Inspection·August 29, 2023

F 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some have their food handler's certification within 10 days of hire. The ADMIN stated it was the responsibility of the Dietary Manager to ensure dietary staff obtain the certification within proper timeframes. The ADMIN stated if dietary staff do not have the proper training [food handler's certificate], there could be a risk of staff not properly handling food, which could lead to residents' exposure to foodborne illnesses. The ADMIN stated dietary staff were in serviced on several dietary topics on 08/28/23, but the food handlers were missed. The ADMIN stated he would implement and additional checklist to ensure food handler's certificates were included in orientation trainings and obtained timely. The ADMIN stated he did not believe the facility had a policy that specifically for needed credentials for dietary staff. Requested policy was not provided prior to exit. Review of page 10 of the Texas Food Establishment Rules accessed on 08/29/23 at https://www.dshs.texas.gov/sites/default/files/foodestablishments/pdf/GuidanceDocs/TFER-2021_TAC-228_August-2021.p read in part: .(d) All food employees, except for the certified food protection manager, shall successfully complete an accredited food handler training course, within 30 days of employment. This requirement does not apply to temporary food establishments. (e) The food establishment shall maintain on premises a certificate of completion of the food handler training course for each food employee . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676209 If continuation sheet Page 2 of 5 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 676209 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Decatur Medical Lodge 701 W Bennett Rd Decatur, TX 76234 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, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen, in that: Residents Affected - Some The facility failed to ensure 4 bottles of cleaning products were not stored in dry storage The facility failed to ensure cracked eggs were not stored in the walk-in cooler The facility failed to ensure vegetables with fuzzy black and brown substances on them, were not stored in the walk-in cooler The facility failed to ensure foods stored in the walk-in cooler were properly sealed, labeled and dated The facility failed to ensure cooler temperatures were monitored and recorded since 07/17/23 These failures could place residents who received meals and/or snacks from the kitchen at risk for food borne illness. The findings included: Observation of the kitchen's dry storage area and walk in cooler on 08/29/23 at 11:50 a.m. to 12:08 p.m., revealed the following: Four 1-gallon bottles of Essential Disinfectant Ultra Bleach were stored on a rolling rack, also holding boxes of cereal and cans of vegetables, at the back of the dry storage area. An open carton of approximately two dozen eggs was observed to have a cracked egg. The egg was missing half of its shelf with yolk completely exposed. A box of approximately for dozen eggs was observed to have three cracked eggs, with exposed yolk. The eggs were stored on a rack in the facility's walk-in cooler. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676209 If continuation sheet Page 3 of 5 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 676209 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Decatur Medical Lodge 701 W Bennett Rd Decatur, TX 76234 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 On the same rack as the eggs, were two boxes of a variety of food items. The first box housed three cucumbers and two bell peppers that were wilted and had fuzzy brown and black substances on them. The second box housed four cucumbers and two tomatoes with fuzzy black and brown substances on them, an open bag of wilted lettuce with a use by date of 09/05/23, a small undated and unlabeled container of cut vegetables, an open and undated container of peeled hard-boiled eggs, and an opened and undated bag of salad mix, which was wilted and brown in color. Residents Affected - Some Observation of the cooler temperature log on 08/29/23 at approximately 12:08 p.m., revealed the temperature log had not been completed since 07/17/23. The cooler's temperature was read at 30 degrees Fahrenheit at the time of this observation. In an interview on 08/29/23 at 12:42 p.m., the Dietary Manager stated she worked as the facility's morning cook for roughly 9 months and was promoted to Manager a week prior to investigation. The DM stated she was not aware of the items observed by surveyor, but she knew they received a delivery earlier in the day and believed the cleaning products observed in the dry storage area was placed there incorrectly, as the dishwasher was new and he assisted in unloading the truck. The DM accompanied surveyor into the dry storage area and walk-in cooler to observe. The DM acknowledged the items and stated she would remove all non-complaint items from the storage areas. The DM stated she did know how long the items were improperly stored. The DM stated all food should be stored in a sanitary and orderly fashion and according to policy, to include being sealed, labeled, and dated. The DM stated it is the responsibility of all