Inspection·August 14, 2024

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few therapy room, and she would usually sit while doing so. He said it did not bother him if staff stood by him or not while feeding him. During an interview on 8/14/2024 at 9:40 a.m., the ADON said staff should be at eye level, sitting by residents when they are assisting them with feeding. She said she was not aware of the incident on 8/12/2024 in the dining room with RA C. She said RA C was contract staff hired through the therapy department and would start including them in the in-services that were conducted with the facility staff. She said she would probably feel embarrassed if someone was standing while feeding her. She said RA C had certain residents on her tasks to assist with feeding but most times she assisted them in the resident's room or in the therapy room. During an interview on 8/14/2024 at 9:45 a.m., the DON said she had been employed in her position since 4/1/2024. She said staff should be sitting down and never standing while feeding a resident. She said staff should take their time while feeding the residents. She said going forward they would continue to in-service staff and redirect if necessary. She said RA C had an in-service on 8/12/2024. During an interview 8/14/2024 at 10:15 a.m., the Administrator said she has been employed since November 2023 and received her license on Friday 8/9/2024. She said staff should be at eye level with residents when assisting with feeding, sitting down in front of them. She said the RA C was in-serviced on dignity and respect on 8/12/2024. She said going forward she would make sure staff knew the rules and regulations of how to perform in the dining room with meals and educated on dignity and respect to make sure everyone was aware of how to assist a resident in the dining room. She said the staff were in-serviced on 8/12/2024 and would continue to monitor. Record review of an in-service training dated 8/12/2024 on dignity and respect regarding resident dining indicated RA C was in attendance by her signature. Record review of a facility policy dated 2001 indicated, .All residents shall be treated with kindness, respect, and dignity FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675940 If continuation sheet Page 2 of 11 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 08/14/2024 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure the residents' environment remained as free of accident hazards as possible for 1 of 4 residents reviewed for accident hazards. (Resident #27) The facility failed to develop and implement a policy and procedure to properly handle the care of Hoyer lift slings including interventions to inspect the Hoyer sling for signs of damage before each use and not removing damaged slings from service for Resident #27. This deficient practice could place residents at risk of falls and injuries if damaged lift sling broke during mechanical lift transfers. The findings were: Record review of a facility face sheet dated 08/12/2024 indicated Resident #27 was a [AGE] year-old male that re-admitted to the facility on [DATE] with quadriplegia (paralysis of all four limbs), and intracranial injury (brain damage) due to motor vehicle accident. Record review of a quarterly MDS assessment dated [DATE] indicated Resident #27 had a BIMS score of 15 indicating intact cognition, impairment of all extremities, and dependent for all transfers. Record review of a comprehensive care plan revised 06/03/2024 indicated Resident #27 required two staff members for transfers. During an observation on 08/12/2024 at 12:30 AM, Resident #27 was sitting in a Geri-chair with a lift sling underneath his buttocks, the straps were faded in color, the blue strap was almost gray in color, the care tags were illegible, torn, crinkled, and [NAME]. During an observation and interview on 08/13/2024 at 09:45 AM, a lift sling in the linen storage closet was fraying with loose stitching and an area of the blue trim pulled apart when stretched by CNA D. CNA D was not aware the manufacturer recommended for them to be taken out of service if the sling had a change in color or the label was illegible, that it indicated it had been worn, bleached, or was compromised. She said she would remove the lift sling being used for Resident #27 because it was unsafe. CNA D said she had 4 residents that required a Hoyer lift for transfers in the facility. CNA D said that if a sling was not available on the hallway, she would go to the linen storage closet and retrieve one for use. CNA D said the resident could suffer an injury or could be scared to get up with a lift if they were dropped . CNA D said she had received training to remove lift slings if they are coming unsewn or had tears. During an interview and observation on 08/13/2024 at 09:55 AM, a lift sling in the linen storage closet had frays in the threading, [NAME] and the blue tab pulled apart from the sling. The DON removed the sling from the closet to discard it. The DON said she worked for the facility for almost 14 months, and she removes slings if they have holes, frays, or strings but she was not aware the manufacturer recommended for them to be taken out of service if the sling had a change in color or the label was illegible, that it indicated it had been worn, bleached, or was compromised. The DON said the resident could suffer an injury if the straps broke and it was all the staff's responsibility to remove defective slings from service. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675940 If continuation sheet Page 3 of 11 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 08/14/2024 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an observation and interview on 08/13/24 at 3:00 PM, of the laundry area revealed there was one lift sling in the dryer. Laundry staff E worked at the facility for 4 months. Laundry staff E said she had received training to remove slings that have ravels on the edges, and threads that were pulling out. Laundry Staff E was not aware the manufacturer recommended for the Hoyer slings to be taken out of service if the sling had a change in color or the label was illegible, that it indicated it had been worn, bleached, or was compromised and she was not aware that some manufacturer's recommended only air drying. During an interview on 8/14/2024 at 9:40 AM, the Administrator said that lift slings are discarded according to the facility policy and manufacturer's suggested guidelines which is that the slings are discarded when the slings show signs of wear or any tears. The administrator said that the CNAs are to inspect the slings for any signs of rips or tears prior to using the sling. She said that the ADON also inspects the slings monthly and replaces any slings with signs of wear and tear with new slings. She said that moving forward staff will be inspecting for rips, tears, and fading. She said that residents are at risk for injury if a sling does not function properly. A record review of Full Body Slings- Medline, Instructions for use www.medline.com accessed 08/14/2024 reflected .Always inspect slings prior to each use. Signs of rips, tears, or frays indicate sling wear which is unsafe and could result in injury. Signs of color fading, bleached areas, or permanent wrinkles on the straps indicate improper laundering which is unsafe and could result in injury. Any slings with signs of wear or improper laundering should be immediately removed from use Sling maintenance best practices .Check condition before each use. If there is any fraying or visible wear and tear, do not use. Reusable slings should be replaced every six months. Follow care instructions on wash tag. If illegible, do not use. Keep at least two reusable slings per patient on hand-one available and one in the laundry. A record review of a facility policy for Lifting Machine, using a Mechanical dated July 2017 indicated .Sling Care: 3. Discard any worn, frayed or ripped slings. A record review of a facility assessment dated [DATE] indicated . Physical Equipment is checked monthly and as needed by maintenance department. Nursing department checks medical equipment before use. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675940 If continuation sheet Page 4 of 11 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 08/14/2024 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 0732 Post nurse staffing information every day. Level of Harm - Potential for minimal harm Based on observation, interview, and record review, the facility failed to ensure nurse staffing data was posted daily and readily accessible to residents and visitors with all required information for for 2 of 3 days reviewed (8/12/2024 and 8/13/2024) nurse staffing posting. Residents Affected - Many The facility failed to post the daily staffing information in a prominent place on 8/12/2024 and 8/13/2024. This failure could place residents, families, and visitors at risk of not being informed of the census and number of staff working each day to provide care on all shifts. Findings: During an observation on 8/12/2024 at 9:15 a.m., there was no daily staffing posting in or around the front entrance or at the nurse station. During an observation on 8/12/2024 at 3:23 p.m., there was a daily staffing posting for the facility on the bulletin board down P-hall by the Administrator's office and the time clock (not in a central location, easily visible to all residents and visitors). The staff posting was dated 8/12/2024 and had all necessary information that included the daily census and number of staff. During an observation on 8/13/2024 at 8:50 a.m., there was a daily staffing posting for the facility on the bulletin board down P-hall by the Administrator's office and the time clock (not in a central location, easily visible to all residents and visitors). The staff posting was dated 8/13/2024 and had all necessary information that included the daily census and number of staff. During an interview on 8/13/2024 at 11:50 a.m., the ADON said she was responsible for completing the daily schedule, but the DON was responsible for putting out the staff posting daily on the bulletin board by the time clock. During an interview on 8/13/2024 at 1:35 p.m., the DON said she had been employed in her position since 4/1/2024 and the ADON was responsible for completing the daily staffing schedule. The DON said she would go into the system and validate the shift and could update it to reflect any changes that were necessary. She said she would print out the staff posting that showed how many staff were providing care in the facility along with the census and put in on the bulletin board by the time clock. She said she kept the previous postings in a binder. She said the weekend RNs would post them as well in the same location. She said the residents were aware of where to find the information. She said the Regional Nurse told her to post it there. She said she was not aware the staff posting had to be in a place that was visible where everyone could see it. She said the current location where the staff information was posted by the time clock and visitors would not be able to see it. She said residents or visitors may think there was not any licensed staff in the building if they did not know where the staff posting was located. During an interview on 8/13/2024 at 1:40 p.m., the Regional Nurse said the DON or ADON was responsible for posting the staffing daily and it should be posted by the front door. She said she was aware that the staff posting was by the time clock earlier that day and it should have been posted by the front door. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675940 If continuation sheet Page 5 of 11 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 08/14/2024 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 0732 Level of Harm - Potential for minimal harm Residents Affected - Many During an interview on 8/14/2024 at 10:15 a.m., the Administrator said she had been employed since November 2023 and received her license on Friday 8/9/2024. She said the staff posting should be placed by the front entrance for everyone to see. She said it had always been placed by the bulletin board by the time clock prior to yesterday 8/13/2024. She said she was not aware that the staff posting had to be placed where people could see it until she was informed by the Regional Nurse on yesterday 8/13/2024. She said the staff posting location was changed and it was not visible to everyone who entered the facility prior to yesterday 8/13/2024. Record review of a facility policy titled Posting Direct Care Daily Staffing Numbers revised July 2016 indicated, .Our facility will post on a daily basis for each shift, the number of nursing personnel responsible for providing care to residents. 1. Within two (2) hours of the beginning of each shift, the number of Licensed Nurses (RN's, LPNs, and LVN's) and the number of unlicensed nursing personnel (CNA's) directly responsible for resident care will be posted in a prominent location (accessible to residents and visitors) and in a clear and readable format . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675940 If continuation sheet Page 6 of 11 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 08/14/2024 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 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 observations, interviews, and record reviews 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 3 of 8 residents (Resident #12, #19 and #27) reviewed for infection control. Residents Affected - Some 1. Facility failed to ensure CNA B and LVN A did not place Resident #12's foley catheter drainage bag (bag that drains urine from bladder) on floor during a transfer on 8/12/24. 2. Facility failed to ensure RA C washed or sanitized her hands between serving/feeding Residents #19 and #27 on 8/12/24. These failures could place residents at risk for cross contamination and infection. Findings include: 1.Record review of a facility face sheet dated 8/12/24 for Resident #12 indicated that she was a [AGE] year-old female admitted to the facility on [DATE] and subsequently readmitted on [DATE] with diagnoses including: chronic kidney disease (a gradual loss of kidney function that can lead to kidney failure), urinary tract infection, and urinary retention (a condition where you are unable to completely empty your bladder). Record review of a Quarterly MDS assessment dated [DATE] for Resident #12 indicated that she had a BIMS score of 11, which indicated that she had moderate cognitive impairment. She required substantial/maximal assistance with most all ADLs, and she had an indwelling catheter. Record review of a comprehensive care plan dated 3/15/24 for Resident #12 indicated that she had an indwelling foley catheter with an intervention to maintain drainage bag off the floor. Record review of a [NAME] dated 8/12/24 for Resident #12 indicated that under Bladder/Bowel section, intervention included .maintain the drainage bag off the floor . Record review of a physician order report dated 8/12/24 for Resident #12 indicated that she had the following order: .Foley Cath Care Q shift and PRN every shift . dated 8/11/23. During an observation and interview on 8/12/24 at 3:04 p.m., CNA B and LVN A were observed transferring Resident #12 from wheelchair to bed. During transfer, CNA B removed foley catheter drainage bag from wheelchair and placed it on the floor underneath chair. After transfer completed, CNA B picked bag up off floor and hung it on side of bed with bottom of bag still touching the floor. Before exiting room, this surveyor asked LVN A if there was anything wrong. She raised resident's bed and bag was no longer touching floor. When asked why the bag should not touch the floor, LVN A replied, Because the bladder won't empty? CNA B was asked if she knew why the bag should not be on the floor and she replied that she did not know. Both staff members said they had been trained on infection (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675940 If continuation sheet Page 7 of 11 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 08/14/2024 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 0880 control. Level of Harm - Minimal harm or potential for actual harm Record review of a Nurse Skills Checklist dated 7/9/24 for LVN A indicated that she had been trained on foley catheter care and infection control. Residents Affected - Some Record review of a Nurse Aide Proficiency dated 7/9/24 for CNA B indicated that she had been trained on catheter care. 2.Record review of an admission Record dated 8/13/2024 for Resident #27 indicated he admitted to the facility on [DATE] and was [AGE] years old with diagnoses of quadriplegia (condition where both arms and legs are paralyzed) and dysphagia (difficulty eating). Record review of a Quarterly MDS assessment dated [DATE] for Resident #27 indicated he did not have any impairment in thinking with a BIMS score of 15. He was dependent on staff for all activities of daily living. Record review of a care plan dated 5/28/2024 and revised on 6/3/2024 for Resident #27 indicated he had an ADL self-care performance deficit with interventions for eating: required total assistance to eat. During an observation on 8/12/24 at 12:19 p.m, in the dining room, Resident #27 was observed in a wheelchair sitting at a table. His lunch tray was served, and RA C assisted him with seasoning and cutting up his food without washing or sanitizing her hands. 