Health inspection·May 24, 2023

F 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 05/22/23 at 04:44 PM, LVN M said the ADON notified the previous DON on 01/20/23 after RN N had contacted hospice for medication refills and was informed it was too early for a refill on the Tramadol 50 mg. LVN M said the ADON reported the information to the previous DON on 01/20/2023 of the suspicion of missing Tramadol dosages. During an interview on 05/23/2023 at 04:50 PM, the DON said the incident of the missing medication was not reported timely to the state agency after a suspicion of a drug diversion was found on 01/20/2023 within 24-hours. The DON said the incident should have been reported on 01/20/2023 according to facility policy. The DON stated it was important to report timely to ensure investigations are handled effectively to prevent and reconcile any type of misappropriation which could result in an increase in pain or suffering of the residents. The DON said she had been employed with the facility since March of 2023. The DON stated the current ADM is considered the Interim ADM and was assigned to the facility this month. During an interview on 05/23/2023 at 5:00 PM, the ADM said the incident of the missing medication was not reported within 24-hours. The ADM said the incident should have been reported on 01/20/2023 according to facility policy. The Interim ADM said he was assigned to the facility in May of 2023. He said the purpose of reporting timely was to ensure the investigations are handled quickly and prevent any type of harm to residents. During an interview by telephone on 05/24/2023 at 5:59 PM, the previous ADM said the incident was reported immediately and timely by him per policy upon his receipt of the information from the previous DON. He stated he did not recall the exact incident; however, he would have reported immediately upon gaining knowledge of any drug diversion. The previous DON was not reachable by telephone for interviewing purposes after 2 requested callback on 05/22/202 at 4:52 PM and 05/24/2023 at 09:52 AM. Record Review of Policy and Procedures: Abuse, Neglect and Exploitation dated 10/24/2022 reflected, a.Shall report to the state agency and one or more law enforcement entities . any responsible suspicion of a crime against any individual who is a resident of or receiving care from the facility B.Shall report immediately, but no later than 2 hours after forming the suspicion .result in serious bodily injury, or not later than 24 hours if the events causing the suspicion do not result in serious bodily injury. B. The Administrator will follow up with the government agencies, during business hours, to confirm the initial report was received, and to report the results of the investigation when final within 5 working days of the incident as required by state agencies. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676294 If continuation sheet Page 2 of 7 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 676294 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heritage House at Paris Rehab & Nursing 150 S.E. 47th Street Paris, TX 75462 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 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, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 1 of 15 (Resident #2) residents reviewed for abuse and neglect. The facility failed to follow their policy regarding abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property reported to the state agency within 24 hours of the suspicion of Resident #2's missing Tramadol medication. This failure could place the residents at risk for drug diversion, misappropriation of property, abuse and neglect not being investigated in a timely manner. Findings included: Record Review of a Face Sheet dated 05/22/2023 indicated Resident #2 was a [AGE] year-old male, admitted to the facility on [DATE] with a primary diagnosis of Dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment). Record Review of Resident #2's MDS dated [DATE] indicated a BIMS of 99 (resident unable to complete the interview), and the resident was difficult to understand or be understood and had a functional level of total dependence. Record Review of Resident #2's Care Plan revised on 01/06/2023 indicated interventions for pain included an order for Tramadol 50mg 1tab by mouth every 6 hours with a focus on effective communication of pain needs. Record Review of the Provider Investigation Report dated 01/23/2023 indicated an Incident involving a drug diversion and misappropriation of medication was reported to the state agency on 01/23/2023 at 04:46 PM. Record Review of a witness statement dated 01/23/23 and signed by the previous DON indicated, On Friday, January 20, 2023, ADON called me regarding a resident running out of a medication too soon and the pharmacy wouldn't fill it. 01/23/2023 after being notified by the floor nurse administering medications that she did not have any Tramadol to administer to Resident #2 during the 06:00 AM medication pass. On 01/23/2023. During an interview on 05/22/23 at 4:24 PM, the ADON said she first learned of the resident's missing Tramadol medication on Friday, 01/20/2023. She said she notified the previous DON on 01/20/2023. The ADON said she verified with hospice the proper amount of Tramadol had been delivered to and received by the facility (120 pills). The ADON said she reported to the previous DON on 01/20/2023 of the suspicion of Resident #2's missing Tramadol dosages. