Health inspection·December 14, 2023

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, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen. Residents Affected - Some 1. The facility failed to date and label food items in the walk-in refrigerator of the facility's kitchen. These failures affected residents by placing them at risk for contamination and food-borne illness. Findings included: An observation of the walk-in refrigerator on 12/12/23 at 8:50 AM revealed: 1 basket of sandwiches that appeared to contain peanut butter and jelly undated and unlabeled 1 small Tupperware container with 4 cut up pieces of tomato undated and unlabeled 1 piece of meat that appeared to be ham in a Ziploc bag undated and unlabeled 2 Large Ziploc bags containing a sandwich, a pack of crackers, cookies and a water bottle. Both bags undated and unlabeled 2 Large zip loc bags with what appeared to be fried chicken undated and unlabeled 1 Large Ziploc bag with several items individually wrapped with aluminum foil undated and unlabeled 1 cube shaped container with an unknown white substance (appears it could be potato salad or chicken pureed), undated and unlabeled 2 large Pitchers with a red liquid, undated and unlabeled (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 12/14/2023 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 Residents Affected - Some An observation upon exit of the walk-in refrigerator revealed a sign on the door that stated, STOP!! Did you date and label. In an interview on 12/12/23 at 9:06 AM [NAME] E stated the staff knew that everything should be dated and labeled. She stated the sandwiches were made that morning for the morning snack. [NAME] E stated it was important to date and label food items to ensure the items did not expire and to prevent resident sickness. In an interview on 12/13/23 at 2:30 PM the Dietary Manager (DM) stated the expectation for the staff was that once food items were brought to the correct temperature, that they were to be dated and labeled accordingly and discarded after 72 hours. The DM stated dating and labeling was important for the safety of the residents. Food that is not labeled or dated could be expired and could cause illness. In an interview on 12/14/23 at 4:15 PM The ADM stated his expectation was that food items be dated and labelled when it came off the truck. Items were to be stored properly and when things were opened they were to be labeled. The ADM stated it was the Dietary Manager's responsibility to ensure this was done and that all staff in the kitchen understood and helped with the process. The ADM stated the potential outcome of not dating and labeling was someone could grab something that was out of date and could serve expired food or not know what they were serving. This could cause damage to someone's health. Review of the facility's policy, Food Storage Policy, revised 6/01/19, revealed, Policy: To ensure that all food served by the facility is of good quality and safe for consumption, all food will be stored according to the state, federal and US Food Codes and HACCP guidelines. 2. Refrigerators d. Date, label and tightly seal all refrigerated foods using clean, nonabsorbent, covered containers that are approved for food storage. e. Use all leftovers within 72 hours. Discard items that are over 72 hours old. Review of the Food and Drug Administration Food Code, dated 2022, reflected: 3-305.11 Food Storage. (A) Except as specified in (B) and (C) of this section, FOOD shall be protected from contamination by storing the FOOD: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination; and (3) At least 15 cm (6 inches) above the floor. (B) FOOD in packages and working containers may be stored less than 15 cm (6 inches) above the floor on case lot handling EQUIPMENT as specified under § 4-204.122. (C) Pressurized BEVERAGE containers, cased FOOD in waterproof containers such as bottles or cans, and milk containers in plastic crates may be stored on a floor that is clean and not exposed to floor moisture. And 3-501.16(A)(2) and (B) Time/Temperature Control for Safety Food, Hot and Cold Holding (P) 23. Proper date marking and disposition FDA Food Code 2022 Annex 7: Model Forms, Guides, and Other Aids Annex 7 -38 IN/OUT This item should be marked IN or OUT of compliance. This item would be IN compliance when there is a system in place for date marking all foods that are required to be date marked and is verified through observation. If date marking applies to the establishment, the PIC should be asked to describe the methods used to identify product shelf-life or consume-by dating. The regulatory authority must be aware of food products that are listed as exempt from date marking. For disposition, mark IN when foods are all within date marked time limits or food is observed being discarded (continued on next page) 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 12/14/2023 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 Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete within date marked time limits or OUT of compliance, such as when date marked food exceeds the time limit or date-marking is not done. N.A. This item may be marked N.A. when there is no ready-to-eat, TCS food prepared on-premise and held, or commercial containers of ready-to-eat, TCS food opened and held, over 24 hours in the establishment. N.O. This item may be marked N.O. when the establishment does handle foods requiring date marking, but there are no foods requiring date marking in the facility at the time of inspection. 