Health inspection·September 27, 2023

F 0550 staff members are involved in providing care to residents to promote and maintain resident dignity 5. When interacting with a resident, pay attention to the resident as an Individual . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676294 If continuation sheet Page 2 of 50 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 09/27/2023 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 0552 Ensure that residents are fully informed and understand their health status, care and treatments. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review the facility failed to ensure residents have the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives and to choose the option he or she prefers for 1 of 5 residents reviewed for the right to be informed. (Resident #2 and Resident #33) Residents Affected - Few 1. The facility failed to ensure Resident #2 had a signed psychotropic consent form for alprazolam (antianxiety medication), Belsomra (sedative-hypnotic medication), and Remeron (antidepressant medication). 2. The facility did not ensure Resident #33 had a signed informed consent based on information of the need, benefits, and risk prior to administering Ativan (a medication used to treat anxiety). These failures could place residents at risk for treatment or services provided without their informed consent. The findings included: 1. Record review of the face sheet, dated 09/27/2023, revealed Resident #2 was an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of recurrent depressive disorders (episodes of depression after periods of time without symptoms), anxiety disorder (characterized by significant and uncontrollable feelings of anxiety and fear), and unspecified atrial fibrillation (disease of the heart characterized by irregular and often faster heartbeat). Record review of the MDS assessment, dated 06/30/2023, revealed Resident #2 had clear speech and was understood by staff. The MDS revealed Resident #2 was able to understand others. The MDS revealed Resident #2 had a BIMS of 5, which indicated severe cognitive impairment. The MDS revealed Resident #2 had a PHQ-9 score of 1, which indicated minimal depression. The MDS revealed Resident #2 had no behaviors or refusal of care. The MDS revealed Resident #2 took an antidepressant and antianxiety medications 7 out of 7 days during the look-back period. Record review of the comprehensive care plan, revised on 05/23/2023, revealed Resident #2 used psychotropic medications (antidepressants and antianxiety). Record review of the order summary report, dated 09/26/2023, revealed Resident #2 had an order, which started on 07/07/2023, for alprazolam (an antianxiety medication). The order summary report revealed an order, which started on 07/05/2023, for Belsomra (a sedative-hypnotic medication). The order summary report further revealed an order, which started on 09/19/2023, for Remeron (an antidepressant medication). Record review of the MAR, dated September 2023, revealed Resident #2 received Belsomra, Remeron, and alprazolam as ordered by the physician. Record review of the electronic medical record, accessed on 09/27/2023 at 4:40 PM, revealed no consent forms for Belsomra, Remeron, or alprazolam. Record review of the Antipsychotic Binder 2023, accessed on 09/27/2023 at 4:42 PM, revealed no (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676294 If continuation sheet Page 3 of 50 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 09/27/2023 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 0552 consent forms for alprazolam, Remeron, or Belsomra. Level of Harm - Minimal harm or potential for actual harm During an observation and interview on 09/25/2023 at 9:36 AM, Resident #2 was sitting up in her recliner with hair combed and clothing neat and clean. Resident #2 was pleasant during interview. Resident #2 stated she was aware she was taking several psychotropic medications including one that increased her appetite. Resident #2 stated she also took a few other medications but could not recall the names. Resident #2 stated she could not remember if she signed a consent form but stated she needed her medications. Residents Affected - Few During an interview on 09/27/2023 at 7:28 PM, RN R stated she recently started working for the facility in August 2023. RN R stated she was unsure who was responsible for completing the psychotropic consent forms, but she assumed it was the admission nurse. RN R stated she had not completed any admissions since starting work at the facility. RN R stated an informed consent form should have been obtained for an antidepressant, antianxiety, sedative-hypnotic, and antipsychotic medications prior to the medication being administered. RN R stated it was important to ensure psychotropic medication consent forms were obtained prior to administering the medications to ensure the resident had given consent and knew the risks and benefits. During an interview on 09/27/2023 at 7:46 PM, ADON V stated the ADONs, and DON were responsible for ensuring psychotropic consent forms were obtained prior to administering the medications. ADON V stated when a resident was admitted to the facility, the ADONs or DON would have filled out a consent form and printed it off in advanced. ADON V stated the nurses were responsible for ensuring the printed consent form was signed. ADON V stated a consent from should have been obtained for Resident #2's Belsomra, Remeron, and alprazolam. ADON V stated the consent forms were missing because of a probable oversight. ADON V stated it was important to ensure consent forms were completed prior to administering medications so that resident's and their family were aware of the medication, side effects, risks, and benefits. ADON V stated it was important so the residents could have made an informed decision. During an interview on 09/27/2023 at 8:35 PM, the DON stated the ADONs, and the DON was responsible for ensuring psychotropic consent forms were completed. The DON stated part of the admission process was reviewing the medication list for psychotropic medications. The DON said the consent forms were filled out in advanced and printed off to be signed by the admitting nurse. The DON stated Resident #2 was missing consent because it was an oversight. The DON stated the consent forms for Resident #2 were being completed since she was made aware. The DON stated it was important to ensure psychotropic consent forms were obtained prior to administering the medications so the resident was aware of the medication, side effects, risks, and benefits. The DON stated it was important so the residents could have made an informed decision. During an interview on 09/27/2023 at 9:07 PM, the Administrator stated he expected psychotropic consent forms to be obtained prior to administering psychotropic medications. The Administrator stated nursing management was responsible for monitoring psychotropic consent forms. The Administrator stated it was important to ensure psychotropic consent forms were obtained prior to administering the medications to ensure the residents were informed of the risks and benefits and provided informed consent. 2. Record review of Resident #33's face sheet, dated 09/27/2023, indicated Resident #33 was an [AGE] year-old male, admitted to the facility on [DATE] with diagnoses which included Parkinson's (brain disorder that causes unintended or uncontrollable movements) and anxiety disorder. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676294 If continuation sheet Page 4 of 50 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 09/27/2023 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 0552 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of the order summary report dated 09/27/2023 indicated Resident #33 had an order for Ativan (antianxiety) with a start date 09/16/2023. Record review of the significant change in status MDS assessment, dated 08/28/2023, indicated Resident #33 made himself understood and usually understood others. The assessment indicated Resident #33 had a BIMS of 2, which indicated his cognition was severely impaired. The assessment indicated Resident #33 had trouble concentration on things, such as reading the newspaper or watching television 2-6 days during the 14-day look-back period. The assessment indicated Resident #33 had no behaviors or refusal of care. The assessment did not indicate Resident #33 received an antianxiety medication during the look-back period. Record review of the comprehensive care plan, revised on 03/05/2023, indicated Resident #33 used psychotropic medications related to depression and generalized anxiety disorder. The care plan interventions included review GDR as needed, administer medications as ordered and monitor and document for side effects effectiveness. Record review of the MAR dated 09/01/2023-09/30/2023 indicated Resident #33 received Ativan on 09/17/2023, 09/20/2023, 09/21/2023 and 09/25/2023. Record review of the facility's electronic charting system on 09/27/2023 did not reveal a consent form signed by the resident or resident representative signature. During an