Inspection·October 11, 2023

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 implement the facility's own written abuse and neglect prevention policy and procedure for one (Resident #1) of eight residents reviewed for abuse and neglect reporting. Residents Affected - Few The Administrator failed to report an incident which occurred when Driver C was driving Resident #1 to an appointment without her seatbelt on, and the resident fell, bumping her head (no injury) and sustaining a skin tear to her forearm. This failure could place residents at risk of being abused or neglected and lack of oversight by a state agency. Findings included: Review of the facility policy for Abuse Investigation and Reporting, dated 10/15/22, reflected the following: Policy Statement All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source ('abuse') shall be promptly reported to local, state and federal agencies and thoroughly investigated by facility management ( .) Policy Interpretation and Implementation: Role of the Administrator: 1. If an incident or suspected incident of resident abuse, mistreatment, exploitation, neglect or injury of unknown source is reported, under the direct supervision of the Administrator will assign the investigation to an appropriate individual ( .) Reporting 1. All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported by the facility Administrator, or his/her designee, to the following persons or agencies; a. The State licensing/certification agency responsible for surveying/licensing the facility; ( .) 2. An alleged violation of abuse, neglect, exploitation or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but not later than: a. Two (2) hours if the alleged violation involves abuse OR has resulted in serious bodily injury; or b. Twenty-four (24) hours if the alleged violation does not involve abuse AND has not resulted in serious bodily injury. Review of Resident #1's face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE], with diagnoses which included altered mental status, kidney cancer, and dialysis. Resident #1 was noted to be her own responsible party. Review of Resident #1's Quarterly MDS assessment, dated 09/12/23, reflected Resident #1 had adequate hearing, and was able to understand others, and be understood. She had a BIMs score of 12, which indicated moderate cognitive impairment. Resident #1 required limited assistance of one person for bed mobility and walking in the corridor with her walker. Resident #1 was able to move herself around in her wheelchair in the facility but required extensive assistance from one person when leaving the facility. Review of Resident #1's incident report, dated 08/28/23, for a witnessed fall reflected Resident #1 had fallen in the facility van during transportation. The document reflected the resident said she (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676209 If continuation sheet Page 2 of 12 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 10/11/2023 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 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few hit her head, and the resident had a skin tear on her left forearm from the fall, which was treated by a nurse in the facility. Resident #1 was administered pain medication for a slight headache. Her neuro-checks during her initial assessment for this incident, and the following 24 hours reflected no concerns. An interview on 09/27/2023 at 2:12 PM with Driver C revealed she was driving when Resident #1 fell in the facility's big van. She said a truck flew in front of them and she tapped the brakes, and Resident #1 scooted, and Resident #1 got hurt. She said Resident #1 was not wearing a seatbelt, because she had not been trained to put it on her. She said she was written up for the incident and had not been allowed to drive again. An interview on 09/28/23 at 1:04 PM with the DON revealed Resident #1 had fallen in the van when Driver C was driving her to an appointment. She said she believed it was a self-report, and it should have been one. She said the incident had not yet been investigated by the state survey agency, and she had expected it sooner. An interview on 09/28/23 at 4:40 PM with Resident #1 revealed she had not been wearing any part of the seatbelt when she fell, and only the chair had been fastened into the van. An interview on 09/28/23 at 3:18 PM with the Administrator revealed Resident #1 fell in the facility van on 08/28/23 and had a pretty good skin tear on her arm, U-shaped, and it was reported to him that she bumped her head during the fall. He said he did not report the incident to HHSC, because at the time he was looking at it like they would look at a fall with a skin tear, and that would not be reportable. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676209 If continuation sheet Page 3 of 12 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 10/11/2023 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury for one (Resident #1) of eight residents reviewed for abuse and neglect reporting. The Administrator failed to report an incident which occurred when Driver C was driving Resident #1 to an appointment without her seatbelt on, and the resident fell, bumping her head (no injury) and sustaining a skin tear to her forearm. This failure could place residents at risk of being abused or neglected and lack of oversight by a state agency. Findings included: Review of the facility policy for Abuse Investigation and Reporting, dated 10/15/22, reflected the following: Policy Statement All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source ('abuse') shall be promptly reported to local, state and federal agencies and thoroughly investigated by facility management ( .) Policy Interpretation and Implementation: Role of the Administrator: 1. If an incident or suspected incident of resident abuse, mistreatment, exploitation, neglect or injury of unknown source is reported, under the direct supervision of the Administrator will assign the investigation to an appropriate individual ( .) Reporting 1. All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported by the facility Administrator, or his/her designee, to the following persons or agencies; a. The State licensing/certification agency responsible for surveying/licensing the facility; ( .) 