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 12/14/2023 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 0814 Dispose of garbage and refuse properly. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to dispose of garbage and refuse properly for the facility's main dumpster reviewed for garbage disposal. Residents Affected - Few 1. The facility failed to ensure the garbage storage area was maintained in a sanitary condition to prevent the harborage and feeding of pest and failed to ensure garbage dumpster lids remained closed. This failure could place residents at risk of contracting disease by attracting pest and disease carrying rodents. Findings included: During an observation on 12/13/2023 at 4:40 PM with CNA A of the garbage disposal areas by the trash dumpsters revealed, a busted open trash bag with food debris on the ground, a broken fluorescent bulb (broken glass), and used medical gloves. During an interview on 12/13/23 at 11:06 AM with Maintenance Director A, he stated that he worked at the facility part-time, about 2 hours a day, and was the only one currently in the department. Maintenance Director A stated that he has been coming to this facility to work part-time for 4 weeks, since the full-time maintenance worker got injured and is not coming back. Maintenance Director A stated he hasn't been able to check for trash on the ground, by the dumpsters, as he works mostly on the problems inside the facility buildings. He stated the facility uses ABC Pest & Lawn for pest control and puts a chemical by the trash dumpsters. During an interview with the Regional Director of Plant Operations (RDPO), on 12/14/23 at 12:40 PM, he stated that his expectation was that there be no trash on the ground, and the trash dumpster's lids and side doors should be closed. He said the the dumpster door should be closed, and the trash picked up, because it could attract various animals and pests. The RDPO stated he did not know if the facility had a policy on trash disposal. On 12/14/23 at 2:25pm, an email was received from the Administrator stating the facility does not have a policy regarding who is responsible for maintaining the outside grounds concerning garbage disposal. During an interview on 12/14/23 at 3:50 PM with the Administrator , it was revealed that the maintenance department is responsible to ensure trash is disposed of properly inside the trash dumpsters. The Administrator stated that Maintenance Director B is out injured on worker's compensation and is not coming back. The Administrator stated that the facility has the RDPO who comes by a few hours a day to work. The Administrator stated that the dumpster's lid is usually closed. The Administrator stated the reason it is important to dispose of trash properly and to ensure trash stays in the dumpster, is to keep out pests and rodents, because they posed a contaminiation risk. The Administrator stated that his expectation is that staff dispose of trash into the dumpster, close the lids, and close the doors. Review of the U.S. Public Health Service Food Code, dated 2022, reflected: 5-501.112 Outside Storage Prohibitions. (A) Except as specified in (B) of this section, REFUSE (continued on next page) 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 12/14/2023 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 0814 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few receptacles not meeting the requirements specified under 5-501.13(A) such as receptacles that are not rodent-resistant, unprotected plastic bags and paper bags, or baled units that contain materials with FOOD residue may not be stored outside. (B) Cardboard or other packaging material that does not contain FOOD residues and that is awaiting regularly scheduled delivery to a recycling or disposal site may be stored outside without being in a covered receptacle if it is stored so that it does not create a rodent harborage problem. 5-501.113 Covering Receptacles. Receptacles and waste handling units for REFUSE, recyclables, and returnable(s) shall be kept covered: (A) Inside the FOOD ESTABLISHMENT if the receptacles and units: (1) Contain FOOD residue and are not in continuous use; or (2) After they are filled; and (B) With tight-fitting lids or doors if kept outside the FOOD ESTABLISHMENT. 6-501.114 Maintaining Premises, Unnecessary Items and Litter. The PREMISES shall be free of: (A) Items that are unnecessary to the operation or maintenance of the establishment such as EQUIPMENT that is nonfunctional or no longer used; and (B) Litter. 