Health inspection·June 25, 2025

F 0804 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of Resident #2's Care Plan, dated 06/02/2025, revealed Resident #2 Focus: ADL self-care performance deficit r/t nondisplaced fracture to the 5th cervical vertebrae. Intervention: eating. Resident #2 required supervision and set-up assistance with eating. During an observation on 06/25/2025 at 12:06 PM in the facility's only dining room revealed 37 residents assembled at multiple tables waiting for lunch service. During an observation on 06/25/2025 at 12:13 PM in the facility's only dining room revealed the first tray was served. At 12:43 PM revealed all residents in the dining room were served a lunch tray. During an observation and interview on 06/25/2025 at 12:50 PM with Resident #2 revealed Resident #2 sitting in his manual wheelchair inside his room. He stated I wish I could get lunch on time it is close to 1:00PM. I think the cook use to work at a 'prison' because the way the food looks. He stated he did not receive condiments with his food and most of the time it is cold by the time I get it. During an observation on 06/25/2025 revealed the following: 12:59 PM- Hall 100 meal trays delivered on tray cart 1:10 PM-Hall 200 meal trays delivered on tray cart 1:18 PM- Hall 300 meal trays delivered on tray cart 1:33 PM-Hall 400 meal trays delivered on tray cart During an observation on 06/25/2025 at 1:13 PM, in the facility dining room revealed; place settings with five bowls of uneaten tomato soup and one bowl with less than 25% of tomato soup eaten. Single serving container of ice cream 100% eaten. Several packets of saltines, which were unopened. Next to the food items was a meal ticket with Resident #1's name printed at the top handwritten in area labeled Special Notes: 2 tomato soup, Ice cream. Observation on 06/25/2025 at 1:24 PM revealed LVN A carried a lunch tray to Resident #2's room. Observation of Mealtimes revealed it was posted in the facility dining room Breakfast: 7:00 am- 8:45 AM; Lunch: 12:00pm-1:15 PM; Supper 5:00pm-6:15PM. During an interview on 06/25/2025 at 11:34 AM the State Surveyors requested DM provide a sample tray with regular texture meal items, same portions and resident set up. The sample tray will be the last tray served . During an interview on 06/25/2025 at 1:11 PM with Resident #1 revealed; out of six bowls of tomato soup they could not get it right they were all cold. He just ate crackers and ice cream for lunch. Interview on 06/25/2025 at 1:24 PM with LVN A revealed she was told to take Resident #2 his lunch tray prior to 400 hall trays being delivered. She stated this was not routine, but she did what she was told to do. She stated residents expected to receive their meals at a certain time. She stated the risk of not receiving lunch on time could result in tensions flaring up and residents getting upset. (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 06/25/2025 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 0804 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interview on 06/25/2025 at 1:28 PM with Resident #2 revealed the lunch tray was on the bedside table positioned across the resident. He received a regular texture food tray. He stated his food looked pleasant and appeared palatable. He stated it did not always look palatable. When asked if he received everything, he needed to enjoy his meal he stated the only thing missing was salt and pepper. Observation and interview on 06/25/2025 at 1:38 PM with the DM and Kitchen Supervisor revealed the sample tray was delivered to conference room by both staff members. The food appeared visually appetizing. Temperatures were taken with facility thermometer by the Kitchen Supervisor. Pork Chop - 150 Seasoned Broccoli 115 Red Beans 141 The DM stated lunch was delayed because the dining room meal tickets were not organized. He stated the kitchen microwave was not working properly during lunch and they were unable to heat items. He stated he notified maintenance to repair the microwave. The Kitchen Supervisor stated the sample tray was missing salt and pepper; the risk was residents could not season food to taste and enjoyment . Interview on 06/25/2025 at 2:53 PM with Maintenance Director revealed he was called to the kitchen during lunch time because the microwave was not working. He stated the microwave was working properly but someone messed with the settings and it was not heating the food. He stated he pushed the settings buttons then put a test plate into the microwave and it worked properly . Interview on 06/25/2025 at 3:38 PM with the DON revealed residents should be happy with their food. She stated the DM started on Monday (06/23/2025) and we must develop a system that works on both sides. She stated Resident #2 voiced prior dining concerns