2. An alleged violation of abuse, neglect, exploitation or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but not later than: a. Two (2) hours if the alleged violation involves abuse OR has resulted in serious bodily injury; or b. Twenty-four (24) hours if the alleged violation does not involve abuse AND has not resulted in serious bodily injury. Review of Resident #1's face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE], with diagnoses which included altered mental status, kidney cancer, and dialysis. Resident #1 was noted to be her own responsible party. Review of Resident #1's Quarterly MDS assessment, dated 09/12/23, reflected Resident #1 had adequate hearing, and was able to understand others, and be understood. She had a BIMs score of 12, which indicated moderate cognitive impairment. Resident #1 required limited assistance of one person for bed mobility and walking in the corridor with her walker. Resident #1 was able to move herself around in her wheelchair in the facility but required extensive assistance from one person when leaving the facility. Review of Resident #1's incident report, dated 08/28/23, for a witnessed fall reflected Resident #1 had fallen in the facility van during transportation. The document reflected the resident said she (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676209 If continuation sheet Page 4 of 12 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 10/11/2023 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few hit her head, and the resident had a skin tear on her left forearm from the fall, which was treated by a nurse in the facility. Resident #1 was administered pain medication for a slight headache. Her neuro-checks during her initial assessment for this incident, and the following 24 hours reflected no concerns. An interview on 09/27/2023 at 2:12 PM with Driver C revealed she was driving when Resident #1 fell in the facility's big van. She said a truck flew in front of them and she tapped the brakes, and Resident #1 scooted, and Resident #1 got hurt. She said Resident #1 was not wearing a seatbelt, because she had not been trained to put it on her. She said she was written up for the incident and had not been allowed to drive again. An interview on 09/28/23 at 1:04 PM with the DON revealed Resident #1 had fallen in the van when Driver C was driving her to an appointment. She said she believed it was a self-report, and it should have been one. She said the incident had not yet been investigated by the state survey agency, and she had expected it sooner. An interview on 09/28/23 at 4:40 PM with Resident #1 revealed she had not been wearing any part of the seatbelt when she fell, and only the chair had been fastened into the van. An interview on 09/28/23 at 3:18 PM with the Administrator revealed Resident #1 fell in the facility van on 08/28/23 and had a pretty good skin tear on her arm, U-shaped, and it was reported to him that she bumped her head during the fall. He said he did not report the incident to HHSC, because at the time he was looking at it like they would look at a fall with a skin tear, and that would not be reportable. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676209 If continuation sheet Page 5 of 12 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 10/11/2023 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 0689 Level of Harm - Immediate jeopardy to resident health or safety 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 observation, interview, and record review the facility failed to ensure the resident environment was free of accident and hazards as was possible for one resident (Resident #1) of three residents reviewed for accidents and hazards. Driver C failed to follow proper safety measures in securing Resident #1 in the van while driving the resident. An Immediate Jeopardy (IJ) was determined to have existed from [DATE] through [DATE]. The IJ was removed on [DATE] because the facility implemented actions that corrected the non-compliance prior to the beginning of the survey. This failure placed residents at risk of severe injury or death. Findings include: Record review of Resident #1's face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included altered mental status, kidney cancer, and dialysis. Resident #1 was noted to be her own responsible party. Review of Resident #1's Quarterly MDS assessment, dated [DATE], reflected Resident #1 had adequate hearing, and was able to understand others, and be understood. She had a BIMs score of 12, which indicated moderate cognitive impairment. Resident #1 required limited assistance of one person for bed mobility and walking in the corridor with her walker. Resident #1 was able to move herself around in her wheelchair in the facility but required extensive assistance from one person when leaving the facility. Review of Resident #1's incident report, dated [DATE], for a witnessed fall reflected Resident #1 had fallen in the facility van during transportation. The document reflected the resident said she hit her head, and the resident had a skin tear on her left forearm from the fall, which was treated by a nurse in the facility. Resident #1 was administered pain medication for a slight headache. Her neuro-checks during her initial assessment for this incident, and the following 24 hours reflected no concerns. An interview and observation on [DATE] at 11:18 AM of Driver A revealed he was securing a resident in his wheelchair in the facility van for transportation to a lunch activity. Driver A said he was a temporary driver, and had been trained by watching some videos, and having one of the drivers (Staffing Coordinator), who was present at the time of this interview, showed him how to do everything and was overseeing him. He was observed to fasten the