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 12/14/2023 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 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 disease and infections for 1 (Residents #64) of 10 residents reviewed for infection control. Residents Affected - Few The facility failed to ensure CNA D washed her hands after barehanded carrying a dirty tray out of a communicable disease isolation room for Resident #242, before barehanded touching Resident #64's bedside table, and barehanded touching Resident #64's call light. The facility failed to ensure CNA D sanitized her hands after exiting Resident #64's room. This failure could place residents at risk of communicable infectious diseases. Findings included: Review of Resident # 242's admission Record dated 12/13/23, reflected he was a [AGE] year-old male, admitted to the facility 12/11/23 with diagnoses of cellulitis (a serious bacterial infection in the wound), both legs amputated below the knee, rheumatoid arthritis (a disease that affects mostly joints by fluid collection, swelling, and deformity), type 2 diabetes mellitus without complications, and chronic kidney disease. Review of Resident #242 baseline care plan dated 12/11/23, reflected Isolation-Strict single room contact isolation initiated 12/12/23. Goal was to remain on isolation until no longer contagious to others. Interventions were Resident #242 on strict isolation precautions due to a bacterial infection (Acinetobacter baumannii) in the wound. Review of resident #242 orders dated 12/11/23, reflected isolation-Strict Single Room, Strict contact isolation. Review of resident # 64 admission Record dated 12/11/23, reflected she was a [AGE] year-old female admitted to facility on 11/25/23 with diagnoses of Brain mass, Hypothyroidism- a condition in which the thyroid gland does not produce enough thyroid hormone., Fluid overload, Low potassium, and Unspecified Dementia. Review of Resident #64 annual MDS assessment, dated 11/30/23, reflected BIMS score was 15, indicating no cognitive impairment. Resident required setup and clean up assistance when eating, partial/moderate assistance to transfer, bath, and personal hygiene. Review of resident #64 care plan dated 12/04/23, reflected Activities of Daily Living (ADLs) Self-care Performance Deficit due to Brain Mass. The goal indicated Resident #64 would improve current level of function. The interventions were: assist as needed in aspects of self-care that are problematic to resident. An observation on 12/13/23 at 09:02 AM, revealed CNA F dressed in blue gown, gloves, and mask stood in Resident # 242's doorway holding a tray with dishes. Signage on the door read Stop. Contact Precautions. Everyone Must: Clean hands, including before entering and when leaving the room. Put on (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 12/14/2023 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few gloves before room entry. Put on gown before room entry and discard gown before room exit. Do not wear the same gown and gloves for the care of more than one person. Use dedicated or disposable equipment. Clean and disinfect reusable equipment before use on another person. CNA F asked if someone could take the resident's tray to the cart for her. CNA D walked over to CNA F barehanded (no gloves) and took the tray from isolation room to the cart. No hand hygiene was performed after placing the tray from the isolation room on the cart. Observation and interview on 12/13/23 at 09:05 AM, revealed CNA D entering Resident #64's room. No hand hygiene is performed before entering the room. CNA D moved resident # 64's table closer to her and asked her if she needed anything. She then handed Resident #64 her call light. CNA D exited the room without performing hand hygiene. CNA D said that she forgot to wash her hands. She said that she usually carried hand sanitizer in her pocket but did not have any on her. She said that she could have used the hand sanitizer in the hallway. CNA D said the risk of not washing her hands could cause Resident #64 to get what Resident #242 has. Interview with CNA F on 12/13/23 at 09:09 AM, revealed CNA F had finished assisting Resident #242 with breakfast. She asked for help with the tray because she was not done in Resident #242's room and needed to keep her gown, mask, gloves, and shield (PPE) on. CNA F said she washed her hands after removing the PPE. She said she washed her hands to prevent infection spreading to other residents and to herself. Interview on 12/13/23 at 03:25 PM with the DON revealed new CNA's are trained with RN's and seasoned CNA's for a total of 100 training hours. The DON said that she would not take a tray out of isolation without gloves. She said that she had in-serviced CNA D on Friday the week before survey. Her expectation is that every nursing staff follow standard hand hygiene practices of hand washing with soap and water and using alcohol-based hand rub and PPE requirements. Interview on 12/13/23 at 03:45 pm with ADM revealed all staff members were expected to follow the infection control protocol as indicated. She expected staff to wash hands and to prevent spread of infection. He expected staff to properly wash hands after and before care. He said the risk of staff not washing hands and following standard hand hygiene protocol can cause a spread of infection. Review of the facility policy Infection Prevention and Control Program COVID, revision date 07/23, reflected . .facility will follow Centers for Medicare & Medicaid Services (CMS), Centers for Disease Control and Prevention (CDC) as well as state and local government guidance . Review of the facility policy Handwashing/Hand Hygiene, revision 08/2019, reflected: 1. All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. 