observation and interview on 09/25/2023 at 2:29 p.m., Resident #33 was sitting in his wheelchair watching television, no s/sx of anxiety observed or adverse effects. Resident #33 was non-interview able as evidenced by confused conversation. During a telephone interview on 09/27/2023 at 5:56 p.m., Resident #33's family member stated she received a phone call on 09/27/2023 indicating Resident #33 received Ativan for anxiety. Resident #33's family member stated she was explained the risk and benefits of the medication. During an interview on 09/27/2023 at 4:38 p.m., the DON stated her and the ADON's were responsible for ensuring consent forms were signed prior to administering, such as antianxiety. The DON stated a consent form should have been obtained for Resident #33's Ativan. The DON stated she was unsure why the consent was not obtained. The DON stated her and the ADON were responsible for monitoring to ensure the consent forms were kept up to date. The DON stated it was important to ensure consent forms were obtained to make sure the family and residents were aware of the medication, side effects and to ensure their rights were respected. During an interview on 09/27/2023 at 8:54 p.m., the Administrator stated he expected consents to be signed prior to administration. The Administrator stated it was important to ensure consent forms were obtained to make sure the family and residents were aware of the medication, side effects and to ensure their rights were respected. Record review of the facility's policy titled Antipsychotic Medication last reviewed on 02/10/2020, indicated, It is the facility's policy that each resident's drug regimen is free from unnecessary drugs, including unnecessary antipsychotic drugs 12. Consents will be obtained as per state guidelines . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676294 If continuation sheet Page 5 of 50 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 09/27/2023 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 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure the residents' rights to formulate an advance directive for 2 of 18 residents reviewed for advanced directives. (Resident #10 and Resident # 73) The facility failed to ensure Resident #10 and Resident # 73's code status was accurate and consistent with all records at the facility. This failure placed the residents at risk of not having their end of life wishes honored. Findings included: Record review of Resident #10's face sheet dated 9/26/23, revealed Resident #10 was a [AGE] year-old female with a diagnose of vascular dementia (changes to memory, thinking, and behavior resulting from conditions that affect the blood vessels in the brain), atherosclerotic heart disease (the buildup of fats, cholesterol and other substances in and on the artery walls), hypertension (when the pressure in your blood vessels is too high (140/90 mmHg or higher), hypothyroidism (when the thyroid gland doesn't make enough thyroid hormones to meet your body's needs) osteoarthritis (degeneration of joint cartilage and the underlying bone) diverticulosis (a condition that occurs when small pouches, or sacs, form and push outward through weak spots in the wall of your colon) Record review of Resident #10's MDS dated [DATE] indicated Resident #10 was able to understand and was understood by others. The MDS indicated Resident #10 had a BIMS score of 15. The assessment indicated Resident #10 required limited assistance with bed mobility, dressing, toilet use and personal hygiene and was independent with transfers, walking, and eating. Record review of Resident #10's care plan dated 3/25/21 with an update of the care plan on 1/11/2022 indicated Resident #10 had requested a code status of do not resuscitate. The goal was her wishes regarding her code status will be maintained on an ongoing basis by the staff being informed of his code status, and to make changes to her code status at her request. Record review of Resident #10's physician order summary report, dated 9/22/23, indicated an active physician's order for code status: DNR with an order date 3/3/2021. Record review of Resident #10's OOH-DNR dated 1/12/2016 revealed missing signature of responsible party and missing signature of witnesses. Record review of Resident #73's face sheet dated 9/26/23, revealed Resident #73 was an [AGE] year-old male with a diagnose of chronic obstructive systolic and diastolic heart failure (In systolic heart failure, the heart muscle is weak, and the ventricle can't contract normally. With diastolic heart failure, the heart muscle is stiff, and the left ventricle can't relax normally), chronic obstructive pulmonary disease (a common lung disease causing restricted airflow and breathing problems), obstructive and reflux uropathy (a disorder of the urinary tract that occurs due to obstructed urinary flow and can be either structural or functional), atherosclerosis of the right leg (occurs due to narrowing of the arteries in the legs), gout (a disease in which defective metabolism of uric acid causes arthritis), gastroesophageal reflux disease (a common condition in which the stomach contents move up into the esophagus). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676294 If continuation sheet Page 6 of 50 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 09/27/2023 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 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of Resident #73's MDS dated [DATE], indicated Resident #73 was able to understand and was understood by others. The MDS indicated Resident #73 had a BIMS score of 15. The assessment indicated Resident #73 required assistance with bed mobility, dressing, toilet use and personal hygiene, transfers, walking, and eating. Record review of Resident #73's care plan dated 9/6/23, indicated Resident #73 had requested a code status of do not resuscitate. The goal was her wishes regarding her code status will be maintained on an ongoing basis by the staff being informed of his code status, and to make changes to her code status at her request. Record review of Resident #73's physician order summary report, dated 9/4/23, indicated an active physician's order for code status: DNR with an order date 10/11/22. Record review of the Resident #73's OOH-DNR dated 5/26/22, revealed missing date of witness. During an interview on 9/27/2023 at 5:13 PM, the Social Worker stated she was she was responsible for ensuring DNRs were accurately completed and documented. The Social Worker stated the DNR was missing a missing signature by the responsible party and witnesses. The Social Worker stated anytime the DNR was not completed it isn't legal. During an interview on 9/27/23 at 9:00 PM, the Administrator stated he expected DNRs to be filled out, including signatures and dates. The Administrator stated the Social Worker was ultimately responsible for ensuring the DNRs were completed fully. The Administrator stated ensuring the DNRs were completed was important to make sure the resident's and family wishes were honored. Record review of the facility's policy titled, Emergency Management: Identification Code Status dated 4/21/2015 revised 1/25/21 indicated, To establish a process for filling and posting patient information in the clinical record so that an accurate code status and advanced directives can be accessed quickly during an emergency FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676294 If continuation sheet Page 7 of 50 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 09/27/2023 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 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to consult with the resident's physician when there was a significant change in the resident's physical and mental status that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications for 2 of 20 (Residents #46 and #135) residents reviewed for notification of change of condition. 1. The facility did not ensure RN D notified the physician when Resident #46 fell on [DATE]. 