Inspection·September 8, 2023

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident #53's Progress Notes revealed that Resident #53 had a fall on 06/25/2023, 07/31/2023, and 08/21/2023. Observation and interview on 09/07/2023 at 1:28 PM, revealed Resident #53 was on bed with fall mat on the floor beside the resident's bed. Her call light was sitting on the nightstand where the resident could not reach it. Resident #53 said she usually pushed the call light if she needed assistance, while pointing at the call light on the nightstand which was not in reach. Observation on 09/07/2023 at 1:37 PM, revealed surveyor pushed Resident #53's call light to check if it was working, CNA L answered the call light. CNA L provided Resident #53 with incontinent care and left the room. Observation on 09/07/2023 at 1:43 PM, revealed Resident #53's call light was still sitting on the nightstand where the resident could not reach it. Interview with LVN E on 09/07/2023 at 1:56 PM, she said the call light should always be with the resident. The call light must be within reach at all times. LVN E added that if the call light is not with the resident, the resident might fall when they try to reach for something that is far from them. LVN E placed the call light that was on the nightstand within the reach of Resident #53. Interview with CNA L on 09/07/2023 at 2:01 PM, CNA L said that the policy for the call light is that the call light should be with the residents at all times. It should be positioned in a place where the resident could reach it and press the red button. CNA L acknowledged she forgot to place the call light near Resident #53. CNA L stated the call light is necessary for the residents because it is what they use to call when they need assistance. If the call light is not with them, they will not be able to call the staff. This may result to fall. Interview on 09/07/2023 at 2:13 PM, ADON R stated the call light should be within reach at all times. The call light is the resident's means of communication. This is one way the residents would let the staff know they need something. The risk of not having the call light near the resident is the resident would not be able to call in an event of an emergency. Interview on 09/07/2023 at 2:24 PM, the DON stated the call light must be within reach of the resident so that they can call the staff if assistance is needed. The DON further stated the policy of the facility is the call light should be with the residents at all times. If the resident is on the bed, the call light should be beside the resident or clipped near the resident. If the resident is on the wheelchair inside the room, the call light should be with the resident on the wheelchair. The DON stated that the expectation is that all the residents could access their call lights if assistance is needed. The expectation is the staff should follow the policy for call lights. Interview on 09/07/2023 at 2:36 PM, the Administrator stated the call light should be in a place where the resident could reach it and press when assistance is needed. Record review of facility's policy Resident Call Light System, Priority management, rev. 6/2023 revealed The purpose of this procedure is to respond to the resident's requests and needs . policy Implementation . allows individual residents to access a system that notifies nursing that the resident has a need . General Guidelines . 4. Ensure that the call light is easily reachable by the resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676217 If continuation sheet Page 2 of 8 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 676217 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Royse City Medical Lodge 901 W Interstate 30 Royse City, TX 75189 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to provide a safe, clean, comfortable, and homelike environment in one facility (carpet throughout facility and Rooms 303, 305, 307, 309, 311, 315, and 317) of one observed for a clean and homelike environment. The facility failed to ensure that the facility carpet and resident rooms were cleaned daily, and in accordance with the facility's Housekeeping Checklist. This deficient practice could place residents at risk of infections and living in an uncomfortable environment leading to a decreased quality of life. Findings include: Observation on 09/06/23 at 10:00 AM, of the carpet throughout the facility revealed, the carpet had deep dark dirt patches throughout the entire facility. Observation of room [ROOM NUMBER] on 09/06/23 at 12:05 PM revealed, the floor under the air-conditioner unit and resident bed displayed built-up dirt stains. The air-conditioner unit was dirty on the outside. The bathroom floor was dirty and stained with some orange spots. The room door entrance was displayed heavy dirt and grime along the edges and corners. Observation of room [ROOM NUMBER] on 09/06/23 at 12:10 PM revealed, the floor under the air-conditioner unit and resident bed displayed built-up dirt stains. The air-conditioner unit was dirty and dusty on the outside. The bathroom floor was dirty and stained with some dark spots, the floor around the toilet was dirty, and the toilet was stained. The room door entrance was displayed heavy dirt and grime along the edges and corners. Observation