Inspection·April 6, 2023

F 0689 2-3 views findings were no acute fracture or subluxations. Level of Harm - Minimal harm or potential for actual harm Interview on 04/06/23 at 9:00 AM with Resident #1 while in bed. Resident #1 stated CNA A transferred her from her wheelchair to bed on 04/05/23 by herself using a Hoyer lift. Resident #1 stated her neck area hit the wall. Resident #1 stated she thought she hit the call light box on the wall. Resident #1 stated it was just an accident. Resident #1 stated her baseline was pain. Resident #1 stated she had chronic pain due to having two hip surgeries and a neck surgery in the past. Resident #1 stated the incident did not cause her anymore pain. Resident #1 stated she did not need any additional pain medication, an ice pack, or heating pack because of the incident. Resident #1 stated she was able to rest last night, and the incident was not a big deal. Resident #1 stated she was fine and without additional pain this morning. Residents Affected - Few Interview on 04/06/23 at 9:43 AM with CNA A revealed she went into Resident #1's room on 04/05/23 around 2:00 PM to transfer Resident #1 from her wheelchair to bed using a Hoyer lift without the assistance of another staff member. CNA A stated Resident #1 did say something about the sling placement on her neck area but Resident #1 did not hit her head or neck area nor did Resident #1 say anything about hitting her head or neck area. CNA A stated Resident #1 said everything was fine once she transferred her into the bed and the transfer was completed. CNA A stated she transferred Resident #1 before and it was normal for her to complain of neck discomfort, every transfer Resident #1 had something to say about her neck or hip comfort. CNA A said she did not get help to transfer Resident #1 using the mechanical lift because her coworker, CNA B was on break. CNA A said she worked at the facility for five years and had read Resident #1's Tasks in the CNA kiosk and did, document resident care she provided in the kiosk. CNA A stated she had training on Hoyer transfers and knew she was supposed to have another coworker with her during all Hoyer transfers. CNA A stated it was her mistake to transfer Resident #1 by herself on 04/05/23 she should have waited for CNA B to get off break to assist with the Hoyer transfer of Resident #1. CNA A stated it was the first time she Hoyer transferred Resident #1 by herself, on 04/05/23. CNA A stated the risk of not performing a Hoyer transfer with assistance could result in injury to the resident and not having a witness of the transfer. Interview and observation on 04/06/23 at 10:45 AM of Resident #1 with ADON C present revealed Resident #1 was up in her wheelchair with no visible injuries to the neck or head. Resident #1's neck and head area were free of redness, bruising and the skin was intact. Resident #1 stated there were no injuries to her neck or head, it was ok, and she had no additional pain in that area. Interview on 04/06/23 at 8:20 AM with the Administrator revealed she had spoken with Resident #1 on 04/05/23 and Resident #1 stated during her Hoyer transfer she hit her head on the call light box on the wall. Resident #1 stated CNA A performed the Hoyer transfer by herself. Resident #1 stated it was just an accident. The Administrator stated there were no visible injuries on 04/05/23, however x-rays were ordered. The Administrator stated Resident #1 had a diagnosis of chronic pain syndrome and had a history of drug seeking. The Administrator stated her expectation was for all Hoyer lifts to be conducted by two staff members. The Administrator stated the risk of doing a Hoyer lift with one person could result in accident or injury to the resident. Interview on 04/06/23 at 11:52 AM with ADON C revealed Resident #1 told her on 04/05/23 that while being Hoyer transferred back to bed by CNA A her right side hit the wall. ADON C stated Resident #1 changed her story during the interview on 04/05/23 when ADON C asked Resident #1 what exactly happened during the Hoyer transfer. Resident #1 then stated she was not sure if she hit the wall, call light box or the side rail. Resident #1 stated she did not see what she hit. ADON C asked Resident #1 if she was sure that it was not the sling and Resident #1 stated she was not sure. ADON C stated the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676424 If continuation sheet Page 2 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676424 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Farmersville Health and Rehabilitation 205 Beech St Farmersville, TX 75442 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 resident had a diagnosis of chronic pain syndrome and had a history of seeking pain and muscle relaxer medications. ADON C stated her expectation was for Hoyer transfers to be conducted by two staff members to prevent incidents and accidents. Interview on 04/06/23 at 11:45 AM with RN E revealed Resident #1 was on her assignment on 04/05/23. RN E stated she was not aware of any incident that occurred on 04/05/23 with Resident #1 during her Hoyer lift transfer. RN E stated Resident #1's baseline was pain due to a chronic pain diagnosis. RN E stated Resident #1 had no complaints of pain on 04/06/23. RN E stated Resident #1 was a two person Hoyer lift transfer. RN E stated she observed Hoyer transfers being conducted by two staff members for Resident #1. Interview on 04/06/23 at 12:26 PM, via telephone, with LVN D regarding the Hoyer transfer incident that occurred on 04/05/23. LVN D stated she did not witness the incident, however, LVN D stated she did the assessment of Resident #1 after the incident. LVN D stated Resident #1's baseline was pain due to her diagnosis of chronic pain. LVN D stated she did not observe any visible injuries to Resident #1's head or neck area. LVN D stated x-rays were ordered. LVN D stated Resident #1 was offered pain/muscle cream and she declined, Resident #1 did not need her PRN Tylenol administrated nor did she accept an ice pack or heating pack on 04/05/23. Record review of Resident #1's physician orders, for April 2023, revealed the following: 04/05/23 x-ray: neck series (cervical spine) 10/20/22 give two tablets orally every six hours as needed for pain, Tylenol Tablet 325 MG, document level of pain (0-10). In progress note describe pain scale used and location of pain and any pain behaviors observed. Tylenol Tablet 325 10/20/22 Hoyer lift for all transfers with 2 persons assist. Record review of Resident #1's Medication Administration Record, for April 2023, revealed the following: No documentation of Tylenol Tablet 325 MG orally every six hours as needed for pain given on 04/05/23 or 04/06/23. Record review of Resident #1's Total Body Skin Assessment, dated 04/06/23, revealed no wounds. Record review of Resident #1's Care Plan, revision on 02/10/21, Resident #1's focus of assist with ADLs, Hoyer lift for transfers, intervention of resident was transferred with Hoyer lift and two persons assist. Focus pain/pain management, revision date on 12/14/22, interventions to administer pain medications as ordered. Teach resident relaxation techniques and diversion therapy as alternative methods of pain management. Use supportive devices to promote and sustain comfortable positions. Focus on risk for increased pain related to chronic pain syndrome, carpal tunnel and muscle spasms. Record review of Atlas Floor Lift Model Pan-PL5500DF, Pan-PL5500DP Owner's Manual, undated, provided by the facility revealed on page 5, Safety Warnings and Cautions, Lift Operation Warning more than one assistant is recommended for all resident lift activities. Record review of CNA A's Relias Training Transcript provided by the facility Administrator on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676424 If continuation sheet Page 3 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676424 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Farmersville Health and Rehabilitation 205 Beech St Farmersville, TX 75442 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 04/06/23 revealed Safe Transfers were completed on 12/25/22 with final exam score of 100. Level of Harm - Minimal harm or potential for actual harm Record review of the facility's, undated, policy titled Transfer of Patient, revealed Two Person Hoyer (mechanical lift) Purpose: To safely get resident from on surface to another when the resident is unable/unwilling to bear weight on his or her lower extremities and cannot be safely transferred using the two-person total lift. Equipment: 4. Two staff members. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676424 If continuation sheet Page 4 of 4