Inspection·October 19, 2023

F 0580 Record review of the Facility Provider Investigation Report, dated 09/22/23, reflected: Level of Harm - Minimal harm or potential for actual harm An email from the DON dated 09/22/23 at 9:37 PM : Residents Affected - Few FM A of resident involved came in for a visit. He was observed by two CNA's sexually fondling this resident. His hand was seen under the resident's skirt, to her genitals. Statements were obtained from the CNA's . Future visits made by FM A will be supervised. Statement from the facility SW, dated 09/25/23, reflected: This social worker called .and reported .inappropriate touching incident of resident's vagina by her FM A . witnessed by two CNAs in this facility .resident is residing in skilled nursing facility and is unable to give verbal consent due to her poor cognition relating to her diagnosis of dementia and senile degeneration of the brain . Statement from CNA C, dated 09/22/23, reflected: On 09/22/23 at or around 4:25 PM, I witnessed FM A with his hand under the resident's gown in the vagina area. I did not physically see his hand inside of her vagina but I witnessed an in and out motion and the resident looked very uncomfortable and disturbed. FM A denied touching Resident #64 inappropriately and said he was agreeable to having all visits with Resident #64 supervised by staff. An observation on 09/26/23 at 1:39 PM with Resident #64 revealed she was lying in bed. She was awake and alert and turned her head when spoken to. CNA A entered the room. The resident was Spanish-speaking only. The resident spoke, but it was nothing understandable. CNA A translated and said the resident was not saying anything that made sense. An interview on 09/26/23 at 1:09 PM with CNA B revealed on 09/22/23 she was assigned to Resident #64's hall. She said she went to her room and saw FM A sitting in a chair next to the resident and her gown was raised up. CNA B said FM A's right hand was on her vagina, inside of her brief. CNA D said FM A told her the resident was wet and used his left hand to point to the brief. CNA B said the resident was not wet. The resident was lying in bed with her eyes closed and she was stiff in the bed. CNA B said after she started talking, the resident sat up in bed, got up, walked to CNA B and started patting her vagina area and saying eeee. CNA B could not understand what the resident was saying. CNA B said she reported what she saw to the nurse who entered the room. CNA B said the resident had a history of being very combative and agitated when FM A came to visit. CNA B said FM A needed to be counseled because he needed to understand that because of her mental capacity, that behavior was no longer acceptable. An interview was attempted on 09/28/23 at 11:32 AM with FM A, but he refused to speak to the Surveyor. An interview with 09/27/23 at 12:14 PM with LVN D revealed she did a head-to-toe exam on Resident #64 with no new findings. The resident already had a nickel-sized bruise at the top of her vagina at the panty line. She said she did not do a vaginal exam because it was outside of her scope of practice and the resident was not sent to the emergency room for an exam because FM A said not to. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676424 If continuation sheet Page 2 of 17 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 10/19/2023 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 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few An interview on 09/27/23 at 2:53 PM with the FNP revealed she was not notified about the allegation of sexual abuse. She said she was on-call and should have been notified. She said it might have been the best thing to do to order a vaginal exam following the allegation, but she was not notified and so she could not say for sure. An interview on 09/28/23 at 9:15 AM with the DON revealed she did not know why the physician/FNP was not notified. A phone message was left for RN E on 09/28/23 at 1:14 PM to find out why she did not notify the FNP, but she did not return the call of the Surveyor. The Administrator was not available for interview during the survey. Review of the Facility Policy and Procedure, Change of Condition-Notification, not dated, reflected: . Procedure: 1. The charge nurse will notify the resident, his/her physician .when there is: a. A change in the resident's condition . c. A need to alter treatment significantly . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676424 If continuation sheet Page 3 of 17 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 10/19/2023 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to provide a safe, clean, comfortable, and homelike environment including but not limited to receiving treatment and supports for daily living safely for areas in the facility for 8 of 20 rooms (Room # 2, 13, 14, 15, 17, 18, 19, 20) observed for a safe, clean, comfortable, and homelike environment. The facility failed to ensure that resident rooms were cleaned and serviced in accordance with the facility's policy on Housekeeping Services. This deficient practice could place residents at risk of infections and living in an uncomfortable environment leading to a decreased quality of life. Findings include: Observation of room [ROOM NUMBER] on 09/26/23 at 10:30 AM and on 09/28/23 at 10:00 AM revealed, the floor displayed light grayish and light brownish stains throughout the room. Observation of room [ROOM NUMBER] on 09/26/23 at 10:44 AM and on 09/28/23 at 10:05 AM revealed, the floor had a dark rust in color stain near the resident's nightstand. Observation of room [ROOM NUMBER] on 09/26/23 at 10:44 AM and on 09/28/23 at 10:06 AM revealed, the floor had a dark rust in color stain near the resident's nightstand. Observation of room [ROOM NUMBER] on 09/26/23 at 10:53 AM and on 09/28/23 at 10:10 AM revealed, the Floor had small clumps of black dirt stuck to the floor, near the entrance of the doorway. Observation of room [ROOM NUMBER] on 09/26/23 at 10:57 AM and on 09/28/23 at 10:13 AM revealed, the Floors displaying a yellowish stain near the resident's bed side table and the corners of floor near resident's bed had dirt particles Observation of room [ROOM NUMBER] on 09/26/23 at 11:04 AM and on 09/28/23 at 10:15 AM revealed, the walls near the resident's bed displayed black markings and brownish stains. Observation of room [ROOM NUMBER] on 09/26/23 at 11:09 AM revealed, the floor had cracks in the tiles. The tiles appeared very worn and broken throughout the room. Observation of room [ROOM NUMBER] on 09/26/23 at 11:13 AM revealed, the floor had cracks in the tiles and the surface underneath the tiles appeared uneven and loved wavy. Interview on 09/28/23 at 10:50 AM with Housekeeping Supervisor revealed the housekeeping staff uses a cleaning calendar to determine when rooms are to be deep cleaned. She stated that they are required to clean all rooms daily, which consisted of mopping the floor and emptying the trash. She stated that they deep clean all rooms at least once a week, and this involves scrubbing the floors, wiping down the walls, dusting, etc. She stated she checked the rooms to ensure that they are thoroughly cleaned. The Housekeeping Supervisor was shown pictures of concerns observed in the resident rooms and she stated that she will retrain her staff on how to thoroughly clean rooms. She stated she had (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676424 If continuation sheet Page 4 of 17 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 10/19/2023 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some taken over as Housekeeping Supervisor in July 2023 and she had just rolled out the cleaning schedule. She was asked about the cracked tiles on some of the room floors and she stated she had reported it to maintenance, and it was placed on his maintenance log. She stated the risk of rooms not being thoroughly cleaned, is an infection control concern. Interview on 09/28/23 at 11:00 AM with Maintenance Director revealed he was shown the pictures of the damaged tiles in resident rooms, and he stated that he was fully aware of the damages to tiles in resident rooms and he is trying to get to all of them. He stated that it was just him making all repairs at the facility and he had not gotten time to get to all of them. He stated that the impact to the resident was that they could have an accident and it was not good. Interview on 09/28/23 at 11:15 AM with Housekeeping Aide D, revealed she had been at the facility for 9 years. She stated that they utilize a cleaning calendar to determine which room was to be deep cleaned for the day. She stated that they are required to strip the floor, wipe down the bed and walls, dust, and clean whatever else needed to be cleaned. She stated they clean all rooms at least once a day and on non-deep cleaning days, they mop the floors and empty the trash. She was shown pictures of the concerns observed and she stated that she thoroughly cleaned her rooms and thinks her co-worker was responsible for cleaning the rooms observed. She stated she had pointed out the cracked tiles to the maintenance director and she writes it into the maintenance repair book. She was asked the risk to the residents of theses concerns not being addressed and she stated that it is not good. Interview on 09/28/23 at 10:30 AM with Director of Corporate Compliance and Assistant Director of Operations revealed, they were sitting in for the Administrator because she was hospitalized . They were shown the pictures of the concerns observed in resident rooms. They advised that the Housekeeping Supervisor was fairly new and they planned to have her shadow a more seasoned Housekeeping Supervisor to observe how she ensures the rooms and all other areas are thoroughly cleaned. They advised the risk of the concerns not being addressed impact the resident's right to a clean and sanitary environment. Review of the facility's Housekeeping Services (undated), revealed The Facility provides a safe, functional, sanitary, and comfortable environment for all residents, staff, and the public. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676424 If continuation sheet Page 5 of 17 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 10/19/2023 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 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property and that establish policies and procedures to investigate any such allegations for 1 of 3 residents (Resident #64) reviewed for abuse and neglect. Residents Affected - Few The facility did not follow their policy for Abuse and Neglect and thoroughly investigate when Resident #64 had an allegation of sexual abuse reported on 09/22/23. This failure could place residents at risk for not having their allegations of abuse and neglect investigated. Findings included: Record review of Resident #64's quarterly MDS assessment, dated 08/31/23, reflected she was a [AGE] year-old female admitted to the facility on [DATE]. Her cognitive skills were severely impaired. She was frequently incontinent of bladder and bowel. Her diagnoses included non-Alzheimer's dementia and non-cancerous brain tumor. Record review of Resident #64's Comprehensive Care Plans, dated 09/26/23, reflected: 1. FM A visiting on 9/22/23 and witnessed by 2 staff members touching resident inappropriately. Goal: Resident's FM A will not act inappropriately when visiting the resident. She is not able to consent to the sexual behavior he is initiating, and FM A's behavior agitates the resident. Facility interventions: .FM A can visit resident, but only when supervised by a staff member. 2. The resident is at risk for bruises r/t use of aspirin, combativeness w/ care, hx of falls, and FM A visits w/ inappropriate touching. Goal: The resident will be free from injury or further bruises x 90days Facility interventions: Provide supervised visits in a common area w/FM A for resident safety. Record review of the Facility Provider Investigation Report, dated 09/22/23, reflected: An email from the DON : The FM A of resident involved came in for a visit. He was observed by two CNA's sexually fondling this resident. His hand was seen under the resident's skirt, to her genitals. Statements were obtained from the CNA's . Future visits made by FM A will be supervised. Statement from the facility SW, dated 09/25/23, reflected: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676424 If continuation sheet Page 6 of 17 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 10/19/2023 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 0607 Level of Harm - Minimal harm or potential for actual harm This social worker called .and reported .inappropriate touching incident of resident's vagina by FM A . witnessed by two CNAs in this facility .resident is residing in skilled nursing facility and is unable to give verbal consent due to her poor cognition relating to her diagnosis of dementia and senile degeneration of the brain . Residents Affected - Few Statement from CNA C, dated 09/22/23, reflected: On 09/22/23 at or around 4:25 PM, I witnessed FM A with his hand under the resident's gown in the vagina area. I did not physically see his hand inside of her vaginavagina, but I witnessed an in and out motion and the resident looked very uncomfortable and disturbed. FM A did report a bruise on the resident at the panty line that was about the size of a quarter to the facility on [DATE]. The bruise was reported to the physician. FM A denied touching Resident #64 inappropriately and said he was agreeable to having all visits with Resident #64 supervised by staff. An observation on 09/26/23 at 1:39 PM with Resident #64 revealed she was lying in bed. She was awake and alert and turned her head when spoken to. CNA A entered the room. The resident was Spanish-speaking only. The resident spoke, but it was nothing understandable. CNA A translated and said the resident was not saying anything that made sense. An interview on 09/26/23 at 1:09 PM with CNA B revealed on 09/22/23 she was assigned to Resident #64's hall. She said she went to her room and saw FM A sitting in a chair next to the resident and her gown was raised up. CNA B said FM A's right hand was on her vagina, inside of her brief. CNA D said FM A told her the resident was wet and used his left hand to point to the brief. CNA B said the resident was not wet. The resident was lying