary. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675940 If continuation sheet Page 63 of 63