2. The facility failed to notify and consult with the physician about the changes in Resident #135's fall. This failure could place residents at risk of a delay in treatment, and a worsening of their condition. Findings included: 1. Record review of Resident #46's face sheet, dated 09/27/2023, indicated Resident #46 was a [AGE] year-old male, originally admitted to the facility on [DATE] with diagnoses which included fracture of right femur (the bone of the thigh) and essential hypertension (high blood pressure). Record review of the Quarterly MDS assessment, dated 08/18/2023, indicated Resident #46 sometimes made himself understood, and usually understood others. The assessment indicated Resident #46 had a BIMS of 6, which indicated his cognition was severely impaired. The assessment indicated Resident #46 had 1 fall since admission /entry or reentry or the prior assessment. Record review of the comprehensive care plan, revised on 08/16/2021, indicated Resident #46 had a potential for fall related to poor balance, history of falls prior to admits, poor safety awareness and weakness. The care plan interventions included anticipate and meet the resident's needs, fall risk screening upon admission and quarterly to identify risk factors and floor mat. Record review of the incident report dated 08/04/2023 at 11:12 a.m., indicated Resident #46 was called to the room by a CNA. The report indicated Resident was on a pad on the floor bedside the bed. The report indicated no apparent injury, assisted Resident #46 to the recliner. Record review of the facility's electronic charting system, accessed on 09/27/2023, revealed there was no documentation of notification made to the physician. During an interview won 09/27/2023 at 3:13 p.m., RN D stated Resident #46 was found on the floor on the right side of the bed on the floor mat by his family member. RN D stated she completed a head-to-toe assessment with no injuries noted at that time. RN D stated she should have contacted the physician after the fall. RN D stated that day was so bad. RN D stated it just slipped my mind. RN D stated it was important notify the physician to ensure Resident #46 wellbeing and safety. During a telephone interview on 09/27/2023 at 3:33 p.m., Physician W stated he expected to be notified when Resident#46 had a fall. Physician W stated if he would have been notified, an x-ray to the pelvis would have been ordered. Physician W stated it was important to notify the physician so he (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676294 If continuation sheet Page 8 of 50 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 09/27/2023 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 0580 could rule out trauma and/or abuse. Level of Harm - Minimal harm or potential for actual harm During an interview on 09/27/2023 at 4:38 p.m., the DON stated she expected the physicians to be notified immediately after the fall. The DON stated RN D was responsible for notifying the physician when Resident #46 fell. The DON stated there was not a system prior to this incident but with this incident she had implemented an in-service/teaching on immediate notification of herself and the MD. The DON stated it was important to notify the physician for continuity of care. Residents Affected - Few During an interview on 09/27/2023 at 8:54 p.m., the Administrator stated he expected RN D to contact the MD immediately after Resident #46 had a fall. The Administrator stated it was important to notify the physician to see if he would like to order anything or send the resident out. 2. Record review of Resident #135's face sheet dated 05/25/23, indicated Resident #135 was a [AGE] year-old female with a diagnose of chronic obstructive systolic and diastolic heart failure (In systolic heart failure, the heart muscle is weak, and the ventricle can't contract normally. With diastolic heart failure, the heart muscle is stiff, and the left ventricle can't relax normally), orthostatic hypotension (a condition in which your blood pressure suddenly drops when you stand up from a seated or lying position), chronic kidney disease, stage 4 (kidneys are moderately or severely damaged and are not working as well as they should to filter waste from your blood), Left Bundle-Branch Block (occurs when something blocks or disrupts the electrical impulse that causes your heart to beat. ), Hypertensive retinopathy, bilateral (is an eye condition in which high blood pressure damages the layer of tissue at the back of your eyeball (retina)), nonrheumatic aortic (valve) stenosis (a narrowing of the aortic valve opening) Record review of Resident #135's MDS dated [DATE], indicated Resident #135 was able to understand and was understood by others. The MDS indicated Resident #135 had a BIMS score of 15. The assessment indicated Resident #135 required assistance with bed mobility, dressing, toilet use and personal hygiene, transfers, walking, and eating. Record review of Resident #135's care plan dated 04/20/23, indicated Resident #135. The interventions of the care plan were to anticipate and meet the resident's needs. Place frequently used items within reach. Place call light within reach and encourage the resident to use it for assistance as needed. Review information on past falls and attempt to determine cause of falls. Educate resident and family as to causes. Record review of Resident #135's progress notes dated 05/19/23, reveals Resident #135 was sent to the emergency room on5/18/23 for chest pain, shortness of breath but no documentation regarding a fall. During an interview on 09/26/23 at 2:35 p.m., LVN X stated she was called to the room where Resident #135 was sitting on the floor. LVN X stated she took Resident #135's vitals. LVN X stated the resident said she got up and missed her chair. LVN X stated she asked Resident #135 if she wanted to go to hospital and she said no. LVN X stated she reported the fall to someone in the office, but she didn't remember who. LVN X stated she always reports her stuff, but she didn't who it was I reported it to, but it wasn't a witnessed fall. LVN X stated she always contacts the family. LVN X stated the types of abuse are verbal, sexual, mental, physical, funds. LVN X stated the administrator was our abuse coordinator. During an interview on 09/27/23 at 2:00 p.m., CNA BB stated she didn't witness the fall. CNA BB (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676294 If continuation sheet Page 9 of 50 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 09/27/2023 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 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few stated she went into Resident #135's room and she was sitting on the floor. CNA stated she immediately went to get the nurse. CNA BB stated they got Resident #135 up and back to her chair. CNA BB stated the nurse assessed her from head to toe. CNA BB stated Resident #135 had no complaints of pain. CNA BB stated Resident #135 said she was trying to get in chair and didn't make it. CNA BB stated she reported to LVN X. CNA BB stated the types of abuse are physical, mental, misappropriation of funds, sexual and verbal. CNA BB stated she reports abuse to the administrator. During an interview on 9/27/23 at 4:57 p.m., the DON stated Resident #135 started complaining of chest pain. The DON stated the CNA came in her office saying Resident #135 had chest pain. The DON stated she went to assess Resident #135. The DON stated she grabbed a nurse doesn't remember who the nurse was. The DON stated after assessing she made the decision to call EMS and sent her out to the hospital. The DON stated the family was then notified. The DON stated when Resident #135 got to the emergency room she had a spinal fracture. The DON stated she immediately started the investigation. The DON stated she spoke with Resident #135's niece because Resident 135's nephew was out of town. The DON stated she started interviewing people on 5/18/2023 reinterviewed on 5/22/2023 and 5/23/2023. The DON stated CNA BB told her that she was walking by and saw Resident #135 sitting on the floor. The DON stated that CNA BB asked Resident #135 if she fell, and Resident #135 said she didn't fall. The DON stated CNA BB went and got LVN X, they assessed Resident #135 and helped her to her recliner. The DON stated Resident #135 denied fall. The DON stated from what she concluded Resident #135 fell but she doesn't know the exact date. The DON stated the fall was prior to 5/18/23. The DON stated the current administrator is the abuse coordinator. The DON stated the types of abuse physical, neglect, sexual, psychosocial and misappropriation of funds. Record review of the facility's policy titled Fall Management System revised on 01/03/2017, indicated It is the policy of this facility that each resident will be assessed to determine his/her risk for falls, and a plan of care implemented based on the resident's assessed needs D. Documentation requirements for residents sustaining a fall . 2. The licensed nurse will document the fall on the nurses notes of the medical record. The documentation will reflect notifications lo legal representatives and attending physician or their agent of the fall . Record review of the facility's policy titled Notification of Changes reviewed on 02/10/21, indicated To provide guidance on when to communicate acute changes in status to MD, NP, and/ responsible party. The facility will immediately inform the resident; consult with the resident's physician; and if known, notify the resident's legal representative or appropriate family member(s) of the following: 1. An accident resulting in injury to the resident that potentially requires physician intervention FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676294 If continuation sheet Page 10 of 50 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 09/27/2023 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 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm Based on interviews and record review, the facility failed to implement written policies and procedures to prohibit and prevent abuse, neglect, and exploitation for 3 of 20 staff members (Physical Therapist, House Keeping and Food Service Supervisor) reviewed for develop and implement abuse policies. Residents Affected - Few The facility failed to ensure the Human Resource (HR) Coordinator implemented the facility's abuse/neglect policy and procedure when she failed to complete an Employee Misconduct Registry (EMR) check for CNA G upon hire and annually for the Maintenance Supervisor, Activity Director, and Food Service Supervisor. This failure could place residents at risk for abuse, neglect, exploitation, and misappropriation of property. Findings included: Record review of the facility's Abuse, Neglect and Exploitation policy revised on 10/24/2022, indicated . It is the police of this facility to provide protection for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property . Screening: Criminal History and Background checks . 