in bed with her eyes closed and she was stiff in the bed. CNA B said after she started talking, the resident sat up in bed, got up, walked to CNA B and started patting her vagina area and saying eeee. CNA B could not understand what the resident was saying. CNA B said she reported what she saw to the nurse who entered the room. CNA B said the resident had a history of being very combative and agitated when FM A came to visit. CNA B said FM A needed to be counseled because he needed to understand that because of her mental capacity, that behavior was no longer acceptable. An interview was attempted on 09/28/23 at 11:32 AM with FM A of Resident #64, but he refused to speak to the Surveyor. An interview on 09/26/23 at 1:46 PM with the DON revealed the treatment nurse did a skin assessment the next day (09/23/23), but the resident was not sent for a vaginal exam because FM A said not to send the resident to the hospital. The DON said the incident was abuse because the resident could not consent. She said FM A was talked to and said he was just checking to see if the resident was wet. The DON said they were doing supervised visits with him because he visited her every day. An interview on 09/26/23 at 1:58 PM with the SW revealed she thought FM A had abused the resident. She said she was told the resident was in bed and he was feeding her. He would give her a bite with one hand. Her dress was up, and his hand other hand was down in the brief. The CNA had just checked the brief and said it was dry. He said he was just checking the brief. The SW said the facility was trying to keep the resident safe. She said the resident was not sent for a vaginal exam because they asked FM A and he refused . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676424 If continuation sheet Page 7 of 17 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 10/19/2023 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 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few An interview with 09/27/23 at 12:14 PM with LVN D revealed she did a head-to-toe exam on Resident #64 with no new findings. The resident already had a nickel-sized bruise at the top of her vagina at the panty line. She said she did not do a vaginal exam because it was outside of her scope of practice and the resident was not sent to the emergency room for an exam because FM A said not to. An interview on 09/27/23 at 12:50 PM with the Corporate Nurse for Resident #64 revealed she was asked what assessment should be completed when there was an allegation of inappropriate touching. The Corporate nurse did not answer the question but did say the facility offered to send the resident to the ER and FM A refused. The Corporate Nurse said the facility allowed FM A to make the determination of whether to send her to the ER because he was her representative party. She said to keep the resident safe going forward, the facility was allowing the resident to have supervised visits with FM A. She said the results of the investigation revealed the resident had a bruise found on the top area of her vagina on 09/21/23 and then FM A was seen touching the resident on 09/22/23. The Corporate Nurse said they thought FM A could have caused the bruise due to inappropriate touching. An interview on 09/27/23 at 2:53 PM with the FNP revealed she was not notified about the allegation of sexual abuse. She said she was on-call and should have been notified. She said it might have been the best thing to do to order a vaginal exam following the allegation, but she was not notified and so she could not say for sure. A phone message was left for RN E on 09/28/23 at 1:14 PM to find out why she did not notify the FNP, but she did not return the call of the Surveyor. An interview on 09/27/23 at 2:04 PM with the Medical Director revealed Resident #64 was on Hospice services and a pelvic exam would have been very traumatic for her. The Administrator was not available for interview during the survey. The Surveyor re-entered the facility following administrative review on 10/19/23 at 5:45 PM. An interview on 10/19/23 at 6:05 PM with the DON revealed Resident #64 passed away on 10/01/23. She said FM A visited the resident on 09/29/23 and was supervised by facility staff as agreed. FM A visited again on 09/30/23 and was supervised by facility staff. On 09/30/23, Resident #64 had a deterioration in condition and was actively dying. FM A stayed with the resident while being supervised by facility staff. Hospice was called and stayed with the resident. The resident passed away on 10/01/23. Review of the Facility Policy and Procedure, Abuse and Neglect, not dated, reflected: . Investigation: All staff in the nursing facility and all residents, responsible parties, and or legal representatives has been properly notified through facility policy that any abuse will not be tolerated at all. All allegations, no matter what types of incidents reported will be investigated fully . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676424 If continuation sheet Page 8 of 17 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 10/19/2023 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 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure all alleged violations of abuse and neglect were thoroughly investigated for 1 of 3 residents (Resident #64) reviewed for abuse and neglect. Residents Affected - Few The facility did not thoroughly investigate when Resident #64 had an allegation of sexual abuse reported on 09/22/23. This failure could place residents at risk for not having their allegations of abuse and neglect investigated. Findings included: Record review of Resident #64's quarterly MDS assessment, dated 08/31/23, reflected she was a [AGE] year-old female admitted to the facility on [DATE]. Her cognitive skills were severely impaired. She was frequently incontinent of bladder and bowel. Her diagnoses included non-Alzheimer's dementia and non-cancerous brain tumor. Record review of Resident #64's Comprehensive Care Plans, dated 09/26/23, reflected: 1. FM A visiting on 9/22/23 and witnessed by 2 staff members touching resident inappropriately. Goal: FM A will not act inappropriately when visiting the resident. She is not able to consent to the sexual behavior he is initiating, and FM A's behavior agitates the resident. Facility interventions: . FM A can visit resident, but only when supervised by a staff member. 2. The resident is at risk for bruises r/t use of aspirin, combativeness w/ care, hx of falls, and FM A's visits w/ inappropriate touching. Goal: The resident will be free from injury or further bruises x 90days Facility interventions: Provide supervised visits in a common area w/ FM A for resident safety. Record review of the Facility Provider Investigation Report, dated 09/22/23, reflected: An email from the DON: FM A of resident involved came in for a visit. He was observed by two CNA's sexually fondling this resident. His hand was seen under the resident's skirt, to her genitals. Statements were obtained from the CNA's . Future visits made by FM A will be supervised. Statement from the facility SW, dated 09/25/23, reflected: This social worker called .and reported .inappropriate touching incident of resident's vagina by FM A . witnessed by two CNAs in this facility .resident is residing in skilled nursing facility and is (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676424 If continuation sheet Page 9 of 17 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 10/19/2023 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 0610 Level of Harm - Minimal harm or potential for actual harm unable to give verbal consent due to her poor cognition relating to her diagnosis of dementia and senile degeneration of the brain . FM A did report a bruise on the resident at the panty line that was about the size of a quarter to the facility on [DATE]. The bruise was reported to the physician. Residents Affected - Few FM A denied touching Resident #64 inappropriately and said he was agreeable to having all visits with Resident #64 supervised by staff. Statement from CNA C, dated 09/22/23, reflected: On 09/22/23 at or around 4:25 PM, I witnessed FM A with his hand under the resident's gown in the vagina area. I did not physically see his hand inside of her vagina but I witnessed an in and out motion and the resident looked very uncomfortable and disturbed. An observation on 09/26/23 at 1:39 PM with Resident #64 revealed she was lying in bed. She was awake and alert and turned her head when spoken to. CNA A entered the room. The resident was Spanish-speaking only. The resident spoke, but it was nothing understandable. CNA A translated and said the resident was not saying anything that made sense. An interview on 09/26/23 at 1:09 PM with CNA B revealed on 09/22/23 she was assigned to Resident #64's hall. She said she went to her room and saw FM Asitting in a chair next to the resident and her gown was raised up. CNA B said FM A's right hand was on her vagina, inside of her brief. CNA D said FM A told her the resident was wet and used his left hand to point to the brief. CNA B said the resident was not wet. The resident was lying in bed with her eyes closed and she was stiff in the bed. CNA B said after she started talking, the resident sat up in bed, got up, walked to CNA B and started patting her vagina area and saying eeee. CNA B could not understand what the resident was saying. CNA B said she reported what she saw to the nurse who entered the room. CNA B said the resident had a history of being very combative and agitated when FM A came to visit. CNA