resident's chair in firmly, and to place the lap and shoulder safety belts on Resident #2. An interview and observation on [DATE] at 1:56 PM with Resident #1 revealed she was self-propelling her wheelchair in the common area, near the nurse's station. She had numerous small skin tears visible on her forearms, and she said she got them all the time from bumping into things, and from falling. Resident #1 stated the staff just cleaned them up for her. She said she was in a car accident and had gotten a wound on her arm (slightly visible but healed) but she was okay now. She said the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676209 If continuation sheet Page 6 of 12 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 10/11/2023 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 0689 accident was in the facility van, with their Driver C. Level of Harm - Immediate jeopardy to resident health or safety An interview on [DATE] at 1:41 PM with Driver E revealed Resident #1 had fallen while in the facility van, but it was before she started driving, about a month ago. She said she was only the driver occasionally and was usually a CNA and worked on the floor. She said she did not know all of the circumstances of the fall, but she felt she had adequate training to transport residents safely. Residents Affected - Few An interview on [DATE] at 1:04 PM with the DON revealed Resident #1 had fallen in the van when Driver C was driving her to an appointment. She said she believed it was a self-report, and it should have been one. She said Driver C was straightforward about what happened on the drive, but there was some controversy about what took place leading up to incident, but that was not her area. She said she was called out of a training when Driver C called. Driver C was crying and distraught because a car had cut her off and she had to brake abruptly, which caused Resident #1 to fall from her wheelchair. She said Driver C did not know whether to take Resident #1 to her appointment or bring her back, and they told her to bring the resident back to the facility. The DON said when they arrived at the facility, she was waiting for them, and assessed Resident #1, who had a very gnarly skin tear on her arm. The DON said she personally cleaned up and reapproximated the skin tear, which took her almost an hour. She said there was no actual vehicle accident to call the police or EMS for, and Resident #1 was okay, except for the skin tear. She said though she was not there, and did now know what happened, she was told Resident #1 was not wearing her seatbelt during the drive. The DON said Driver C was no longer a driver, but still worked at the facility. She said the incident had not yet been investigated by the state, and she had expected it sooner than this. An interview on [DATE] at 1:44 PM with Driver D revealed she heard about Resident #1's fall in the facility van. She said she drove the van before this incident but wanted to return to working on the floor as a CNA. She said during the time she drove; Driver C was a backup driver. She said after the incident the Administrator asked her if Driver C had been trained, and she said she had watched both of the required videos (videos demonstrating the restraint systems on both vans). Driver D said she and the Maintenance Director also showed Driver C how to do the restraint systems in the vans. She said she heard Resident #1 was not wearing her seatbelt and fell when the driver braked. She said when she drove Resident #1, the resident had never taken off her own seatbelt, and always fell asleep as soon as they started moving. She said she felt her training was good, and besides the two videos, the Maintenance Director demonstrated everything and went with her on drives before she ever drove by herself. An interview on [DATE] at 2:12 PM with Driver C revealed she was driving when Resident #1 fell in the facility's big van and was the van driver for a month or two. She said a truck flew in front of them and she tapped on the brakes, and Resident #1 scooted. She said nobody ever showed her where the doctors' offices were, or anything, and she was having to figure it out for herself. She said she received some training from Driver D, but she was never shown the seat belts and shoulder belts, only the restraints for the wheelchair itself. She said Driver D took her out to the small van and showed her the wheelchair restraints with her hands and there was no wheelchair involved in the demonstration and the shoulder straps were never brought up. She said she got no training, and nobody rode with her, and because of it, Resident #1 got hurt. Driver C was crying during the interview, and said she did not put the seatbelt on the resident because she was not trained to, and she did not know why she did not think of it, because she knew everyone in a car was required to wear a seatbelt, but she only was told about the chair being locked in. She said she felt cheated out of being able to do the transportation position because she did not get the right training, and she was told she would be able to drive again, but nobody had talked to her about it since. She said there was never any (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676209 If continuation sheet Page 7 of 12 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 10/11/2023 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few sort of competency checklist, and she was written up. She said she was wearing her own seatbelt, and she never told anyone she did not feel like she had enough training to do the job safely. She said she asked Driver D to show her the shoulder belt once, because she still had not seen the videos, and Driver D showed her in a fast-paced way, and she tried to watch her, but could not remember what she showed her. An interview on [DATE] at 3:18 PM with the Administrator revealed Resident #1 fell in the facility van on [DATE], around 4:00 PM to 4:30 PM. He said when the resident was back in the building, she was very calm, and said she felt