Health inspection·July 24, 2024

F 0837 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many administrator, she would report them to the Assistant Administrator, and did not know if the Assistant Administrator reported the incidents to the Regional Director of Operations or not. She said the Regional Director of Operations would come to the facility about once a month. During an interview on 7/23/2024 at 3:00 PM the Assistant Administrator said she had worked at the facility since November of 2023. She said she was hired at the facility in the middle of November 2023 and worked with the Previous Administrator under his license until November 30, 2023, which was his last day of employment. She said then on December 1st, 2023, she continued at the facility and worked as the administrator by proxy under the Regional Director of Operation's license who was the licensed administrator for the facility. She said the Regional Director of Operations had been the licensed administrator for the facility since 12/1/2023 to current. She said the Regional Director of Operations would come to the facility maybe 3 times a month, and the last time he was here was about 2 weeks ago. The Assistant Administrator said if there were any incidents that needed to be reported to the administrator, she would notify the Regional Director of Operations by phone. She said it was her fault the facility had not had a full-time administrator in 8 months because she was supposed to have her administrators license in December of 2023 and did not pass her test. She said she had now passed the first 2 portions of her test and was scheduled to take the final portion on 7/31/24. During an interview on 7/24/2024 at 12:15 PM the Regional Director of Operations said he had worked for the company for 18 years and his official title was Regional Director of Operations. He said he did not know why the Assistant Administrator had introduced herself to the Surveyor as the administrator because she was hired as the Assistant Administrator. He said he had not been the licensed administrator for the facility since December 1, 2023, when the Assistant Administrator was hired because he had been using his license in sister facilities. He said he could not remember the exact date but said he thought it was around February 2024 when he started using his administrator license for this facility. He said he knew the Assistant Administrator's test was scheduled for 7/31/2024 and said he would either have a licensed administrator at that time or would be advertising for one. He said he would be the licensed administrator for the facility starting on 7/29/2024. He said he knew the facility had deficient practice by not having a licensed administrator and knew it would be cited. During an interview on 7/24/2024 at 1:00 PM the Business Office Manager said she had worked at the facility since 11/8/2021. She said she did not keep up with who was the sitting licensed administrator for the building. She said hiring for all department heads was done at the corporate level. She said that once corporate had decided they were going to hire a department head they would reach out to her and ask that she run employee background check and employee misconduct checks on the employee. She said other than that she did not have anything to do with the hiring process for a department head. She said the Assistant Administrator's official job title was Assistant Administrator. She said she did not know who the licensed administrator for the facility was at that time. During an interview on 7/24/2024 at 1:24 PM the Corporate Clinical Director said he had worked for the company for about 10 ½ years. He said the Regional Director of Operations was the licensed administrator for the facility from 3/18/2024 to 6/19/2024. He said he had been at the facility 6 days in the month of June 2024 and had not seen the Regional Director of Operations. The Corporate Clinical Director said he was a licensed nursing home facility administrator but had never used his license for this facility. The Corporate Clinical Director said he was also an RN and worked strictly on the clinical side. He said it was the responsibility of the Assistant Administrator to notify the Regional Director of Operations of any incidents or allegations of abuse or neglect. The Corporate Clinical Director said he would report all incidents to him and he would also make sure the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675940 If continuation sheet Page 2 of 3 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 07/24/2024 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 0837 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Regional Director of Operations was notified of any incidents or allegations that needed to be reported to the administrator. He said the Regional Director of Operations was always readily available for any administrator tasks if he was in the facility or via technology if he was not in the facility. Record review of facility employee list dated 7/22/2024 titled Employee Demographics revealed the Assistant Administrator was hired fulltime on 11/16/2023 with the job title of Administrator. Record review of facility New Hire Ticket undated revealed the Assistant Administrator was hired on 11/16/2023 with the Discipline/Job Title: Assistant Administrator. It also revealed that once the Assistant Administrator passed her exams she would be promoted to Administrator. Record review of facility's Quality Assurance and Performance Improvement committee reports, and performance improvement plans dated 2/13/2024, 2/28/2024, 3/13/2024, 4/4/2024, 5/15/2024, 5/30/2024, 6/12/2024 revealed: the Assistant Administrator held all meetings signed as the administrator, the Regional Director of Operations did not attend any meetings. Record review of the facility's Assistant Administrator job description dated November 1, 1999, revealed: Position Summary: Under the direction of the Administrator, the Assistant Administrator leads and directs certain aspects of the facility operations in accordance with state and federal regulations, and facility policies and procedures. B. Administrative Responsibilities: 1. Assists the Administrator in managing facility operations . Summary of Qualifications: 2. Maintains a current, valid Texas Nursing Home Administrator's License. 4. Possesses strong knowledge regarding state, federal and local regulations as they pertain to long term care. Record review of the Facility Assessment Tool dated 6/03/2024 revealed: Persons (names/titles) involved in completing assessment listed under Administrator the Regional Director of Operations, the Assistant Administrator proxy. Record review of the facility policy titled Administrator with revised date of March 2021 revealed: Policy Statement: A licensed administrator is responsible for the day-to-day functions of the facility. Policy Interpretation and Implementation 1. The governing board of this facility has appointed an administrator who is duly licensed in accordance with current federal and state requirements. The administrator is responsible for, but not limited to: a. managing the day-to-day functions of the facility; i. maintaining his/her license on a current status as required by law and maintaining a copy of such license or registration on premises. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675940 If continuation sheet Page 3 of 3