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676294 If continuation sheet Page 3 of 7 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 676294 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heritage House at Paris Rehab & Nursing 150 S.E. 47th Street Paris, TX 75462 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 During an interview on 05/22/23 at 04:44 PM, LVN M said the ADON notified the previous DON on 01/20/23 after RN N had contacted hospice for medication refills and was informed it was too early for a refill on the Tramadol 50 mg. LVN M said the ADON reported the information to the previous DON on 01/20/2023 of the suspicion of missing Tramadol dosages. During an interview on 05/23/2023 at 04:50 PM, the DON said the incident of the missing medication was not reported timely to the state agency after a suspicion of a drug diversion was found on 01/20/2023 within 24-hours. The DON said the incident should have been reported on 01/20/2023 according to facility policy. The DON stated it was important to report timely to ensure investigations are handled effectively to prevent and reconcile any type of misappropriation which could result in an increase in pain or suffering of the residents. The DON said she had been employed with the facility since March of 2023. The DON stated the current ADM is considered the Interim ADM and was assigned to the facility this month. During an interview on 05/23/2023 at 5:00 PM, the ADM said the incident of the missing medication was not reported within 24-hours. The ADM said the incident should have been reported on 01/20/2023 according to facility policy. The Interim ADM said he was assigned to the facility in May of 2023. He said the purpose of reporting timely was to ensure the investigations are handled quickly and prevent any type of harm to residents. During an interview by telephone on 05/24/2023 at 5:59 PM, the previous ADM said the incident was reported immediately and timely by him per policy upon his receipt of the information from the previous DON. He stated he did not recall the exact incident; however, he would have reported immediately upon gaining knowledge of any drug diversion. The previous DON was not reachable by telephone for interviewing purposes after 2 requested callback on 05/22/202 at 4:52 PM and 05/24/2023 at 09:52 AM. Record Review of Policy and Procedures: Abuse, Neglect and Exploitation dated 10/24/2022 reflected, a.Shall report to the state agency and one or more law enforcement entities . any responsible suspicion of a crime against any individual who is a resident of or receiving care from the facility B.Shall report immediately, but no later than 2 hours after forming the suspicion .result in serious bodily injury, or not later than 24 hours if the events causing the suspicion do not result in serious bodily injury. B. The Administrator will follow up with the government agencies, during business hours, to confirm the initial report was received, and to report the results of the investigation when final within 5 working days of the incident as required by state agencies. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676294 If continuation sheet Page 4 of 7 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 676294 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heritage House at Paris Rehab & Nursing 150 S.E. 47th Street Paris, TX 75462 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 observations, interviews, and record reviews the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases or infections and the facility failed to ensure linens were handled, stored, processed, and transported to prevent the spread of infection for 3 of 4 halls (100 hall, 200 hall, and 400 hall), and 6 out of 58 employees (CNA C, CNA D, CNA E, HA F, MA G, and CNA H) reviewed for infection control practices. Residents Affected - Some 1. The facility did not ensure CNA D handled glasses of ice without her fingernails touching the ice inside of the glass and the facility did not ensure CNA D, CNA E, and HA F performed hand hygiene in between handling meal trays, during the