it was not Driver C's fault. She had a pretty good skin tear on her arm, U-shaped, and it was reported she bumped her head during the fall. The DON and another nurse assessed her, and the DON treated the skin tear. Her head, and her vitals and neuro-signs were fine. Driver C was a mess, freaking out, with anxiety through the roof. Driver C said another driver had cut them off, and she had not strapped Resident #1 completely, missing the shoulder belt, or maybe the whole thing (lap and shoulder), but he could not remember for sure. He re-walked Driver C through the strapping for the restraint system and had her watch the videos again. He did not know if the resident fell completely or not, but the wheelchair was near the driver's seat, and she might have hit it. Driver C was trained multiple times, by Driver D, and by the Maintenance Director (who was on extended leave with an injury) and watched both of the videos. He said the training consisted of showing her the restraint systems in both vans, which included the restraints for locking the wheelchair to the floor, and how the straps went on the chair and on the person. He said Driver D showed her and he saw the Maintenance Director show her on another occasion. He did not know if either of them rode with her or watched her put a wheelchair in the van. He said before this incident happened, the Maintenance Director and Driver D attended a training by the company that made the restraint systems for both of the vans. When he investigated the incident Driver D told him, Driver C would routinely call on her for instruction on how to do things, she had already shown her. He said he only had documentation of the training Driver C got on [DATE], after the incident, they did not have documentation of the training done before it. He said Driver C was primarily a backup driver until Driver D wanted to return to her CNA duties, and the schedule they had only showed the appointments, but not which driver drove to them. He said he did not personally go on a ride-along, but he did with all the other drivers and that Driver C was upset she did not get that. He said Driver C was a very conscientious CNA, in part because of her anxiety, but they had postponed talking with her about the driving position, because her anxiety might have made her not a good candidate for it. He said he did not report it to HHSC, because at the time he was looking at it like they would look at a fall with a skin tear, and that would not be reportable. An interview on [DATE] at 4:14 PM with Driver D revealed the Maintenance Director had trained both her and Driver C on the small van at the same time, the floor restraints, the lap and shoulder belt, verbally and physically. She said he was also present when she trained Driver C on the large van, the same way. She said there was an empty wheelchair in the van, and she showed her how to use the system on it. She said there was no checklist for the training, but she went through it, and when she asked Driver C if she understood, she said she did, and it seemed pretty simple. An interview on [DATE] at 4:40 PM with Resident #1 revealed she had not been wearing any part of the seatbelt when she fell, and only the chair had been fastened into the van. She also expressed an opinion Driver C was not trained to use the belts, or she would have done so, because she was very protective of the people at the facility. An interview on [DATE] at 4:44 PM with the Staffing Coordinator revealed she had the training video for the restraint system on the large facility van (the van the incident occurred in) on her (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676209 If continuation sheet Page 8 of 12 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 10/11/2023 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few computer. She said it was one of the two videos everyone who drove the vans were required to watch before they drove. The video viewed during the interview reflected a clear demonstration of how to attach the restraints to the floor and the wheelchair, and how to attach the lap and shoulder belts to the restraint system and place them on the resident. Review of an employee corrective action form, dated [DATE], reflected Driver C was written up for not securing a resident seat belt on a trip. The document reflected one-on-one counsel with the Administrator on safety protocols, and in servicing with the videos. It was noted on the document though the write-up occurred on [DATE]. Review of documents dated [DATE] reflected Documentation of training for Driver C, and included a Transportation Van Driver Safety and Prerequisites Checklist signed on [DATE] by Driver C, indicating she watched two videos and was instructed on the safe loading and restraint of the residents and their wheelchairs in the van, and performed a return demonstration. Review of an in-service form dated [DATE] reflected in-service training by the Administrator with HR detailing HR's responsibility for ensuring the appropriate videos were viewed by new drivers and documentation was placed in their file. It also stated HR would create a checklist for driver training, which would receive final approval from the Administrator. Review of an In-service form dated [DATE] reflected Driver C received driver safety training by the Administrator, and viewed the videos. Review of the facility policy Standards of Care Policy and Procedures for Transporting Residents, revised 04/23, reflected Personnel accompanying residents must be thoroughly trained in routine and emergency procedures to ensure that every aspect of the transportation process is safety oriented. All employees who drive a company owned van or bus will adhere to these standards and requirements at all times. The following policies and procedures will be followed before, during and after transporting residents in the company-owned bus or van . Loading of Residents . 