that he would like more gravy on his potatoes and double portions. Resident #1 asked for his soup to be hotter. She stated Resident #1 hadn't expressed prior dietary issues. She stated she wanted them to have a meal that made them happy, and they enjoyed. Interview on 06/25/2025 at 4:00 PM with LVN B revealed she was in the dining room during lunch when Resident #1 stated his soup was cold and asked if he could get another order of soup at a temperature he would enjoy. She stated she stirred the soup with a spoon, and it appeared thick like it was cold and not thin when it was warm. She stated she told the kitchen staff, and they prepared two more bowls of soup. She delivered the second bowls of soup to Resident #1. again he stated the soup was cold. She stated she informed the kitchen staff the resident again said the soup was cold. The kitchen staff informed her they thought it was the microwave. The third round of soup was taken to the resident; she stated it appeared to have steam coming from the soup. She stated the bowl felt warmer. She stated after the third attempt Resident #1 declined additional soup. She stated residents should receive food they could eat and enjoy; this was their home. The risk was resident's would not eat and that would put them in a bad mood, you have to eat and get nutrition. The LVN B stated she felt bad there was a risk he would not get his adequate intake . Interview on 06/25/2025 at 4:32 PM with Resident #1 revealed he stated he was disappointed because he really liked tomato soup. He stated he would be okay until dinner and declined the offer to get another lunch tray . (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 06/25/2025 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 0804 Level of Harm - Minimal harm or potential for actual harm Interview on 06/25/2025 at 4:45 PM with the ADMIN revealed the facility wanted the residents to enjoy their meals; hot foods should be served hot and cold foods should be served cold. Residents should receive everything with their meal which included salt and pepper that was important to all of us. The risk was dissatisfaction, and residents tended not to eat; had weight loss and not well nourished could affect the body. Residents Affected - Some Record review of the Food Temperature Log, dated 06/25, revealed no entry for soup. Record review of Work Orders, dated 06/25/2025, revealed; Summary- Microwave not working. Record review of [The Facility] Resident Council dated May 13, 2025, revealed; 1. Dietary: Resident council resident stated oatmeal tastes funny and scrambled eggs are not creamy. Resident council resident stated they can't get her order right and breakfast was cold (06/12/2025). Resident council resident stated her food is cold . Record review of [The Facility] Resident Council Responses, dated 05/13/2025, revealed talked to cook about not putting anything in oatmeal and make sure eggs are prepared right for residents. Talked to staff about getting order right and make sure food goes to room quickly. Talked to staff about getting food out quickly. Record review of [The Facility] Resident Council, dated June 12, 2025, revealed 1. Dietary: Resident council resident stated she wanted a baked potato, and they didn't have one in the kitchen (06/10/2025 in the evening). Resident council resident says she eats in her room and the meals get to her late and she wants to know why. Resident council resident says she asked for a piece of bread on (06/11/2025) at the evening meal and didn't get it . Record review of [The Facility] Resident Council Responses, dated 06/12/2025, revealed talked to kitchen and they had some (potatoes) coming on the next truck order the next day. Resident's hall is sometimes last to serve, new cook starting 06/23/2025 and new staff. The staff will be informed of times and will improve on getting to halls on time. Resident was told they had ran out of bread and it was coming on next truck order the next day . Record review of Love, Satisfaction, and Well-being form, dated 06/15/2025, revealed Event: Meal (Food Preference); Resident #2 complained that kitchen staff prepared food like it was 'prison food.' Complained that he did not receive condiments last night with hamburger. Another time he did not receive toppings with baked potato. Additional Follow-up Action, If Applicable Dietary Manager also visited with him about food preferences and to ensure that all condiments, etc . were on the meal tray. Record review of the facility's policy Preparing the Resident for a Meal, revised September 2010, revealed The purpose of this procedure is to prepare the resident and the environment in order to help make mealtime pleasant for the resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676209 If continuation sheet Page 4 of 4