dietary staff to ensure food is stored and prepared in sanitary conditions. The DM stated it was her expectation for the cooler's temperature be checked daily and the temperature be recorded on the log on the door of the cooler. The DM stated it was the responsibility of the cook to ensure the temperature was checked and recorded. The DM acknowledged the log had not been completed since 07/17/23, but stated we check the temperature, but forget to write it down because of, time, being short staffed and workload. The DM stated she planned to retrain staff on proper food storage and temperature checks and logs moving forward. In an interview on 08/29/23 at 6:29 p.m., the ADMIN stated the DM made him aware of the items found stored incorrectly in the dry storage area and cooler. The ADMIN stated staff were expected to ensure foods were stored, handled, and prepared in sanitary conditions. He states foods should not be stored unsealed, undated, and unlabeled. The ADMIN stated spoiled foods should be discarded according to facility policies and procedures. The ADMIN stated improper food storage could lead to residents being sick. The ADMIN stated he will work with the DM to Inservice all dietary staff to ensure these errors did not occur in the future. Review of the facilities policy entitled Food Receiving and Storage, revised in July 2014, read in part: Foods shall be received and stored in a manner that complies with safe food handling practices. Policy Interpretation and Implementation: . 7. All foods stored in the refrigerator and freezer will be covered, labeled and dated (use by date) . 11. Functioning of the refrigeration and food temperatures will be monitored at designated intervals by the Food Services Manager or designee and documented according to state specific requirements . 15. Soaps, detergents, cleaning compounds or similar substances will be stored in separate storage areas from food storage. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676209 If continuation sheet Page 4 of 5 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 676209 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Decatur Medical Lodge 701 W Bennett Rd Decatur, TX 76234 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 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews, and record review the facility failed to maintain an effective pest control program so that facility was free of pests and rodents for the facility's only kitchen. Residents Affected - Few The facility did not maintain an effective pest control program to ensure the facility was free of flies in the kitchen. These findings could place residents at risk for an unsanitary environment and a decreased quality of life. The findings included: Record review of the facility's pest control binder revealed pest control visited the facility bi-weekly to treat for pests and insects. The kitchen was last treated for flies on 08/21/23. Observation of the facility's kitchen on 08/29/23 at 12:09 p.m., revealed approximately six flies flying around [NAME] A, as she took food temperatures before lunch was served. The flies were observed landing on food preparation stations that were not in use and on top of the plate warming station and on eating utensils wrapped in napkins. Further observation of the kitchen two rolls of fly tape hanging from the ceiling of the kitchen near the door next to the cooking range and another fly tape roll near the entrance of the walk-in cooler. Both fly trap tapes were filled with captured flies. In an interview on 08/29/23 at 12:42 p.m., the DM stated she placed the fly traps in the kitchen in an attempted to capture all of the flies that were in the kitchen area. The DM stated pest control was recently at the facility, but she was not sure what areas was treated. The DM stated she changed the fly traps every two days to keep the flies at bay. The DM stated normally flies in the kitchen was not aa problem, but she does not know why they keep getting flies in the kitchen. The DM stated having flies in the kitchen could result in flies getting in food, walking on plates, which could contaminate food prepared in the kitchen. In an interview on 08/29/23 at 3:09 p.m., The ADMIN stated the DM made him aware of the insect issue in the kitchen prior to speaking with surveyor. The ADMIN stated they have pest control out frequently for flies. The ADMIN stated he believed the heat was the reason flies kept getting into the kitchen, as they use the side door to exit the kitchen to discard trash and accept deliveries. The ADMIN stated having flies in the kitchen could be bad, as flies could get into the food. The ADMIN stated he will continue to work with pest control to solve the fly problem in the kitchen and they will be placing a door fan at the exterior door of the kitchen to prevent insects from entering the kitchen. Record review of the facility policy entitled Pest Control, revised in May 2008, read in part: Policy Statement: Our facility shall maintain an effective pest control program. Policy Interpretation and Implementation: 1. This facility maintains an ongoing pest control program to ensure the building is kept free of insects and rodents . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676209 If continuation sheet Page 5 of 5