2. All potential employees will be screened for history of abuse, neglect or mistreating of elderly/individuals as defined by the applicable requirements 483.12 (c) (1) (ii) (A) and (B). The facility will not knowingly employee individual with convictions barring employment as noted in section 250.006 of the Texas Health and Safety Code . 4. The facility will obtain verification from appropriate licensing boards and registries and maintain verification of results . 7. Employee will be screened for abuse, neglect, and exploitation of the elderly by accessing the Employee Misconduct Registry. The hiring authority will follow the automated response prompts to screen the employee for abuse, neglect, exploitation of a resident or misappropriation of resident's or consumer's misconduct registry checks on every employee . The policy did not indicate how often the EMR should be checked. Record review of Physical Therapist personnel file on 09/27/23, Indicated he was hired on 5/8/23. Physical Therapist employee misconduct registry was not completed upon hire. Physical Therapist EMR was completed on 05/15/23. Record review of House Keeping Supervisor's personnel file on 09/27/23, Indicated he was hired on 03/30/21. House Keeping Supervisor's employee misconduct registry was not completed upon hire. House Keeping Supervisor's EMR was completed on 7/20/22. During an interview with the Payroll Coordinator on 9/27/23 at 7:22 PM. The Payroll Coordinator stated employee misconduct registry should be ran monthly. The Payroll Coordinator stated the Physical Therapist was a rehire. The Payroll Coordinator stated the Physical Therapist has been employed here (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676294 If continuation sheet Page 11 of 50 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 09/27/2023 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 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few before. The Payroll Coordinator stated the Physical Therapist employee misconduct registry should have been done prior to his hire date but he didn't sign the new hire paperwork so she could run it. The Payroll Coordinator stated the Food Service Supervisor, and the House Keeping Supervisor's employee misconduct registry should be run annually within their hire month, The Payroll Coordinator stated she was responsible for the employee misconduct registry. The Payroll Coordinator stated she has a list of all the employees. The Payroll Coordinator stated the employee misconduct registry was supposed to be done upon hirer and annually in their hire month. The Payroll Coordinator stated she goes down the employee sheet monthly, and during evaluation she run the employee misconduct registry again. The Payroll Coordinator stated she didn't realize she was supposed to run the Food Service Supervisor and the House Keeping Supervisor employee misconduct registry. The Payroll Coordinator stated its important to make sure the employees are not on the employee misconduct registry, because it could put the residents at risk for abuse. During an interview on 09/27/23 at 9:00 PM, the Administrator stated the Payroll Coordinator was responsible for ensuring the employee misconduct registry was checked upon hire and annually. The Administrator stated it was important to check the employee misconduct registry because the employee could be on there for abuse. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676294 If continuation sheet Page 12 of 50 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 09/27/2023 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 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility failed to ensure assessments accurately reflected the resident status for 2 of 20 residents (Resident #34 and Resident #42) reviewed for MDS assessment accuracy. Residents Affected - Few The facility did not ensure Resident #34's and Resident #42's MDS assessments were accurately coded to reflect their level II PASRR (Preadmission Screening and Resident Review) status for mental illness. This failure could place residents at risk for not receiving care and services to meet their needs. Findings included: 1. Record review of a face sheet dated 09/27/2023, indicated Resident #34 was an [AGE] year-old female initially admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses which included major depressive disorder (a serious mood disorder involving one or more episodes of intense psychological depression or loss of interest or pleasure that lasts two or more weeks with hallucinations or delusions), recurrent, severe with psychotic symptoms, anxiety disorder, unspecified (mental illness defined by feelings of uneasiness, worry and fear), and unspecified atrial fibrillation (rapid, irregular heart rate). Record review of the Comprehensive MDS assessment, dated 11/25/2022, indicated Resident #34 was not considered by the state level II PASRR process to have serious mental illness. Record review of Resident #34's care plan, last revised 08/08/2023, did not address Resident #34's PASRR status. Record review of the Level II PASSR evaluation, dated 08/23/2021, indicated Resident #34 met the PASRR definition of mental illness. 2. Record review of a face sheet dated 09/27/2023, indicated Resident #42 was a [AGE] year-old female initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses which included bipolar disorder, in partial remission, most recent episode depressed (a disorder associated with episodes of mood swings ranging from depression lows to manic highs), major depressive disorder, recurrent, unspecified (a serious mood disorder involving one or more episodes of intense psychological depression or loss of interest or pleasure that lasts two or more weeks) , and generalized anxiety disorder (severe, ongoing anxiety that interferes with daily activities). Record review of the Comprehensive MDS assessment, dated 06/21/2023, indicated Resident #42 was not considered by the state level II PASRR process to have serious mental illness. Record review of the care plan, initiated on 07/20/2022, indicated Resident #42 was deemed PASRR positive by the PASRR Evaluation related to a history of a mental illness, bipolar disorder. Record review of the Level II PASSR evaluation, dated 07/13/2022, indicated Resident #42 met the PASRR definition of mental illness. During an interview on 09/27/2023 at 4:03 PM, MDS Coordinator A said MDS Coordinator B and herself (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676294 If continuation sheet Page 13 of 50 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 09/27/2023 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 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few were responsible for completing the MDS assessments. MDS Coordinator A said Resident #34's and Resident #42's positive PASRR status should have been coded on the MDS assessment. MDS Coordinator A said it was not coded accurately because it was missed. MDS Coordinator A said corporate monitored the MDS assessments randomly for accuracy, but she was unaware of how often they did the random checks. MDS Coordinator A said it was important for the MDS assessments to be coded accurately because the MDS assessments painted a clear picture of the residents and for the staff to know how to care for the residents. During an interview on 09/27/2023 4:22 PM, MDS Coordinator B said MDS Coordinator A and herself were responsible for completing the MDS assessments. MDS Coordinator B said when she signed an MDS completed she did not review the MDS prior to signing it. MDS Coordinator B said she had not noticed that Resident #34's and Resident #42's PASRR positive status was not coded on the MDS assessment. MDS Coordinator B said corporate performed random audits on the MDS assessments to check them for accuracy. MDS Coordinator B said it was important for the MDS assessments to be completed accurately for reimbursement and financial reasons, and to ensure the residents receive the care they need. During an interview on 09/27/2023 at 4:58 PM, the Administrator said he expected the MDS assessments to be completed accurately. The Administrator said the MDS Coordinators were responsible for completing the MDS assessments and ensuring they were completed accurately. The Administrator said it was important for the MDS assessments to be completed accurately to make sure everything was captured for each resident because that directed the level of care and payment received for each resident, and because it was part of the regulation. Record review of the facility's policy revised 10/24/2022, titled, MDS Accuracy Guidelines, indicated, Purpose The purpose of the MDS guideline is to ensure each resident receives an accurate assessment by qualified staff that are familiar with his/her physical, mental, and psychosocial well-being in order to identify the specific needs of the resident in accordance with the RAI Manual . The assessment must accurately reflect the resident's status . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676294 If continuation sheet Page 14 of 50 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 09/27/2023 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, and record review, the facility failed to develop or implement a comprehensive person-centered care plan to meet resident's medical, nursing, mental and psychosocial needs identified in the comprehensive assessment for 3 of 20 residents reviewed for care plans. (Resident #25, #34, and #60) 1. The facility failed to care plan Resident #25's refusal of showers. 2. The facility failed to care plan that Resident #34 was PASRR (Preadmission Sceening and Resdient Review) positive. 3. The facility failed to care plan Resident #60's cracked teeth. These failures could place residents at risk for inaccurate care plans and decreased quality of care. The findings included: 1. Record review of the face sheet, dated 09/27/2023, revealed Resident #25 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of unspecified dementia, without behavioral disturbance (group of symptoms that affects memory, thinking and interferes with daily life), essential (primary) hypertension (high blood pressure), and chronic atrial fibrillation (disease of the heart characterized by irregular and often faster heartbeat). Record review of the MDS assessment, dated 07/29/2023, revealed Resident #25 had clear speech was understood by staff. The MDS revealed Resident #25 was able to understand others. The MDS revealed Resident #25 had a BIMS of 14, which indicated she was cognitively intact. The MDS revealed Resident #25 had no behaviors or refusal of care during the 7-day look-back period. The MDS revealed Resident #25 required limited, one-person assistance with bathing. The MDS revealed Resident #25 required supervision or touching assistance with showering. Record review of Resident #25's comprehensive care plan, last revised on 07/26/2023, did not address her refusal of care during showers. Record review of the shower sheets for July 2023, August 2023, and September 2023, revealed Resident #25 refused her shower on the following dates: 07/17/2023, 07/21/2023, 08/07/2023, 08/18/2023, and 08/28/2023. During an interview on 09/25/2023 at 10:27 AM, Resident #25 was sitting up in her recliner. Resident #25 had clean hair and nails. Resident #25 had clean clothes and was free of odors. Resident #25 stated she did not always get her showers when they were scheduled. Resident #25 stated she received her scheduled shower that morning. During an interview on 09/27/2023 at 6:31 PM, CNA T stated Resident #25 refused her showers sometimes. CNA T stated if a resident refused their shower, she was supposed to let the nurses know. CNA T stated the nurses were supposed to have charted if a resident refused a shower. CNA T stated it also was documented on the shower sheet and placed in the shower book. CNA T stated she was able to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676294 If continuation sheet Page 15 of 50 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 09/27/2023 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 0656 Level of Harm - Minimal harm or potential for actual harm access the [NAME] (simplified and pertinent information in the electronic charting system that is generated from care plan interventions), which revealed residents who refused care. CNA T was unsure if Resident #25's [NAME] indicated a refusal of showers. CNA T stated it was important to ensure refusal of showers was included on the care plan to come up with other ways and interventions for residents who refused showers. Residents Affected - Some During an interview on 09/27/2023 at 7:28 PM, RN R stated nursing management was responsible for ensuring the care plan was updated. RN R stated she was made aware Resident #25 refused her showers by staff. RN R stated refusal of care or showers should have been included on the care plan. RN R stated it was important to ensure refusal of care and showers was included on the care plan, so the residents were not forced to take showers against their rights. RN R stated it was important to include refusal of shower on the care plan to make sure everyone was on the same page. During an interview on 09/27/2023 at 7:46 PM, ADON V stated Resident #25 did refuse to take her showers sometimes. ADON V stated she found out Resident #25 refused her showers today as she was going through the shower book. ADON V stated refusal of care and showers should have been included on the care plan. ADON V stated the ADON, and DON were responsible for ensure the care plan was updated. ADON V stated Resident #25's refusal of care or showers might have been missed because it was not reported to the management staff. ADON V stated CNAs should write refusal of showers on the shower sheet and report it to the charge nurse. ADON V stated the charge nurse should have talked to the resident, and then call the family and doctor with the reason. ADON V stated she expected the nursing staff to communicate continued refusal of care or showers to the management staff, so it was addressed. ADON V stated it was important to ensure refusal of care was included on the care plan for continuity of care. During an interview on 09/27/2023 at 8:35 PM, the DON stated care plans were completed and updated with an IDT approach. The DON stated refusal of care or showers should have been included on the care plan. The DON stated she was unaware Resident #25 refused her showers. The DON stated Resident #25's refusal of showers should have been reported to nurse management so it could have been addressed and included in the care plan. The DON stated it was important to ensure refusal of care or showers was included on the care plan to ensure continuity of care. During an interview on 09/27/2023 at 9:07 PM, the Administrator stated he expected refusal of care to be included on the care plan. The Administrator stated the IDT was responsible for monitoring to ensure the care plan was updated. The Administrator stated it was important to ensure refusal of care and showers was included on the care plan to ensure staff was aware of the residents wishes and normal status. The Administrator stated it was also important for the continuity of care. 2. Record review of a face sheet dated 09/27/2023, indicated Resident #34 was an [AGE] year-old female initially admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses which included major depressive disorder (a serious mood disorder involving one or more episodes of intense psychological depression or loss of interest or pleasure that lasts two or more weeks with hallucinations or delusions), recurrent, severe with psychotic symptoms, anxiety disorder, unspecified (mental illness defined by feelings of uneasiness, worry and fear), and unspecified atrial fibrillation (rapid, irregular heart rate). Record review of the Comprehensive MDS assessment, dated 11/25/2022, indicated Resident #34 was not considered by the state level II PASRR process to have serious mental illness. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676294 If continuation sheet Page 16 of 50 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 09/27/2023 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 0656 Level of Harm - Minimal harm or potential for actual harm Record review of the Level II PASSR evaluation, dated 08/23/2021, indicated Resident #34 met the PASRR definition of mental illness. Record review of Resident #34's care plan, last revised 08/08/2023, did not address Resident #34's PASRR status. Residents Affected - Some 3. Record review of a face sheet dated 09/27/2023 indicated Resident #60 was a [AGE] year-old male initially admitted to the facility on [DATE], readmitted on [DATE], with diagnoses which included hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left non-dominant side (weakness of the left side of the body caused by decreased circulation to the brain), heart failure, unspecified (chronic, progressive condition in which the heart muscle is unable to pump enough blood to meet the body's needs for blood and oxygen), and unspecified atrial fibrillation (rapid, irregular heart rate). Record review of the Quarterly MDS assessment dated [DATE], indicated Resident #60 understood others and was able to make herself understood. The MDS assessment indicated Resident #60 had a BIMS score of 15, which indicated his cognition was intact. The MDS assessment indicated Resident #60 was independent for bed mobility, transfers, dressing, toilet use, personal hygiene, and supervision for eating. The MDS assessment indicated The MDS assessment indicated Resident #60 had not had any weight loss. The MDS assessment indicated Resident #60 did not have mouth or facial pain, discomfort or difficulty chewing. Record review of the Order Summary Report dated 03/01/2023-09/30/2023, indicated Resident #60 had an order for Cleocin (antibiotic) 300 mg by mouth three times a day for a tooth infection for 7 days with a start date of 04/22/2023 and an end date of 04/29/2023. Record review of the care plan date initiated 09/14/2023 did not indicate Resident #60 had a cracked tooth and required oral surgery to remove the tooth. Record review of the progress notes indicated: 05/14/2023 6:17 PM, RN D indicated, Dentist here and unable to extract teeth due blood thinners. 