3. Hand hygiene products and supplies (sinks, soap, towels, alcohol-based hand rub, etc.) shall be (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 12/14/2023 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 0880 readily accessible and convenient for staff use to encourage compliance with hand hygiene policies. Level of Harm - Minimal harm or potential for actual harm 4. Triclosan-containing soaps will not be used. Residents Affected - Few 5. Residents, family members and/or visitors will be encouraged to practice hand hygiene through the use of fact sheets, pamphlets and/or other written materials provided at the time of admission and/or posted throughout the facility. 6. Wash hands with soap (antimicrobial or non-antimicrobial) and water for the following situations: When hands are visibly soiled; and After contact with a resident with infectious diarrhea including, but not limited to infections caused by norovirus, salmonella, shigella and C. difficile. 7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: Before and after coming on duty; . Before and after direct contact with residents; Before preparing or handling medications Before performing any non-surgical invasive procedures . Before and after handling an invasive device (e.g., urinary catheters, IV access sites); . Before donning sterile gloves; . Before handling clean or soiled dressings, gauze pads, etc.; Before moving from a contaminated body site to a clean body site during resident care; . After contact with a resident's intact skin; . After contact with blood or bodily fluids; . After handling used dressings, contaminated equipment, etc.; . After contact with objects (e.g., medical equipment) in the immediate vicinity of the resident; . After removing gloves; . Before and after entering isolation precaution settings; . Before and after eating or handling food; . Before and after assisting a resident with meals; ( .) 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 12/14/2023 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to maintain an effective pest control program to keep the facility free of pests for one (Hall 400) of four halls. Residents Affected - Some The facility failed to keep the environment free of flies. This failure could affect residents by placing them at risk for the potential spread of infection, food-borne illness, and decreased quality of life. Review of Resident #57's face sheet, dated 12/13/2023, reflected he was a [AGE] year-old male, admitted on [DATE] with diagnoses of unspecified dementia with behavioral disturbance, heart disease, and history of stroke. Review of Resident #57's MDS assessment, dated 12/05/23, reflected he was usually able to understand others and to be understood by them. He had a BIMS score of 14, indicating intact cognition. Resident #57 exhibited no behaviors or psychosis during the assessment period. He required partial to moderate assistance with most of his ADLs. Review of Resident #69's face sheet, dated 12/13/2023, reflected he was a [AGE] year-old male, admitted on [DATE], with diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting left side (one-sided weakness following a stroke), epilepsy, and generalized anxiety disorder. Review of Resident #69's significant change MDS assessment, dated 09/24/23, reflected he was able to understand and be understood by others, and had a BIMS score of 14, indicating intact cognition. Resident #69 exhibited no behaviors or psychosis during the assessment period. He required extensive to total assistance for ADLs, except he was able to feed himself. An interview and observation on 12/12/23 at 10:13 AM of Resident #69 revealed him to be in his bed, watching TV. A fly was flying around his side of the room, and during the observation it landed on his blanket, the bedside table, a water cup, and the state surveyor. He said that they had flies sometimes but he was not too bothered by them. An interview and observation on 12/12/23 at 10:13 AM of Resident #57 revealed him to be in his room, lying on his bed. While talking with the state surveyor, he swatted a fly away from his face and body several times. It was observed landing on his shirt, bare arm, feet, and table. He said they usually had flies, but they were a lot worse when it was warm out. He said he killed a lot of flies every day in his room when it was warm, at least three or four a day, sometimes more. He said he told the staff when there were flies in the room, but they did not do anything about them, so he just killed them himself. An interview on 12/14/23 at 11:06 AM with Maintenance Director A revealed he was only part time, because he worked full time at a sister facility in a nearby town and came over to help out for about two hours a day. He said he had been doing that for about four weeks, because their former maintenance director was no longer employed there, and they were looking for someone else full time. Due to the limited time he had in the facility, he had to prioritize which issues he addressed. He was not aware if the facility had a fly program with their pest control company, and he had not looked at pest issues in the facility. He said when he got to the facility, he looked at the maintenance log, and (continued on next page) 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 12/14/2023 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 he addressed the more urgent issues on it. Level of Harm - Minimal harm or potential for actual harm An interview on 