Inspection·January 9, 2025

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an observation on 01-07-2025 at 10:21 AM Resident #14 was not in his room. Resident #14's roommate reported that Resident #14 was at dialysis. Resident #14 had an O2 concentrator next to the left side of his bed with the O2 tubing dated 1-6-2025. Observed was the nasal cannula hanging off the back of Resident #14's concentrator on the floor with the nasal prongs facing upward. During an observation on 01-07-2025 at 11:02 AM Resident #14's O2 concentrator was at his bedside with the nasal cannula on the floor behind the machine with the nasal prongs facing upward. During an observation on 01-07-2025 at 02:02 PM Resident #14's O2 concentrator was at his bedside with the nasal cannula on the floor behind the machine with the nasal prongs facing upward. Resident #14's room was observed to have been cleaned and his bed had been made. During an observation and interview on 01-07-2025 at 03:38 PM Resident #14 was in his room lying on his bed. Resident #14 was difficult to understand, appeared to be confused, and did not respond effectively to questions. Resident #14's O2 concentrator was at his bedside with the nasal cannula on the floor behind the machine with the nasal prongs facing upward. During an observation on 01-08-2025 at 07:45 AM Resident #14's O2 tubing (dated 1-6-2025) and nasal cannula was observed stored in a bag laying on the floor behind his O2 concentrator. During an observation on 01-09-2025 at 08:02 AM Resident #14's O2 concentrator was at his bedside with the nasal cannula on the floor to the right side of the concentrator behind the machine on the floor with the nasal prongs facing upward. During an interview on 01-09-2025 at 08:05 AM the DON reported that floor staff are to make rounds on resident every 2 hours. The DON reported that floor staff where to check the residents for incontinence or of they had any other needs. The DON verified that the staff were to check on the resident's equipment to include the respiratory equipment. The DON reported that if a nasal cannula was found on the floor then the nasal cannula would need to be changed because the nasal canula would be exposed to the floor and who knows what is on that floor. The DON reported that the floor could be dirty with any substance and if the resident was immunocompromised then they would be at even more risk. The DON reported that she would immediately start an in-service to correct the issue. During an interview on 01-09-2025 at 08:36 AM the DON reported that the facility did not have a policy on employee round responsibilities, and they were looking for a policy on respiratory tubing care. During an interview on 01-09-2025 at 08:57 AM the DON reported that the facility did not have a policy on respiratory tubing care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675282 If continuation sheet Page 2 of 7 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 675282 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/09/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Amarillo Medical Lodge 9 Medical Dr Amarillo, TX 79106 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review the facility failed to store and distribute food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food safety. Residents Affected - Some 1. The facility failed to ensure stored foods were properly labeled and dated. 2. The facility failed to ensure expired foods were discarded. 3. The facility failed to store foods in accordance with professional standards. These failures could place residents who ate the food from the kitchen at risk for food-borne illness and a diminished quality of life. Findings included: On 01/07/2025 at 8:11AM an initial tour of the kitchen was conducted and revealed the following: Facility Refrigerator: (1) 2-quart bag of strawberries with an expiration date of 12/19/2024. 15 sausage patties with no date opened and open to air. (1) 40 count cartons of chocolate milk with no date received. (7) 40 count cartons of white milk with no date received. Facility Freezer: (1) 5-pound bag of frozen strawberries with no date received and open to air. (1) 2-pound bag of frozen green beans with no date received and open to air. 11 frozen hashbrown patties with an expiration date of 6/19/2024. 15 frozen eggrolls with no date received and open to air. (1) 10-pound bag of frozen corn with no date received and open to air. 80 count frozen hamburger patties with no date received and open to air. Facility Dry Pantry: (1) 1.57-pound bag of cream soup base with an expiration date of 10/24/2024. An interview with the Dietary Manager on 1/8/25 at 10:30AM revealed the negative outcome of serving (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675282 If continuation sheet Page 3 of 7 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 675282 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/09/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Amarillo Medical Lodge 9 Medical Dr Amarillo, TX 79106 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 foods which were not properly dated and/or expired would be residents could become sick from a food-borne illness, which could reduce their quality of life. Level of Harm - Minimal harm or potential for actual harm Record Review of the undated facility policy for Food Storage revealed the following: Residents Affected - Some Refrigerated food storage: (f) All foods should be covered, labeled, and dated. All foods will be checked to assure that foods (including leftovers) will be consumed by their safe use by dates, or frozen (where applicable), or discarded. Frozen food storage: (c) All food should be covered, labeled, and dated. All foods will be checked to assure that foods will be consumed by their safe use by dates or discarded. There was no food storage policy regarding expiration dates or discard by dates, for the dry pantry. Record Review of FDA Food Code dated 2022 revealed the following: 3-602 Labeling 3-602.11 Food Labels. (A) FOOD PACKAGED in a FOOD ESTABLISHMENT, shall be labeled as specified in LAW, including 21 CFR 101 - Food labeling, and 9 CFR 317 Labeling, marking devices, and containers. (B) Label information shall include: (1) The common name of the FOOD, or absent a common name, an adequately descriptive identity statement; 3-602.12 Other Forms of Information. (B) FOOD ESTABLISHMENT or manufacturers' dating information on FOODS may not be concealed or altered. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675282 If continuation sheet Page 4 of 7 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 675282 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/09/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Amarillo Medical Lodge 9 Medical Dr Amarillo, TX 79106 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to 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 1 (CNA A) of 5 staff observed for resident care Residents Affected - Few CNA A did not wear the proper PPE when assisting with wound care per Enhanced Barrier Precautions, increasing the risk of MDRO contamination. This deficient practice could place residents at risk of cross-contamination and infections. Findings include: Record review of Resident #155's clinical record revealed a [AGE] year-old female resident admitted to the facility on [DATE] with diagnoses to include metabolic encephalopathy (a chemical imbalance in the blood that causes problems in the brain), obesity (a disorder involving excessive body fat that increase the risk of health problems), chronic kidney disease (longstanding disease of the kidneys leading to kidney failure), and muscle weakness (a lack of muscle strength). Record review of Resident #155's clinical record revealed her last MDS was an admission completed 12-17-2024 listing her with a BIMS of 11 indicating she had a moderately impaired cognitive function, and she has a functionality of requiring supervision or touching assistance with most of her activities of daily living. Record review of Resident #155's care plan with admission date of 12-17-2024 revealed the following: Focus: Resident has a pressure ulcer r/t decreased mobility-right buttocks stage 3-date initiated 12-17-2024 Interventions: Use Enhanced Barrier Precautions-date initiated 1-2-2025 During an observation on 01-08-2025 at 11:06 AM LVN B was performing wound care for Resident #155's Stage 3 pressure ulcer with the assistance of CNA A. LVN B donned a gown and gloves for the procedure. CNA A was only wearing gloves. CNA A did not don a gown. CNA A rolled the resident on her right side after removing the resident's covers and pulling the residents brief to her knees to expose the wound area for care. CNA A assisted the resident to maintain this position for the entire wound care procedure, then returned the resident to her back, put her brief back in place, and pulled her covers back up. During an interview on 01-08-2025 at 02:37 PM CNA A verified that he did not wear a gown during the wound care provided for Resident #155's Stage 3 pressure ulcer and reported that he did not think that he was supposed to because he was not touching the wound. CNA A verified that he performed incontinent care on the resident with the Stage 3 pressure ulcer prior to the wound care because the resident was incontinent and that he had removed the residents covers and pulled down her brief to prepare for her wound care all without wearing a gown because he did not touch the wound. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675282 If continuation sheet Page 5 of 7 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 675282 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/09/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Amarillo Medical Lodge 9 Medical Dr Amarillo, TX 79106 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 01-08-2025 at 11:44 AM LVN B stated Resident #155 (that she had performed wound care with the assistance of CNA A) was on EBP for a Stage 3 pressure ulcer and that CNA A did not don a gown for the procedure. LVN B stated not following EBP could result in the spread of infection and result in negative effects for residents such as infections and cross-contamination. During an interview on 01-08-2025 at 02:25 PM the DON reported that a staff member such as a CNA assisting with care on a resident that had a wound or catheter, may use their discretion if they feel they will not have direct contact with the wound or catheter, especially if the residents did not have an MDRO. The DON reported that only if they are going to touch the wound then they need to use EBP. The DON reported that education for staff, visitor, and family would have been done by posting signage on the resident's door if they required EBP. Also gloves, gowns, and isolation boxes for disposal of used PPE would have been placed in the resident's room. The DON reported that currently the facility had no residents that required EBP precautions because no residents were currently positive for MDRO infections. During an interview and record review on 1-9-2025 at 08:57 the DON reported they provide signage for a resident's doorway when the resident was placed on EBP, and the DON provided the signage that revealed the following: Enhanced Barrier Precautions Everyone Must: Clean their hands, including before entering and when leaving the room. Providers and staff must also: Wear gloves and gown for the following High-Contact Resident Care Activities: .Providing Hygiene Changing Briefs or assisting with toileting Device care of use: Central line, urinary catheter, feeding tube, tracheostomy. Wound care: any skin opening requiring a dressing. Record review of the facility provided policy titled, Infection Prevention and Control Program Revised July 2022, revealed the following: 3. Enhanced Barrier Precautions (EBP): expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDRSs to staff hands and clothing. MDROs may be indirectly transferred from resident-to-resident during these high-contact care activities. Nursing home resident with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization of MDROs. a. PPE: The use of gown and gloves for high-contact resident care activities is indicated, when contact precautions do not otherwise apply, for nursing home resident with: i. Wounds and/or indwelling medical devices regardless of MDRA colonization resident, for staff (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675282 If continuation sheet Page 6 of 7 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 675282 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/09/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Amarillo Medical Lodge 9 Medical Dr Amarillo, TX 79106 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 performing care. Level of Harm - Minimal harm or potential for actual harm ii MDRO infection or colonization. Residents Affected - Few c. Examples of high-contact resident care activities requiring gown and glove use for Enhanced Barrier Precautions include: iv. Providing Hygiene vi. Changing briefs . vii. Device care or use: central vascular line (including hemodialysis catheters), indwelling urinary catheters, feeding tube, . viii. Wound care: any skin opening requiring a dressing. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675282 If continuation sheet Page 7 of 7