6. Once all residents have been assisted onto the vehicle, each resident should be fastened into the appropriate safety restraint. This includes seatbelts, shoulder straps or a combination of both. Regarding the residents' rights to refuse restraints does not apply in any moving vehicle. Residents must agree to the use of seatbelts and/or shoulder harnesses or transportation will be refused. Most residents feel more secure with a seatbelt and refusals are seldom a problem . 8. After all residents have been seated on the vehicle, and before the vehicle is moved, the staff member should do a walk-thru to ensure that they are properly secured in seatbelts, shoulder harnesses or other restraining devices The policy included a checklist page, which included signature lines for the staff member and a facility representative: Transportation Aide Acknowledgement: I acknowledge that I have received orientation and training on the use and operation of the facility's bus or van in which I will operate in a safe manner while transporting any resident of this facility to and from this facility for the purpose of any medical appointment or social function or for any other reason as designated by management. I have received copies of the following documents and have read these documents and fully understand their contents and the duties which I must perform: _The Priority Management Driving and Transport Safety Standards. _The Standards of Care Policy and Procedures for Transporting Residents. _The Vehicle Use Acknowledgement Form. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676209 If continuation sheet Page 9 of 12 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 10/11/2023 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 0689 _The Verification of Wheelchair Lift Competency and Proficiency Level of Harm - Immediate jeopardy to resident health or safety (if applicable) Residents Affected - Few _The Required Items to Be Kept or Maintained on All Company- _The Daily Vehicle Visual Safety Inspection Log Owned Buses or Vans _The Transportation Aide Job Description _The Verification of Training in Cardio- Pulmonary Resuscitation (CPR) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676209 If continuation sheet Page 10 of 12 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 10/11/2023 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 0809 Level of Harm - Potential for minimal harm Residents Affected - Many Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure each resident received and the facility provided at least three meals daily, at regular times comparable to normal mealtimes in the community or in accordance with resident needs, preferences, requests and plan of care for one meal (Lunch on 09/27/23) observed for frequency of meals. The facility failed to serve the 09/27/23 lunch meal on time at the scheduled time. This failure could place residents at risk for decreased meal satisfaction, decreased intake, loss of appetite, side effects from medication given without food, and diminished quality of life. The findings include: Record review of Resident #5's, undated, face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #5 had diagnoses which included: Aphasia following Cerebral Infarction and Chronic Viral Hepatitis C. Record review of Resident #5's Care Plan, dated 07/26/23, revealed Problem/Need: Nutritional Risk; Goal and Target: Will maintain nutritional status as evidenced by weight remaining stable; Approaches; monitor intake q meal, notify RN regarding problems, complaints or request, supervise dining and encourage to eat. Record review of Resident #6's, undated, face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #6 had diagnoses which included: Unspecified Dementia and Heartburn. Record Review of Resident #6's Care Plan dated 06/21/2023 reflected Problem/need; Nutritional Altered; Goal and Target; will maintain nutritional status as evidenced by weight remaining stable. Approaches: Supervise dining and encourage to eat. Record Review of Resident #8's, undated, face sheet reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #8 had diagnoses which included: Polyneuropathies. Observation on 09/27/23 at 12:09 PM revealed meal times posted in the dining room reflected: Breakfast 7:00 AM-8:15 AM; Lunch 11:30 AM-12:45 PM; and Dinner 5:00 PM-6:15 PM Observation on 09/27/23 at 1:18 PM revealed lunch trays delivered to residents on hall 400. Interview on 09/27/23 at 1:15 PM with Resident #6 revealed the resident was in his room(Hall 400) sitting in front of his bedside table. Resident stated lunch is over an hour and a half late. Interview on 09/27/23 at 1:17 PM with Resident #5 revealed the resident was in her room (Hall 400) sitting in front of her bedside table. Resident stated she is wanting for lunch. Interview on 09/27/23 at 3:00 PM with Resident #8 revealed, Dining room is no on an exact schedule, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676209 If continuation sheet Page 11 of 12 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 10/11/2023 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 0809 Level of Harm - Potential for minimal harm Residents Affected - Many Dinner is served whenever they bring it. She stated, I would like my meals on time. She stated that on unknown date dinner was not served until 7:00 pm and that was close to her bedtime. She stated, We don't know when we are going to eat. Interview on 09/28/23 at 10:06 AM with the Dietary Manager revealed the dietary team was not fully staffed. She stated she worked all meals with limited support staff. She stated they needed four people, but they currently had 3. She stated the facility had trouble hiring and retaining dining staff because of wages. She stated, If I am not here to babysit then it will not get out on time. Record review of cy Frequency of Meals, revised July 2017. revealed each resident shall receive at least three (3) meals daily, at times comparable to typical mealtimes in the community, or in accordance with resident needs, preferences, requests and the plan of care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676209 If continuation sheet Page 12 of 12