07/23/2023 9:19 PM, LVN E indicated she had notified the doctor around 7:00 PM that Resident #60 was scheduled for a tooth extraction on Wednesday, and he instructed not to stop the residents blood thinners. 09/07/2023 9:54 AM, the Social Worker indicated Resident #60, and his mother had been questioning why his tooth had not been pulled. The Social Worker indicated she had contacted the dentist and the dental office said they were waiting on medical clearance from the facility doctor and heart doctor. The Social Worker indicated the dentist office called her back and informed her Resident #60 had called them last week and requested a refund so unless he called them back to keep the money, they could not continue services. The Social Worker indicated she would follow up with the resident and see what he wanted to do about getting the tooth pulled. The Social Worker indicated she had contacted the mobile dentist company advisor and he had instructed her to try to get releases from Resident #60's doctors and send them to him, so he could have the mobile dentist company pay the local dentist office. The Social Worker indicated she would do this, so she could try to get the resident's money back to his mother. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676294 If continuation sheet Page 17 of 50 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 09/27/2023 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of a History and Physical performed by the mobile dental company dentist dated 05/14/2023 indicated an evaluation was done due to pain on the lower left side and an infection. Resident #60 had broken teeth on the lower right and upper right and required extraction of the teeth. The History and Physical indicated Resident #60 was on blood thinners and the Medical Director had not taken him off of them and did not want to take him off of them. The History and Physical indicated Resident #60 was at high risk for bleeding and she recommended the extraction be performed at an oral surgeon. During an interview on 09/25/2023 at 4:01 PM, Resident #60 said the tooth on his bottom left side was cracked, and it had been infected. Resident #60 said when the tooth was infected, he had some pain but was managed with Tylenol. Resident #60 said the pain resolved after the antibiotics. Resident #60 said sometimes it was hard to eat on that side, but he used the other side to eat. Resident #60 denied any pain. Resident #60 said the cracked tooth was not disrupting his sleep. Resident #60 denied any weight loss. Resident #60 said he was told he would have to pay for the extraction of his tooth and was currently awaiting clearance from the heart doctor. Resident #60 said he had an appointment with the heart doctor at the beginning of October. During an interview on 09/27/2023 at 4:25 PM MDS Coordinator A said Resident #34's PASRR status and Resident #60's dental issues could have been put in the care plan by her or the IDT. MDS Coordinator A said these things were missed. MDS Coordinator A said Resident #60's cracked teeth should be in his care plan. MDS Coordinator A said it was important for this to be in the care plan to ensure all the staff were aware of this problem. MDS Coordinator A said Resident #34's PASRR status should have been included in the care plan. MDS Coordinator A said it was important for the care plans to include the residents needs to ensure all the staff knew how to care for the residents and they could see what interventions were in place and to give the CNAs information on how to care for the residents. During an interview on 09/27/2023 at 4:28 PM, MDS Coordinator B said she could have put in the care plan Resident #60's dental issues and Resident #34's PASRR status. MDS Coordinator B said somehow these got missed. MDS Coordinator B said she checked the care plans after the completion of the MDS assessments to ensure they were complete. MDS Coordinator B said she performed occasional, random audits on the care plans to see if anything was missing. MDS Coordinator B said it was important for the residents' care plans to include all of their needs and problems, so the IDT knows what is going on with the residents, and the care plan was a line of communication for the residents' needs. During an interview on 09/27/2023 at 5:41 PM, the DON said the IDT completed the care plan. The DON said the IDT should have care planned Resident #34's PASRR status and Resident #60's dental issues. The DON said it was important for the residents' care plans to include all their needs for continuity of care. During an interview on 09/27/23 4:57 PM, the Administrator said he expected for the residents' care plans to include all their needs and ongoing problems. The Administrator said the IDT and the MDS Coordinators were responsible for ensuring the care plans were complete. The Administrator said it was important for the residents' care plans to include all the residents needs so the residents were taken care of and could maintain their best quality of life. Record review of the Comprehensive Care Plans policy, implemented on 02/10/2021, revealed 3. The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676294 If continuation sheet Page 18 of 50 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 09/27/2023 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 0656 Level of Harm - Minimal harm or potential for actual harm well-being. B. Any services that would otherwise be furnished but are not provided due to the resident's exercise of his or her right to refuse treatment. C. Any specialized services or specialized rehabilitation services the nursing facility will provide as a result of PASARR recommendations . Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676294 If continuation sheet Page 19 of 50 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 09/27/2023 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 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 that residents requiring respiratory care were provided such care, consistent with professional standards of practices for 2 of 5 residents (Resident #17, #69) reviewed for respiratory care. Residents Affected - Few 1. The facility failed to ensure Resident #17's oxygen was set at 3 LPM as ordered by the physician. 2. The facility failed to ensure Resident #69 oxygen concentrator filters were cleaned. These failures could place residents who receive respiratory care at risk for developing respiratory complications and a decreased quality of care. The findings included: 1. Record review of the face sheet, dated 09/27/2023, revealed Resident #17 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of COPD (chronic inflammatory lung disease that causes obstructed airflow from the lungs) and shortness of breath. Record review of the MDS assessment, dated 09/27/2023, revealed Resident #17 had clear speech and was understood by staff. The MDS revealed Resident #17 was able to understand others. The MDS revealed Resident #17 had a BIMS of 15, which indicated she was cognitively intact. The MDS revealed Resident #17 had no refusal of care. The MDS revealed Resident #17 received oxygen while a resident at the facility during the 14-day look-back period. Record review of the comprehensive care plan, revised 10/19/2022, revealed Resident #17 used oxygen therapy routinely and was at risk for ineffective gas exchange. The interventions included: Administer oxygen therapy per physician's orders. Record review of the order summary report, dated 09/27/2023, revealed Resident #17 had an order, which started on 07/14/2023, for oxygen at 3 LPM via N/C. Record review of the MAR, dated September 2023, revealed Resident #17 wore oxygen daily. During an observation and interview on 09/25/2023 beginning at 11:24 AM, Resident #17's was wearing a nasal cannula and her oxygen concentrator was set at 2.5 LPM. Resident #17 stated the facility staff was responsible for adjusting her oxygen settings. Resident #17 stated she preferred her oxygen at 2.5 liters per minute because she did not like to hear the oxygen blowing. Resident #17 stated her oxygen was set at 3 LPM a couple of weeks ago and she made them adjust it. During an observation on 09/25/2023 at 4:32 PM, Resident #17 was wearing a nasal cannula and her