lunch meal. 2. The facility did not ensure the clean linen carts on 100 hall, 200 hall, and 400 hall were completely covered while not being used. 3. The facility did not ensure CNA H placed soiled linen and trash in the appropriate barrels after providing care. These failures could place residents at increased risk for infection or cross-contamination that could diminish the resident's quality of life. The findings included: 1. During an observation on 05/22/2023 between 12:01 PM - 12:26 PM, CNA D, CNA E, and HA F were passing out meal trays on 200 hall. CNA D took a meal tray to a resident sitting in the dining room, did not perform hand hygiene, came back to the tray cart, did not perform hand hygiene, took another meal tray to room [ROOM NUMBER], and did not perform hand hygiene. CNA D went down the hallway to obtain several cups of ice, without performing hand hygiene. CNA D came back up the hallway carrying four clear, plastic cups filled with ice. CNA D was carrying the cups by holding the inside of the cups with one hand while her artificial fingernails were touching the ice in 2 out of 4 of the cups. CNA D took a cup of ice into room [ROOM NUMBER]. CNA D did not perform hand hygiene. CNA E took a meal tray into room [ROOM NUMBER], did not perform hand hygiene, came back to the tray cart, did not perform hang hygiene, took another meal tray into room [ROOM NUMBER], did not perform hand hygiene, came back to the tray cart, did not perform hand hygiene, took another meal tray into room [ROOM NUMBER], and did not perform hand hygiene. HA F took a meal tray into room [ROOM NUMBER], did not perform hand hygiene, came back to the tray cart, did not perform hand hygiene, took another meal tray into room [ROOM NUMBER], and did not perform hand hygiene. During an interview on 05/23/2023 at 1:54 PM, HA F stated staff should have performed hand hygiene between different resident's meal trays. HA F stated she normally performed hand hygiene while passing out meal trays, but she had some anxiety on 05/22/2023 because there was normally not that many people helping to pass out meal trays. HA F stated performing hand hygiene was important, so staff did not pass germs from room to room. During an interview on 05/23/2023 at 1:57 PM, CNA D stated staff should perform hand hygiene between different resident's meal trays. CNA D stated she should not have carried cups of ice holding the inside of the cups. CNA D stated her fingernails should not have been touching the ice. CNA D stated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676294 If continuation sheet Page 5 of 7 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 676294 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heritage House at Paris Rehab & Nursing 150 S.E. 47th Street Paris, TX 75462 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 - Some she did not have help and was in a hurry passing out the meal trays and just did not think about her hands touching the ice or performing hand hygiene. CNA D stated performing hand hygiene and ensuring cups were handled properly was important so staff did not pass anything on to anyone. During an interview on 05/23/2023 at 2:43 PM, CNA E stated staff should have performed hand hygiene while passing meal trays. CNA E stated she did not perform hand hygiene every time while passing out meal trays. CNA E stated cups should be carried by the handle or around the outside of the cup. CNA E stated carrying cups appropriately and performing hand hygiene while passing out meal trays was important to maintain hygiene for the resident's and for the staff. During an interview on 05/24/2023 at 6:09 PM, the DON stated she expected staff to perform hand hygiene, ensure cups were carried correctly, and ensure fingernails were not touching the ice while passing out meal trays. The DON stated this was monitored by random observations and education. The DON stated performing hand hygiene and ensuring cups were handled correctly was important because of infection control. During an interview on 05/24/2023 at 6:44 PM, the Administrator stated he expected staff to ensure cups were carried correctly, fingernails were not touching the ice, and hand hygiene was performed while passing out meal trays. The Administrator stated management staff were responsible for monitoring facility staff. The Administrator stated performing hand hygiene, ensuring cups were carried correctly, and ensuring fingernails were not touching the ice was important because of infection control. 