3.Record review of an admission Record dated 8/13/2024 for Resident #19 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of Alzheimer's Disease (a brain disorder that slowly destroys memory and thinking skills), heart failure, and major depressive disorder (persistent feeling of sadness and loss of interest). Record review of a Quarterly MDS assessment dated [DATE] for Resident #19 indicated she had severe impairment in thinking with a BIMS score of 5. She required partial/moderate assistance with eating. Record review of a care plan dated 6/5/2024 for Resident #19 indicated she had an ADL self-care performance deficit related to Alzheimer's Disease with interventions for eating that included: required one staff participation to eat. During an observation on 8/12/24 at 12:21 p.m. in the dining room, Resident #19 was moved to the table with Resident #27. RA C was assisting Resident #27 with eating. RA C did not wash or sanitize her hands and stood by Resident #19 and started cutting up her food and explained to Resident #19 what the foods were on the plate. RA C then proceeded to help Resident #27 with eating his meal and she did not wash or sanitize her hands after contact with Resident #19's utensils. During an interview on 8/12/24 at 12:40 p.m., RA C said she had been employed for 6 months and was contract staff for the therapy department. She said she assisted with mealtimes with residents #27 and #19. She said she would observe how they ate and would assist with feeding if needed. She said she made sure if they were eating to check for swallowing issues. She said she did not sanitize her hands before assisting Residents #19 and #27 and said she just did not think about it. She said there could be a risk for bacteria or viruses if staff did not wash or sanitize their hands. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675940 If continuation sheet Page 8 of 11 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 08/14/2024 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 0880 Level of Harm - Minimal harm or potential for actual harm During an interview on 8/14/24 at 9:40 a.m., the ADON said she was not aware of the incident on 8/12/24 in the dining room with RA C. She said RA C was contract staff hired through the therapy department and would start including them in the in-services that were conducted with the facility staff. She said staff should wash or sanitize their hands before assisting with resident meals and in between residents. She said there was a risk for cross contamination. Residents Affected - Some During an interview on 8/14/24 at 9:45 a.m., the DON said she had been employed in her position since 4/1/2024. She said staff should sanitize their hands before and after assisting with meals, and before changing to assist another resident. She said there was a risk for infections, germs, or cross contamination. She said going forward they would continue to in-service staff and redirect if necessary. She said RA C had an in-service on 8/12/2024 on hand hygiene. During an interview on 8/14/24 at 10:11 a.m.-10:15 a.m., the Administrator said she had been here in training since November and just received her license this past Friday 8/9/2024. She said having the foley bag on the floor could be an infection control risk or something could possibly crawl up the bag to the resident from the floor. She said going forward they will be holding in-services and training all staff on infection control and foley care. She said the risk to residents include infection or harm. She said RA C was in-serviced on hand hygiene and hands should be sanitized prior to assisting with meals, between each resident, and residents should have their hands sanitized as well. She said there was a risk for bacteria, infections, and diseases to be passed on from one resident to another. She said going forward she would make sure staff knew the rules and regulations of how to perform in the dining room with meals and make sure everyone was aware of how to assist a resident in the dining room. She said the staff were in-serviced on 8/12/2024 and would continue to monitor. Record review of a facility in-service training dated 8/12/2024 on hand hygiene indicated RA C was in attendance by her signature. During an interview on 8/14/24 at 10:25 a.m., the ADON said she was the infection preventionist and that the foley bag being on the floor could cause a resident to get an infection. She said going forward she would be training staff on proper placement of foley bags. Record review of a training transcript dated 8/12/24 for CNA B indicated that she had been trained on infection control and prevention on 4/26/24. Record review of a facility policy titled Handwashing/Hand Hygiene revised October 2023 indicated, .This facility considers hand hygiene the primary means to prevent the spread of healthcare associated infections. 2. All personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infections to other personnel, residents, and visitors. Indications for Hand Hygiene: 1. Hand hygiene is indicated: a. Immediately before touching a resident; d. after touching a resident; e. after touching the resident's environment . Record review of a facility policy titled Catheter Care, Urinary dated 2001 and revised in September 2014 read .Be sure the catheter tubing and drainage bag are kept off the floor . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675940 If continuation sheet Page 9 of 11 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 08/14/2024 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 0919 Make sure that a working call system is available in each resident's bathroom and bathing area. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to be equipped to allow residents to call for staff through a communication system which relayed the call directly to a centralized staff work area for 2 of 29 residents reviewed for call lights. (Resident #11 and Resident #21) Residents Affected - Few The facility failed to ensure Resident #11 and Resident #21's emergency call light in the bathroom had a cord enabling it to be reachable from the floor. This failure could place residents at risk of not receiving care and services to maintain highest level of well-being. Findings included: 1.Record review of a facility face sheet dated 08/13/2024 indicated Resident # 11 was an [AGE] year-old female that admitted to the facility on [DATE] with diagnosis of Alzheimer's Disease (a disease that affects memory, thinking and interferes with daily life). Record review of a quarterly MDS assessment dated [DATE] indicated Resident # 11 had a BIMS of 99 indicating severe impaired cognition, and inability to answer questions. She required substantial assistance with toileting and is frequently incontinent of bowel and bladder. Record review of a comprehensive care plan revised 08/13/2024 indicated needing limited assist with toileting and had frequent bowel and bladder incontinence. 2. Record review of a facility face sheet dated 08/13/2024 indicated Resident #21 was an [AGE] year-old female that admitted to the facility on [DATE] with diagnosis of Alzheimer's Disease (a disease that affects memory, thinking and interferes with daily life). Record review of a quarterly MDS assessment dated [DATE] indicated Resident # 21 had a BIMS of 99 indicating severe cognitive impairment inability to answer questions and received substantial assistance with toileting. It indicated that Resident #21 was frequently incontinent of bladder but continent of bowel. Record review of a comprehensive care plan revised 06/10/2024 indicated Resident # 21 had intervention to take resident to the toilet at the same time every day for bowel continence. And that she had an ADL self-care performance deficit related to Alzheimer's disease and required assistance with bladder incontinence. During an observation and interview on 08/12/24 at 9:45 AM room [ROOM NUMBER], the bathroom call light had a string 2 inches long sticking out of the wall. Resident #21 was not interviewable. She smiled and shook head yes when spoken to. During an observation and interview on 08/12/24 at 10:00 AM room [ROOM NUMBER], the call light string in the bathroom does not reach the floor by 2 feet. Resident # 11 was not interviewable, she was unable to answer questions appropriately. During an interview on 08/14/24 at 09:30 AM with CNA F, she said that she had worked at the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675940 If continuation sheet Page 10 of 11 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 08/14/2024 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 0919 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few facility for 1 month, said that Resident #21 is able to go to the bathroom on her own. She said that staff will assist at times, but the resident will go to the bathroom independently. CNA F said that Resident #11 required assistance to go to the bathroom. CNA F said that if there is a missing or short call light string in the bathroom it is reported to the maintenance supervisor, and he fixes it immediately. CNA F said that if the call light string in the bathroom is too short then the resident would not be able to reach it to call staff for help and that would result in a delay in helping the resident. During an interview on 08/14/24 at 10:00 AM, the Administrator said that the direct care staff is responsible for identifying and reporting issues that include the call light cords. She said that she and the maintenance supervisor do daily rounds to identify environmental issues. She said that the staff can communicate any maintenance issues by putting a note in the maintenance notebook located at the nurse's station. She said that the maintenance supervisor checks the communication book daily. She stated that the call lights and cords are checked daily. She said that if the call light chord in the bathroom was not long enough that a resident would not be able to call for assist if they fall. During an interview on 08/14/24 at 10:30 AM, the maintenance supervisor said that housekeeping and direct care staff report any problems with the call light or missing call light strings. He said if there is a missing call light string in the bathroom, the staff is to report to maintenance immediately and the nurse is to be in the room with the resident until the string can be replaced. The maintenance supervisor said that he does daily rounds and checks the rooms for call light issues and any short or missing strings. He said that if the call light string in the bathroom is broken or too short then a resident that needs assistance is not able to alert the staff and get the help that he needs. Record review of a facility policy revised March 2021 Answering the call light Policy: .be sure the call light is within easy reach of the resident. And Report all defective call lights to the nurse supervisor promptly. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675940 If continuation sheet Page 11 of 11