12/14/23 at 12:36 PM with the RDPO revealed, he was at the facility one to two days a week now. He said when he came in, he changed bulbs, fixed holes in the walls, repaired sinks and toilets, did the generator log, fire doors, and everything. He said he looked at the maintenance log, and he had a book that showed him what he needed to do each month. He said they did have a fly issue, they put bait around the dumpster, and got it under control around the middle of August of 2023. He said that people went in and out the door by the dining room all the time, and he felt like that was how the flies got in. He said that he walked the grounds, had done so that week, and he picked up cigarette butts people left, but did not see problems with flies or trash. He said he had not seen flies in the building and had not heard complaints from residents about flies in their rooms. He said because they had once been a problem, they put some fly lights in the dining room, one in the kitchen, and they changed the sticky boards in them out monthly. He said it would be the Maintenance Director's duty to review the pest control recommendations, and that had probably not been done since he was out with an injury. Residents Affected - Some An interview on 12/15/23 at 3:51 PM with the Administrator revealed, he was not aware of current issues with flies in the resident rooms. He said the Maintenance Director would have had the responsibility for monitoring the grounds and addressing pest issues, but he had been out on prolonged workman's compensation leave, so they could not replace him, and it had been a struggle for the facility. He said recently the former Maintenance Director said he would not be coming back, so they started looking for another Maintenance Director. He said Maintenance Director A was coming to help him out, but he was there two to three hours a day, and RDPO was coming in and helping them some too. He said they had done things to address houseflies, like the fly trap devices they installed, and he felt the best thing was that they kept things clean to help keep them out. He said the flies were a contamination risk. Review of a pest control invoice for a visit on 12/04/23 reflected treatment of the building for flies. It reflected Open Conditions: Exterior- Dumpster Area: Condition: Dumpster/ Trash can uncovered; Action: Keep dumpster lids and doors closed to reduce fly population The note was marked with a severity of high and responsibility customer and was created on 03/06/23, and last inspected on 12/04/23. Review of a pest control invoice for a visit on 11/15/23 reflected treatment of the building for flies. It reflected Open Conditions: Exterior- Dumpster Area: Condition: Dumpster/ Trash can uncovered; Action: Keep dumpster lids and doors closed to reduce fly population The note was marked with a severity of high and responsibility customer and was created on 03/06/23, and last inspected on 11/15/23. Review of a pest control invoice for a visit on 11/01/23 reflected treatment of the building for flies. It reflected Open Conditions: Exterior- Dumpster Area: Condition: Dumpster/ Trash can uncovered; Action: Keep dumpster lids and doors closed to reduce fly population The note was marked with a severity of high and responsibility customer and was created on 03/06/23, and last inspected on 11/01/23. Review of a pest control invoice for a visit on 10/16/23 reflected treatment of the building for flies. It reflected Open Conditions: Exterior- Dumpster Area: Condition: Dumpster/ Trash can uncovered; Action: Keep dumpster lids and doors closed to reduce fly population The note was marked with a severity of high and responsibility customer and was created on 03/06/23, and last inspected on (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 12/14/2023 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 10/16/23. Level of Harm - Minimal harm or potential for actual harm Review of a pest control invoice for a visit on 10/02/23 reflected treatment of the building for flies. It reflected Open Conditions: Exterior- Dumpster Area: Condition: Dumpster/ Trash can uncovered; Action: Keep dumpster lids and doors closed to reduce fly population The note was marked with a severity of high and responsibility customer and was created on 03/06/23, and last inspected on 10/02/23. Residents Affected - Some Review of a pest control invoice for a visit on 09/18/23 reflected treatment of the building for flies. It reflected Open Conditions: Exterior- Dumpster Area: Condition: Dumpster/ Trash can uncovered; Action: Keep dumpster lids and doors closed to reduce fly population The note was marked with a severity of high and responsibility customer and was created on 03/06/23, and last inspected on 09/18/23. Review of the undated facility Pest Control policy reflected Pest Control: Policy Statement: Our facility shall maintain an effective pest control program. Policy Interpretation and Implementation: 1. This facility maintains an on-going pest control program to ensure that the building is kept as free as possible of insects and rodents. 2. Pest control services are provided by [pest company name]. ( .) 4. Maintenance services assist, when appropriate and necessary, in providing pest control services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676209 If continuation sheet Page 12 of 12