2. During an observation on 05/23/2023 between 5:01 AM - 5:51 AM, the clean linen cart on 200 hall was open, with the front cover laying on top of the clean linen cart. Dirty linen and trash barrels were approximately 3 feet from the open clean linen cart. During an observation on 05/23/2023 between 5:04 AM - 5:12 AM, the clean linen cart on 100 hall was open, with the front cover laying on top of the clean linen cart. During an observation on 05/23/2023 between 5:09 AM - 5:28 AM, the clean linen cart on 400 hall was open, with the front cover laying on top of the clean linen cart. During an interview on 05/23/2023 at 5:44 AM, HA A stated clean linen carts should have been kept covered. HA A stated she probably forgot to close the clean linen cart on 400 hall because she was helping out on another hall. HA A stated it was important to ensure clean linen carts remained closed because of infection control. During an interview on 05/23/2023 at 5:51 AM, CNA B stated clean linen carts should have been covered and the front cover should have been down. CNA B stated he forgot to pull it down on 200 hall. CNA B stated it was important to ensure clean linen carts remained closed because it could have caused cross-contamination. During an interview on 05/23/2023 at 5:57 AM, CNA C stated clean linen carts should have been kept covered. CNA C stated she put the front cover down when she realized it was up on 100 hall. CNA C stated it was important to ensure clean linen carts remained closed to prevent cross-contamination. During an interview on 05/24/2023 at 6:09 PM, the DON stated she expected the nursing staff to ensure clean linen carts were kept covered. The DON stated that was monitored by random checks. The DON (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676294 If continuation sheet Page 6 of 7 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 676294 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heritage House at Paris Rehab & Nursing 150 S.E. 47th Street Paris, TX 75462 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 - Some stated it was important to ensure linen carts were kept covered to prevent the spread of infection or cross-contamination. During an interview on 05/24/2023 at 6:44 PM, the Administrator stated he expected staff to ensure clean linen carts were covered. The Administrator stated management staff were responsible for monitoring. The Administrator stated it was important to ensure clean linen carts were kept covered to prevent the spread of infection or cross-contamination. 3. During an observation on 05/23/2023 at 2:32 PM, a soiled, used incontinent brief and draw sheet was laying in the floor behind Resident #1's door. CNA H entered Resident #1's room, donned gloves, removed the trash bag from Resident #1's trash can, and picked up the soiled, used incontinent brief and draw sheet, placed it in the bag, and took it out of Resident #1's room. During an interview on 05/23/2023 at 3:01 PM, CNA H stated she did not normally leave soiled linens and trash on the floor in resident's rooms. CNA H stated she had just finished providing care to Resident #1 and had not retrieved her barrel yet. CNA H stated it was important to ensure soiled linens and trash were not kept in the floor to prevent infections and ensure a sanitary environment. During an interview on 05/24/2023 at 6:09 PM, the DON stated she expected staff to ensure dirty, soiled linen and trash was placed in the appropriate barrels after care was provided. The DON stated that was monitored by random checks by the nurse management staff. The DON stated she recently hired another nurse manager that would be responsible for monitoring the CNAs. The DON stated it was important to ensure dirty, soiled linen and trash were not placed in the floor to prevent the spread of infection. During an interview on 05/24/2023 at 6:44 PM, the Administrator stated he expected staff to ensure dirty, soiled linen and trash was placed in the appropriate barrels after care was provided. The Administrator stated it was important to ensure dirty, soiled linen and trash were not placed in the floor to prevent the spread of infection. Record review of the Bedside Water Pass policy, dated 3/16/2014, revealed Do not allow ice to touch hands . The policy further revealed hands should have been washed or sanitized before and after the procedure. Record review of the Infection Prevention and Control Program policy, revised 04/12/2023, revealed 4. Standard Precautions: b. Hand hygiene shall be performed in accordance with our facility's established hand hygiene procedures. The policy further revealed 11. Linens: d. Linen shall be stored on all resident care units on covered carts, shelves, in bins, drawers, or linen closets. E. Soiled linen shall be collected at the bedside and placed in a linen bag. When the task is complete, the bag shall be closed securely and placed in the soiled utility room. Soiled linen shall not be kept in the resident's room or bathroom. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676294 If continuation sheet Page 7 of 7