B said FM A needed to be counseled because he needed to understand that because of her mental capacity, that behavior was no longer acceptable. An interview was attempted on 09/28/23 at 11:32 AM with FM A of Resident #64, but he refused to speak to the Surveyor. An interview on 09/26/23 at 1:46 PM with the DON revealed the treatment nurse did a skin assessment the next day (09/23/23), but the resident was not sent for a vaginal exam because FM A said not to send the resident to the hospital. The DON said the incident was abuse because the resident could not consent. She said FM A was talked to and said he was just checking to see if the resident was wet. The DON said they were doing supervised visits with him because he visited her every day. An interview on 09/26/23 at 1:58 PM with the SW revealed she thought FM A had abused the resident. She said she was told the resident was in bed and he was feeding her. He would give her a bite with one hand. Her dress was up, and his hand other hand was down in the brief. The CNA had just checked the brief and said it was dry. He said he was just checking the brief. The SW said the facility was trying to keep the resident safe. She said the resident was not sent for a vaginal exam because they asked FM A and he refused. An interview with 09/27/23 at 12:14 PM with LVN D revealed she did a head-to-toe exam on Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676424 If continuation sheet Page 10 of 17 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 10/19/2023 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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few #64 with no new findings. The resident already had a nickel-sized bruise at the top of her vagina at the panty line. She said she did not do a vaginal exam because it was outside of her scope of practice and the resident was not sent to the emergency room for an exam because FM A said not to. An interview on 09/27/23 at 12:50 PM with the Corporate Nurse for Resident #64 revealed she was asked what assessment should be completed when there was an allegation of inappropriate touching. The Corporate nurse did not answer the question but did say the facility offered to send the resident to the ER and FM A refused. The Corporate Nurse said the facility allowed FM A to make the determination of whether to send her to the ER because he was her representative party. She said to keep the resident safe going forward, the facility was allowing the resident to have supervised visits with FM A. She said the results of the investigation revealed the resident had a bruise found on the top area of her vagina on 09/21/23 and then FM A was seen touching the resident on 09/22/23. The Corporate Nurse said they thought FM A could have caused the bruise due to inappropriate touching. An interview on 09/27/23 at 2:53 PM with the FNP revealed she was not notified about the allegation of sexual abuse. She said she was on-call and should have been notified. She said it might have been the best thing to do to order a vaginal exam following the allegation, but she was not notified and so she could not say for sure. A phone message was left for RN E on 09/28/23 at 1:14 PM to find out why she did not notify the FNP, but she did not return the call of the Surveyor. An interview on 09/27/23 at 2:04 PM with the Medical Director revealed Resident #64 was on Hospice services and a pelvic exam would have been very traumatic for her. The Administrator was not available for interview during the survey. The Surveyor re-entered the facility following administrative review on 10/19/23 at 5:45 PM. An interview on 10/19/23 at 6:05 PM with the DON revealed Resident #64 passed away on 10/01/23. She said FM A visited the resident on 09/29/23 and was supervised by facility staff as agreed. FM A visited again on 09/30/23 and was supervised by facility staff. On 09/30/23, Resident #64 had a deterioration in condition and was actively dying. FM A stayed with the resident while being supervised by facility staff. Hospice was called and stayed with the resident. The resident passed away on 10/01/23. Review of the Facility Policy and Procedure, Abuse and Neglect, not dated, reflected: . Investigation: All staff in the nursing facility and all residents, responsible parties, and or legal representatives has been properly notified through facility policy that any abuse will not be tolerated at all. All allegations, no matter what types of incidents reported will be investigated fully . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676424 If continuation sheet Page 11 of 17 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 10/19/2023 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to refer all level II residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change in status assessment for one (Resident #36) of three resident assessments reviewed for PASRR evaluations. 