Inspection·November 29, 2023

F 0755 Level of Harm - Minimal harm or potential for actual harm Furosemide Oral Tablet 20 MG (Furosemide) Give 1 tablet by mouth one time a day for Edema-Start Date-11/28/2023 0700 (7:00AM) scheduled time 0700 (7:00AM). Eliquis Oral Tablet 5 MG (Apixaban) Give 1 tablet by mouth two times a day for Clot prevention-Start Date11/28/2023 0700 (7:00AM) scheduled time 0700 (7:00AM),1900 (7:00PM). Residents Affected - Some Observation on 11/29/23 at 9:54AM revealed CMA A given Resident #1 the following medications more than an hour passed scheduled time during medication pass. The medication was (Bupropion HCL ER 150MG scheduled at 0700AM, Osphena TABLET 60MG scheduled at 0700, Thiamine HCL tablet 100MG scheduled at 0700AM, Ciprofloxacin in HCL 500MG scheduled twice a day at 0700 and 1900, Furosemide tablet 20MG scheduled at 0700, Eliquis tablet 5MG scheduled twice a day at 0700 and 1900. Interview on 11/29/23 at 1:00PM with CMA A Revealed She has too many Residents to pass medication to, out of the two halls she was responsible for. She stated the nurses help her with vitals but that was it. She stated the facility was nly allowed to have two CMA and they recently have had a lot of residents be admitted to the facility. She also stated she can't just give medication and get out of the room because she was supposed to explain to the residents their medication and what they were taking. Once doing the calculations she revealed she had 49 patients today to pass medication to which is too many for one person. She then stated the risk factor of residents not receiving medications on time could mean the medication won't have a therapeutic result like it should. Record review of the admission face sheet, dated 11/29/23, reflected Resident #2 was a [AGE] year-old female admitted on [DATE] with a diagnosis included: EPILEPSY, UNSPECIFIED (seizure disorder), primary hypertension (high blood pressure), major depressive disorder, and CONVERSION DISORDER WITH SEIZURES OR CONVULSIONS (physical and sensory problems). Record review of the MAR for Resident #2 dated 11/29,2023, times of administration for the scheduled medications. to be administered: Hydroxyzine HCl Oral Tablet 25 MG (Hydroxyzine HCl) Give 1 tablet by mouth in the morning every Mon,Wed, Fri for ANXIETY GIVE 1 HOUR BEFORE DIALYSIS-Start Date- 09/15/2023 0900 (9:00AM) scheduled time 0900 (9:00AM). Keppra Oral Tablet 250 MG (Levetiracetam) Give 1 tablet by mouth two times a day for SEIZURE ACTITIVITY-Start Date-09/04/2023 1600 (4:00PM)scheduled times 0730(7:30AM),1600(4:00PM). Hydralazine HCl Oral Tablet 100 MG(Hydralazine HCl)Give 1.5 tablet by mouth two times a day for hypertension HOLD FORSBP<110 OR PULSE <60-Start Date-10/18/2023 1600 (4:00PM)scheduled times 0730 (7:30AM) ,1600 (4:00PM). Keppra Oral Tablet 250MG (Levetiracetam)Give 1 tablet by mouth two times a day for SEIZURE ACTITIVITY-Start Date-09/04/2023 1600 (4:00PM) scheduled times 0730(7:30AM),1600 (4:00PM). Pantoprazole Sodium Tablet Delayed Release 40MG Give 1 tablet by mouth one time a day for GERD TAKEONE TABLET DAILY FOR GERD-Start Date-10/22/2023 0900(9:00AM) scheduled time 0900 (9:00AM). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676209 If continuation sheet Page 2 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676209 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/29/2023 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 0755 Level of Harm - Minimal harm or potential for actual harm Observation on 11/29/23 at 10:35AM revealed CMA B given Resident #2 the following medications more than an hour passed scheduled time during medication pass. The medication was (Hydralazine tablet 100MG scheduled at 0730, Amlodipine tab 10MG scheduled at 0900, Hydroxyzine HCL 25MG scheduled at 0730, Pantoprazole tab 40MG scheduled at 0900 and Keppra tab 250MG scheduled twice a day at 0730 and 1600. Residents Affected - Some Interview on 11/29/23 at 1:20PM with CMA B Revealed she could give medications one hour before the medication is due and one hour after the medication is due. She stated the facility has more residents now then they use to. We have told the Admin and DON that it is too much for us to do but nothing has been done. She also revealed the risk factor of not giving the medications on time could result in the medications being given too close together if they are given more than once a day. Interview on 11/29/23 at 1:40PM with DON Revealed the MAR medications can be either scheduled or set to be given in the morning, afternoon, or evening. The ones that are scheduled should be given priority over the ones that just state morning, afternoon, or evening. She stated she can't assure the ones that are scheduled are being given on time. She stated her and the ADON audit medications whenever they get a chance to. She can't give a specific time the medications are audited for the residents. She also revealed their census has been higher than normal and she has tried to higher another CMA but the higher ups won't allow her to do so. She stated when the CMA aren't there, she has passed out medications for them and knows it is a lot for one CMA to do. Then she stated the risk factors of resident snot getting their medication on time could be medications overlapping each other if they are scheduled for multiple times a day. The expectation for her staff is to pass medications out in a timely manner which would be a hour before time or a hour after the scheduled time they are due. Record Review of the current roster dated 11/28/23 revealed hall 100 has 25 residents, hall 200 has 27 residents, hall 300 has 22 residents and hall 400 has 19 residents. CMA A has hall 200 and 300 hall which is 49 residents. CMA B has hall 100 and 400 hall which is 49 residents. Current census is 93. Review of Administering Medications policy dated April 2019 Policy Statement Medications are administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation 3. Medications are administered in accordance with prescriber orders, including any required time frame. 4. Medication administration times are determined by resident need and benefit. Factors that are considered include: a. Enhancing optimal therapeutic effect of the medication; b. Preventing potential medication or food interactions; and c. Honoring resident choices and preferences, consistent with his or her care plan. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676209 If continuation sheet Page 3 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676209 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/29/2023 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 0755 6. Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders). Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676209 If continuation sheet Page 4 of 4