of room [ROOM NUMBER] on 09/06/23 at 12:17 PM revealed, the floor under the air-conditioner unit displayed built-up dirt stains. The air-conditioner unit was dirty and dusty on the outside. The bathroom floor was dirty and stained with some dark spots, the floor around the toilet was dirty, and the toilet was stained. The sink was dirty and had used paper towels thrown on it (Resident advised housekeeping was already in). Observation of room [ROOM NUMBER] on 09/06/23 at 12:20 PM revealed, the floor under the air-conditioner unit displayed built-up dirt stains. The air-conditioner unit was dirty and dusty on the outside. The bathroom floor was dirty and stained with some dark spots, the floor around the toilet was dirty, and the toilet was stained on the inside. The room door entrance was displayed heavy dirt and grime along the edges and corners. Observation of room [ROOM NUMBER] on 09/06/23 at 12:24 PM revealed, the floor under the air-conditioner unit displayed built-up dirt stains. The room door entrance was displayed heavy dirt and grime along the edges and corners. The air-conditioner unit was dirty and dusty on the outside. The bathroom floor was dirty and stained with some dark spots, the floor around the toilet was dirty, and the toilet was stained on the inside. Observation of room [ROOM NUMBER] on 09/06/23 at 12:33 PM revealed, the floor under the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676217 If continuation sheet Page 3 of 8 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 676217 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Royse City Medical Lodge 901 W Interstate 30 Royse City, TX 75189 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some air-conditioner unit displayed built-up dirt stains. The room door entrance was displayed heavy dirt and grime along the edges and corners. The air-conditioner unit was dirty and dusty on the outside. The bathroom floor was dirty and stained with some dark spots, the floor around the toilet was dirty, and the toilet was stained on the top seat. Interview with Housekeeping S on 09/08/23 at 1:22 PM, revealed she had been at the facility for 3 months and she cleans the rooms on the 300 hall. She stated that they showed her how to clean the rooms and then hands on training. She stated every day she cleaned the floor, handles, button, dusting, every other day and as needed. Clean bathrooms every day. She stated she does not use a checklist and when she sees it dirty, she cleans it. She stated the risk to the resident of the rooms not being cleaned thoroughly and they could get sick, and bacteria could spread. Interview with Housekeeping Manager on 09/08/23 at 1:34 PM, revealed that she had been at the facility for 1 year. She stated she trained the housekeepers by showing them the cleaning instructions for cleaning in a nursing home, and then they trained them. She stated the housekeepers did not have a cleaning list; however, she used a cleaning list and she inspected it. She stated they were trained and checked on what to and how to clean. She stated that they did not have a floor technician and they were short staffed. She stated she had met with the Administrator and advised him that the floor needed to be stripped and rewaxed and the carpet needed to be deep cleaned. She stated they had just gotten sufficiently staffed but need to train staff more. She stated the impact of a dirty room could make residents ill. Interview with Administrator on 09/08/23 at 2:30 PM, revealed he was shown the pictures of the concerns discovered in the facility's only kitchen. He advised that his Housekeeping Manager had not met with him yet to discuss the concerns, but he would be meeting with her to address. He advised that he was surprised to hear that of concerns regarding the cleanliness of the facility. He said he had already notified Corporate of the condition of the carpet throughout the facility and hoped to replace it. He advised that he expected his facility not to be in that type of condition and said if he was a resident, he would not want to be living in those conditions. He said that was not considered a clean, sanitary, and homelike environment that could make residents ill. Review of the facility's Homelike Environment dated 02/2021, revealed The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. The Characteristics include clean, sanitary, and orderly environment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676217 If continuation sheet Page 4 of 8 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 676217 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Royse City Medical Lodge 901 W Interstate 30 Royse City, TX 75189 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 0695 Provide safe and appropriate respiratory care for a resident when needed. 