1. The facility did not complete a new PASRR Level 1 Screening for Resident #36 when he was diagnosed with PTSD on 06/21/23. These failures could affect residents with psychiatric diagnoses who may not be evaluated and receive needed PASRR services. Findings included: 1. Review of Resident #36's quarterly MDS Assessment, dated 07/18/23, revealed he had active diagnoses of PTSD, anxiety disorder, and depression. The resident's cognition was intact. Review of Resident #36's care plan, dated 06/21/23, reflected: The resident had ineffective coping skills related to diagnosis of PTSD. (Loss of wife and daughter one year apart) Resident can have verbal outbursts and be argumentative. Review of Resident #36's PASRR Level 1 screening, dated 06/01/22, reflected he did not have a mental illness. There was no PASRR Level 2 screening. An interview on 09/28/23 at 1:05 PM with Resident #36 revealed he did not receive PASRR services and did not know what PASRR services were. He said he was interested in receiving PASRR services. An interview on 09/27/23 at 1:30 PM with the MDS Coordinator revealed she said she added the new diagnosis of PTSD on 06/21/23 and should have completed a new PASRR Level 1 screening. An interview on 09/28/23 on 9:22 AM with the DON revealed the SW and MDS Coordinator were responsible for completing new PASRR Level 1 screenings as needed. An interview on 09/28/23 at 11:37 AM with Corporate MDS Coordinator [NAME] revealed the facility MDS Coordinator was responsible for completing a new PASRR Level 1 screening if a new qualifying diagnosis was added. She said if a resident did not receive the correct PASRR Level 1 screening the resident was at risk for not receiving the proper services. Review of the facility policy for, Pre-admission Screening for Individuals with Mental Illness and Intellectual of Development Disabilities, not dated, reflected: If during a resident's stay they receive a new diagnosis from their physician that could be considered a positive PASRR for MI, ID, DD, the facility will complete a form 1012 and follow through to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676424 If continuation sheet Page 12 of 17 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 10/19/2023 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 0644 see if a physical and mental evaluation is needed. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676424 If continuation sheet Page 13 of 17 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 10/19/2023 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interviews and record reviews the facility failed to ensure food was stored, prepared, distributed and served in accordance with professional standards for food service safety for the facility's only kitchen reviewed for kitchen sanitation. The facility failed to ensure kitchen equipment was clean and sanitary. This failure could place residents at risk for cross contamination and other illnesses. Findings include: Observation on 09/26/23 at 09:15 AM in the facility's only kitchen revealed: Sugar, rice, breadcrumbs, and flour Bins, located in the dry storage area were dirty on the outside and along the opening of the bins. The sugar bin had dirt particles along the walls of the inside of the bin and some unidentified particles were in the sugar. One cast iron griddle, used for cooking steaks had rust all over it. Interview and Observation with Dietary Manager on 09/26/23 at 09:15 AM revealed she had been employed at the facility for three years and the Dietary Manager for over three months. She observed the rusted Cast Iron Griddle and the dirty bins. She stated the kitchen equipment are cleaned thoroughly once a month but should also be observed for cleanliness daily. She stated the risk of these concerns not being addressed could result in food contamination and residents becoming ill. Interview on 09/28/23 at 10:30 AM with Director of Corporate Compliance and Assistant Director of Operations revealed, they were sitting in for the Administrator because she was hospitalized . They were shown the pictures of the concerns observed in the kitchen. They advised that their expectations are for the kitchen to follow state and federal guidelines and they will follow up with staff to ensure these concerns are addressed. They advised of these items not being cleaned could result in contamination. Record Review of the Facility's policy on Kitchen Sanitation dated 01/01/10, revealed Food bins will be cleaned when empty or a minimum of once a month All kitchen equipment must be cleaned and sanitized. Review of the U.S. Food and Drug Administration (FDA) Code (2022) revealed, All equipment and utensils must be cleaned and sanitized. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676424 If continuation sheet Page 14 of 17 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 10/19/2023 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to 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 one (Resident #119) of three residents observed for infection control. Residents Affected - Few CNA A failed to perform hand hygiene while providing incontinence care to Resident #119. This failure could place residents at risk for spread of infection through cross-contamination. Findings included: An observation and interview on 09/27/23 at 10:53 AM of Resident #119 revealed CNA A performed catheter care and incontinence care. She pulled down the soiled brief, changed her gloves, but did not perform hand hygiene. CNA A cleaned the Foley catheter and changed her gloves but did not perform hand hygiene. The resident was assisted to turn to his left side and CNA A cleansed the bowel movement off the resident. CNA A changed her gloves but did not perform hand hygiene before putting a clean brief on the resident. CNA A was asked why she did not perform hand hygiene. She said she was supposed to perform hand hygiene every time she changed gloves. She said she forgot to perform hand hygiene and that failure could lead to cross contamination. She said she had been trained to perform hand hygiene. An interview with the DON on 09/27/23 at 2:45 PM revealed staff were supposed to perform hand hygiene between glove changes and failure to do so could lead to infection. Review of the facility policy, Hand Washing, not dated, reflected: Hand washing is required before and after a procedure that involves direct or indirect contact with a resident . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676424 If continuation sheet Page 15 of 17 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 10/19/2023 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 0912 Level of Harm - Potential for minimal harm Residents Affected - Many Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure 34 (Room number's 2, 3, 4, 6, 7, 8, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37 and 39) out of 34 multiple-resident bedrooms, measured at least 80 square feet per resident. The facility failed to ensure multiple resident Room number's 2, 3, 4, 6, 7, 8, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37 and 39 met the required minimum of 80 square feet per resident. This failure could place residents at risk of not having sufficient space. Findings included: Interview on 09/28/23 at 10:30 AM with Director of Corporate Compliance and Assistant Director of Operations revealed, they were sitting in for the Administrator because she was hospitalized . the facility had a room size waiver in place for the bedrooms measuring less than the required square footage. They also stated nothing has changed in the past years regarding resident's room square footage. They stated that the risk of residents not having the appropriate space could result in residents possibly having accidents because of the lack of space or they may not have the privacy they want. Review of Form DADS 3740 (Bed Classifications Form), completed by the facility on 08/28/2022, revealed all 34 bedrooms in the facility had two beds and were classified as Medicare and Medicaid. Review of the facility's license on 08/28/2022 at 2:30 PM revealed the facility was licensed for 74 beds. Review of the resident bedroom measurements listing, undated provided by the Administrator on 09/28/23 revealed the following: 1) Resident Rooms 2, 3 and 4 measured 127 square feet; 2) Resident Rooms 6, 8 and 10 measured 132 square feet 3) Resident room [ROOM NUMBER] measured 146 square feet 4) Resident rooms [ROOM NUMBERS] measured 147 square feet 5) Resident Rooms 12, 14, 15, 16, 17 and 19 measured 156 square feet 6) Resident room [ROOM NUMBER] measured 159 square feet 7) Resident Rooms 20, 22, 24, 26 and 28 measured 151 square feet 8) Resident Rooms 23, 25, 27, 29, 30, 31, 32, 33, 34, 35, 36, 37 and 39 measured 153 square feet. Waiver issued to the facility on [DATE] indicated that the following waiver was approved and would (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676424 If continuation sheet Page 16 of 17 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 10/19/2023 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 0912 remain in effect unless conditions are found to exist that would cause reconsideration or rescission: Level of Harm - Potential for minimal harm

F912, 483.90(e)(1)(ii), Measure at least 80 square feet per resident in multiple resident bedrooms, and at least 80 square feet in single resident rooms. Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676424 If continuation sheet Page 17 of 17