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 ensure the services provided or arranged by the facility, as outlined by the comprehensive care plan meet professional standards of quality for 1 of 3 residents (Resident #27) reviewed for respiratory care. Residents Affected - Few The facility failed to ensure Resident #27's oxygen concentrator filter was clean. This failure placed residents at risk of not receiving safe and sufficient respiratory care. Findings include: Record review of Resident #27's Face Sheet, dated 09/08/2023, revealed he was admitted on [DATE] for long term care services. Relevant diagnoses included chronic respiratory failure, dysphagia (difficulty swallowing,) major depressive disorder, urinary tract infection, type 2 diabetes, dementia, atrial fibrillation (irregular heartbeat,) anxiety disorder, Parkinson's disease, and malignant neoplasm of the prostate. Record review of MDS dated [DATE], indicated Resident #27 was moderately cognitively impaired, and had a BIMS score of 10. Record review of Resident #27's Physician Orders revealed: Oxygen: Change Mask, O2 tubing, water bottle and clean concentrator filter . every night shift every Sun weekly . with a start date of 09/03/2023 at 10:00 PM. Oxygen: May have oxygen at 2-4 liters per minute . every shift . with a start date of 08/30/2023 at 2:00 PM. Suction PRN . every 1 hours as needed related to Dysphagia Oropharyngeal phase . with a start date of 08/16/2023 at 7:00 PM. NPO diet, NPO texture . with a start date of 08/15/2023 at 1:47 PM. An observation and interview with Resident #27 on 09/06/2023 at 1:08 PM, revealed resident was receiving approximately 3 liters of oxygen per minute via nasal cannula. The back of Resident #27's oxygen concentrator revealed the air filter had a significant accumulation of grey, brown, and black sediment. Resident #27 stated that he was not sure when or if the nurse had cleaned his oxygen concentrator filter and he was not aware it was dirty. He denied shortness of breath at this time. In observation and interview with Resident #27 on 09/07/2023 at 10:29 AM, revealed resident receiving approximately 3 liters per minute of oxygen via nasal cannula. The back of Resident #27's oxygen concentrator revealed the air filter still had a significant accumulation of grey, brown, and black sediment present. Resident #27 still denied shortness of breath at this time. In observation and interview with LVN H on 09/07/2023 at 1:40 PM, revealed her inspection of the oxygen concentrator device. She stated the air filter was dirty and it was the responsibility of the Sunday night shift nurse to ensure the oxygen concentrator filter was cleaned. She stated that nurses (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676217 If continuation sheet Page 5 of 8 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 676217 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Royse City Medical Lodge 901 W Interstate 30 Royse City, TX 75189 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few should be checking the oxygen concentrator and filter daily to ensure it was completed but said she did not do that for Resident #27 on 09/06/2023 or 09/07/2023. She stated if residents' oxygen concentrator filters were dirty, it affected the delivery of oxygen to the resident. In interview with the DON on 09/08/2023 at 3:12 PM, she stated she was aware of the oxygen concentrator filter concern, and she stated that it was her expectation that the shift nurses ensure that each resident oxygen concentrator filters were maintained and clean. She stated that the night shift nurse on Sundays were responsible for cleaning the filters and each shift following to inspect the filter as needed. She stated that if resident oxygen concentrator filters were not clean, respiratory and allergy related concerns could occur. She further explained that nursing leadership did rounding on Mondays to ensure compliance in multiple resident care areas, including a resident's respiratory equipment and devices. She stated ADON R was assigned to Resident #27 and it was her responsibility to have inspected his oxygen concentrator. She stated there was not a formal checklist for the areas she expected nursing leadership to inspect, but again confirmed that resident oxygen concentrators would be under that scope. In interview with ADON R on 09/08/2023 at 3:30 PM, she stated that nursing leadership was responsible for quality of care rounding each week, primarily on Mondays; but she was not assigned to Resident #27. She stated she was assigned to a different hall. She stated that she was not sure who was assigned to that room but stated resident oxygen concentrator filters need to be kept clean otherwise residents will be breathing in dirty air. In interview with the Administrator on 09/08/2023 at 4:00 PM, he stated his expectations were for the DON to ensure resident concentrators were clean and the filters maintained appropriately. He stated that if resident oxygen concentrator filters were not maintained and clean, a resident could suffer adverse effects. Review of facility policy Departmental (Respiratory Therapy) - Prevention of Infection, rev 11/2011 revealed Steps in the Procedure . Infection Control Consideration Related Oxygen Administration . 9. Wash filters from oxygen concentrators every seven days with soap and water. Rinse and squeeze dry. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676217 If continuation sheet Page 6 of 8 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 676217 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Royse City Medical Lodge 901 W Interstate 30 Royse City, TX 75189 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 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interviews and record reviews the facility failed to ensure food was stored, prepared, distributed and served in accordance with professional standards for food service safety for the facility's only kitchen reviewed for kitchen sanitation. The facility failed to ensure foods in the facility's dry storage area, refrigerator, and freezer were stored and dated according to guidelines. The facility failed to ensure proper discarding of expired and damaged food stored in the refrigerator and dry storage area. The facility failed to ensure the Ice Scooper Holder, located in the facility's only kitchen, was clean and sanitary. The facility failed to ensure the Iced Tea dispenser, prepared for residents, was covered, and sealed from air-borne diseases once prepared. The facility failed to ensure kitchen equipment was clean and sanitary. These failures could place residents at risk for cross contamination and other air-borne illnesses. Findings include: Observations of the kitchen on 09/06/23 at 09:15 AM revealed the following: Ice Machine Scoop Holder was dirty on the outside and inside, with a lot of dirt particles dried up on the bottom of the Ice holder, Iced Tea dispenser filled with tea, did not have a top on it and the tea was exposed, 12 8-ounce cups of miscellaneous juices and water sitting uncovered in the refrigerator, Two large trays of bacon and breakfast sausages in the refrigerator with aluminum foil placed on top of the trays, but not sealed, Large Powdered Sugar, Sugar, and Flour bins were dirty on the outsides of the containers and along the inside openings, One unsealed bag of hamburger buns (4), Twenty Loaves of white bread with an expiration date of 09/02/23 was undated, One 7.3 lb. can of Baked beans with a large dent, and One Large container of Cheerios was not completely sealed. Interview with Dietary Aide P on 09/06/23 at 09:30 PM revealed, he made the iced Tea that morning (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676217 If continuation sheet Page 7 of 8 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 676217 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Royse City Medical Lodge 901 W Interstate 30 Royse City, TX 75189 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 at 06:30 AM. He stated he forgot to put the top back on the dispenser once he was done, which he normally does. He stated the risk of not covering the dispenser once the tea was done could result in something falling into the tea and contaminating it, which could make residents sick. Interview and observation with the Dietary Manager and Dietitian on 09/07/23 at 01:30 PM, revealed the Dietary Manager was overall responsible for ensuring the kitchen was complying to Federal and State guidelines. The Dietary Manager stated that she had the Ice machine, Ice Scooper, and Ice Scooper Holder cleaned at least once a week, but had not been checking for cleanliness recently. They were advised of the Iced Tea Container being uncovered for at least three hours and she advised that she always had to remind the kitchen aides to place the cover back on the dispenser once the tea is done preparing. They were shown the pictures of the dirty bins and she advised that all equipment in the kitchen should be cleaned weekly and there was a schedule for everyone to follow. She was shown the pictures of the concerns observed in the kitchen and the Dietary Manager advised that she needed to complete an in-service on proper food storage, and she advised that she discarded the 20 loaves of expired white bread. The Dietary Manager stated the risk of not ensuring all these concerns were addressed could result in residents getting ill because of food contamination. Interview with Administrator on 09/08/23 at 2:30 PM, revealed he was shown the pictures of the concerns discovered in the facility's only kitchen. He advised that the Dietary Manager had notified him of some of the concerns but not all. He advised that he definitely not want to see the concerns observed. He advised that he would meet with the Dietary Manager to address her plan to correct the concerns observed. He advised the risk of the concerns identified could result in food contamination, and residents getting ill. Record Review of the Facility's policy on Food Storage and Kitchen Sanitation dated 12/01/11, revealed All foods will be stored according to Federal and State guideline. All refrigerated food are labeled, dated, and tightly sealed. Scoops are stored covered in a protected area. Scoops are washed weekly or as needed. Review of the U.S. Food and Drug Administration (FDA) Code (2022) revealed, Except for containers holding FOOD that can be readily and unmistakably recognized such as dry pasta, working containers holding FOOD or FOOD ingredients that are removed from their original packages for use in the FOOD ESTABLISHMENT, such as cooking oils, flour, herbs, potato flakes, salt, spices, and sugar shall be identified with the common name of the FOOD. Processed reduced oxygen foods that exceed the use-by date or manufacturer's pull date cannot be sold in any form and must be disposed of in a proper manner. All equipment and utensils must be cleaned and sanitized. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676217 If continuation sheet Page 8 of 8