oxygen concentrator was set at 2.5 LPM. During an observation on 09/26/2023 at 10:43 AM, Resident #17 was wearing a nasal cannula and her oxygen concentrator was set at 2.5 LPM. During an interview on 09/27/2023 at 7:28 PM, RN R stated oxygen should have been set at the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676294 If continuation sheet Page 20 of 50 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 09/27/2023 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 0695 Level of Harm - Minimal harm or potential for actual harm correct LPM. RN R stated a new physician order should have been obtained if a resident preferred her oxygen at a different level than what was prescribed. RN R stated she personally had never looked at Resident #17's oxygen settings, she just obtained her oxygen level. RN R stated it was important to ensure the orders for oxygen settings were correct to reflect the correct care and services provided to the resident. RN R stated oxygen administered at a lower rate could have made Resident #17's oxygen level drop. Residents Affected - Few During an interview on 09/27/2023 at 8:35 PM, the DON stated the charge nurse was responsible for ensuring oxygen settings were set at the correct LPM. The DON stated it was monitored by nursing management through walking rounds and random observations. The DON stated the doctor should have been notified if Resident #17 preferred her oxygen set at lower rate. The DON stated it was important to ensure the physician orders were followed and oxygen was set at the correct LPM to ensure continuity of care. The DON stated oxygen administered at a lower rate could have made Resident #17's respiratory status decline. During an interview on 09/27/2023 at 9:07 PM, the Administrator stated he expected staff to ensure oxygen was set at the prescribed LPM. The Administrator stated he expected staff to notify the doctor if a resident preferred a lower rate of administration. The Administrator stated the charge nurse was responsible for ensuring the oxygen was set at the correct LPM. The Administrator stated it was important to ensure the physician orders were followed and oxygen was given at the prescribed rate to prevent respiratory distress. 2. Record review of Resident #69's face sheet, dated 09/27/2023, indicated Resident #69 was a [AGE] year-old male, originally admitted to the facility on [DATE] with diagnoses which included COPD (chronic inflammatory lung disease that causes obstructed airflow from the lungs), and dependence on supplemental oxygen. Record review of the order summary report dated 09/27/2023 indicated Resident #69 had an order for oxygen at 2 liters per minute via N/C with a start date 09/19/2023. Record review of the admission MDS assessment, dated 09/25/2023, indicated Resident #69 made himself understood and understood others. The assessment indicated Resident #69 had a BIMS score of 15, which indicated her cognition was intact. The assessment indicated Resident #69 was receiving oxygen therapy. Record review of the comprehensive care plan, revised on 09/19/2023, indicated Resident #69 used oxygen therapy routinely or as needed and was at risk for infective gas exchange related to COPD. The care plan interventions included oxygen at 2 liters per minute via N/C, monitor O2 saturation, and monitor for signs and symptoms or respiratory distress (a life-threating lung injury that allows fluid to leak into the lungs) and report to the physician as needed. During an observation and interview on 09/25/2023 at 10:40 a.m., Resident #69 was lying in bed watching tv. Resident #69 was wearing oxygen via nasal cannula at 3 liters per minute. Resident #69's oxygen concentrator filter had a thick grey, fuzzy material. Resident #69 stated he wore oxygen all the time because of COPD. During an observation on 09/26/2023 at 9:43 a.m., Resident #69 was lying in bed visiting with his spouse. Resident #69 was wearing oxygen via nasal cannula at 2 liters per minute. Resident #69's oxygen concentrator filter had a thick grey, fuzzy material. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676294 If continuation sheet Page 21 of 50 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 09/27/2023 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an observation on 09/27/2023 at 9:30 a.m., Resident #69 was lying in bed watching tv. Resident #69 was wearing oxygen via nasal cannula at 2 liters per minute. Resident #69's oxygen concentrator filter had a thick grey, fuzzy material. Record review of the MAR dated 09/01/2023-09/30/2023 indicated RN S cleaned or changed Resident #69's filter on 09/20/2023. An attempted telephone interview on 09/27/2023 at 4:17 p.m. with RN S, the RN that documented she changed or cleaned Resident #69's oxygen filter, was unsuccessful. During an interview on 09/27/2023 at 4:38 p.m., the DON stated she expected the oxygen filters to be changed or cleaned weekly on Wednesdays. The DON stated the 6pm-6am charge nurse was responsible for cleaning the filters. The DON stated rounds were done randomly to monitor oxygen filters. The DON stated the last wound was done on 9/20/23 prior to Resident #69 being readmitted to the facility. The DON stated if RN S documented that she completed the task she expected her to clean or change the oxygen filter. The DON stated the risk associated with not changing the filters could cause a respiratory infection. During an interview on 09/27/2023 at 8:54 p.m., the Administrator stated he expected filters to be cleaned/changed weekly and as needed. The Administrator stated if RN S documented that she completed the task he expected the task to be done. The Administrator stated the risk associated with not changing the filters could cause a respiratory infection. Record review of the facility's policy titled Oxygen Administration last reviewed on 01/05/2020, indicated, Procedure 1. Verify the physician order Concentrator 1. Clean filter weekly . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676294 If continuation sheet Page 22 of 50 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 09/27/2023 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure all drugs were stored in a locked compartment, only accessible by authorized personnel, and labeled and dated correctly for 2 of 2 nurses' carts (Nurse Cart Hall 1&4, and Nurse Cart Hall 2&3) reviewed for drugs and biologicals and storage of medications. The facility failed to ensure Nurse Cart Hall 1&4, and Nurse Cart Hall 2&3 were secured and unable to be accessed by unauthorized personnel. The facility failed to ensure 1 insulin pen (device used to administer insulin to residents with high blood sugars) on the Nurse Cart Hall 2&3 was dated when opened. These failures could place residents at risk of misuse of medications, drug diversions, and not receiving the therapeutic benefit of medications Findings included: During an observation and interview on [DATE] at 7:06 AM, LVN X left nurse cart unlocked while in resident room performing blood sugar check. LVN X stated the cart should be locked. LVN X stated she just forgot to lock the nurse cart. LVN X stated it was important to keep the cart lock to protect the residents. LVN X stated residents could overdose if they took medication from the cart. During an observation and interview on [DATE] at 4:10 PM, RN Z walked away from unlocked nurse cart to assist a resident. RN Z stated the cart should be locked. RN Z stated she was getting ready to go home when the resident needed her, and she forgot to lock the cart. RN Z stated it was important to lock the cart to keep residents and other employees from taking medications from the cart. RN Z stated the resident could be harmed if they ingested the medication. During an observation and interview on [DATE] at 1:18 PM, LVN AA was observed sitting down at the nurse's station talking to other staff members. The nurse cart was facing away from nurse's station unlocked. When LVN AA noticed surveyors looking at nurse cart, she jumped up, walked around nurses' station and she locked the cart. LVN AA stated she forgot to lock cart. LVN AA stated the cart should have been locked. LVN AA stated it was important to lock the cart, so the residents don't get into cart. LVN AA stated residents could be harmed if they took medication. During an observation on [DATE] at 9:45 AM, 1 insulin pens on nurse cart hall 2&3 were opened and not dated. LVN Y stated the pen should have open date. During an interview on [DATE] at 4:29 PM, LVN Y stated insulin pens should be dated after opened because they were only good for 28 days. LVN Y stated she opened the pen that morning, she grabbed it out of the refrigerator and hadn't had time to date. LVN Y stated the person that opened a medication was responsible for putting the open date on it. LVN Y stated it was important to put open date on the insulin pens because they were only supposed to be open for 28 days. LVN Y stated it was important to put an open date on the pen to ensure you're not using past the expiration date and the insulin was still good. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676294 If continuation sheet Page 23 of 50 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 09/27/2023 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on [DATE] at 8:45 PM, the DON stated she expected the staff to always lock the nurse carts. The DON stated audits are done of everything in the carts and she walks around to check carts daily. The DON stated if the cart was left unlocked the resident could be injured. The DON stated it was important to lock the carts for safety of the residents and visitors. The DON stated the nurse are responsible for ensuring the insulin pens are dated correctly. The DON stated it was important for the insulin pen to be labeled and dated so the nurse doesn't give expired medication or the wrong insulin. The DON state this could harm the resident if wrong dose or medication were given. During an interview on [DATE] at 9:00 PM, the Administrator stated he expected staff to lock the nurse carts. The Administrator stated it was important to lock the carts to ensure the safety of the drugs. The Administrated stated he expected the staff to label and date insulin pen. The administrator state it was important to label and dated insulin pens to ensure staff was not giving something that was expired. Record review of the facility's policy titled, Medication Storage dated [DATE], revealed, medication housed on premises will be stored dated and labeled according to manufacturer's recommendations. Medication must be under direct observation of the person administering medications or locked in medication storage area/cart. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676294 If continuation sheet Page 24 of 50 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 09/27/2023 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 0791 Provide or obtain dental services for each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to assist residents in obtaining routine dental services to meet the needs of 1 of 20 (Resident #60) residents reviewed for dental services. Residents Affected - Few The facility failed to ensure Resident #60 obtained prompt dental services when he had cracked teeth and a tooth infection. These failures could place residents at risk of not receiving needed dental care and a decreased quality of life. Findings included: Record review of a face sheet dated 09/27/2023 indicated Resident #60 was a [AGE] year-old male initially admitted to the facility on [DATE], readmitted on [DATE], with diagnoses which included hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left non-dominant side (weakness of the left side of the body caused by decreased circulation to the brain), heart failure, unspecified (chronic, progressive condition in which the heart muscle is unable to pump enough blood to meet the body's needs for blood and oxygen), and unspecified atrial fibrillation (rapid, irregular heart rate). The face sheet indicated Resident #60's primary payer was Medicaid. Record review of the Quarterly MDS assessment dated [DATE], indicated Resident #60 understood others and was able to make herself understood. The MDS assessment indicated Resident #60 had a BIMS score of 15, which indicated his cognition was intact. The MDS assessment indicated Resident #60 was independent for bed mobility, transfers, dressing, toilet use, personal hygiene, and supervision for eating. The MDS assessment indicated The MDS assessment indicated Resident #60 had not had any weight loss. The MDS assessment indicated Resident #60 did not have mouth or facial pain, discomfort or difficulty chewing. Record review of the Order Summary Report dated 03/01/2023-09/30/2023, indicated Resident #60 had an order for Cleocin (antibiotic) 300 mg by mouth three times a day for a tooth infection for 7 days with a start date of 04/22/2023 and an end date of 04/29/2023. Record review of the progress notes indicated: 05/14/2023 6:17 PM, RN D indicated, Dentist here and unable to extract teeth due blood thinners. 07/23/2023 9:19 PM, LVN E indicated she had notified the doctor around 7:00 PM that Resident #60 was scheduled for a tooth extraction on Wednesday, and he (the physician) instructed not to stop the residents blood thinners. 09/07/2023 9:54 AM, the Social Worker indicated Resident #60 and his mother had been questioning why his tooth had not been pulled. The Social Worker indicated she had contacted the dentist and the dental office said they were waiting on medical clearance from the facility doctor and heart doctor. The Social Worker indicated the dentist office called her back and informed her Resident #60 had called them last week and requested a refund so unless he called them back to keep the money, they could not continue services. The Social Worker indicated she would follow up with the resident and see what he wanted to do about getting the tooth pulled. The Social Worker indicated she had contacted (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676294 If continuation sheet Page 25 of 50 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 09/27/2023 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 0791 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the mobile dentist company advisor and he had instructed her to try to get releases from Resident #60's doctors and send them to him, so he could have the mobile dentist company pay the local dentist office. The Social Worker indicated she would do this, so she could try to get the resident's money back to his mother. Record review of a History and Physical performed by the mobile dental company dentist dated 05/14/2023 indicated an evaluation was done due to pain on the lower left side and an infection. Resident #60 had broken teeth on the lower right and upper right and required extraction of the teeth. The History and Physical indicated Resident #60 was on blood thinners and the Medical Director had not taken him off of them and did not want to take him off of them. The History and Physical indicated Resident #60 was at high risk for bleeding and she recommended the extraction be performed at an oral surgeon. Record review of the care plan date initiated 09/14/2023 did not indicate Resident #60 had a cracked tooth and required oral surgery to remove the tooth. During an interview on 09/25/2023 at 3:47 PM, Resident #60's mother said the facility did not offer to pay for Resident #60's dental procedures to be performed. Resident #60's mother said they were told by the Social Worker they would have to pay the dentist for his tooth to be extracted. Resident #60's mother said she did not remember when Resident #60 started having issues with his teeth. Resident #60 said they were waiting from clearance from the heart doctor so Resident #60 could have his tooth removed. During an interview on 09/25/2023 at 4:01 PM, Resident #60 said the tooth on his bottom left side was cracked, and it had been infected. Resident #60 said when the tooth was infected, he had some pain but was managed with Tylenol. Resident #60 said the pain resolved after the antibiotics. Resident #60 said sometimes it was hard to eat on that side, but he used the other side to eat. Resident #60 denied any pain. Resident #60 said the cracked tooth was not disrupting his sleep. Resident #60 denied any weight loss. Resident #60 said he was told he would have to pay for the extraction of his tooth and was currently awaiting clearance from the heart doctor. Resident #60 said he had an appointment with the heart doctor at the beginning of October. During an interview on 09/26/2023 at 2:15 PM, the Social Worker said she was responsible for referring the residents for dental services. The Social Worker said she was having a huge problem with the new mobile dental company that was seeing the residents. The Social Worker said she was having difficulty having them come to the facility to see the residents. The Social Worker said around April 2023 Resident #60 had to be treated with antibiotics for an abscessed tooth, and she had referred him to the mobile dental company. The Social Worker said she spoke with the previous Administrator regarding Resident #60's infection and need for the tooth to be extracted and he said because it was emergent the facility would pay for the tooth to be extracted. The Social Worker said Resident #60 was seen 05/14/2023 by the mobile dental company, and they were unable to extract his teeth because he was on blood thinners. The Social Worker said oral surgery was recommended from this visit. The Social Worker said she was having difficulty finding a local dentist office that would take his insurance. The Social Worker said Resident #60 was seen by the local dentist office on 07/26/2023 and was told he would need to get clearance from his heart doctor before they could do the oral surgery. The Social Worker said Resident #60 had an appointment with the heart doctor on 10/11/2023. During an interview on 09/27/2023 5:46 PM, the DON said for routine services the mobile dentist saw the residents periodically. The DON said for emergent dental services the residents should be taken (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676294 If continuation sheet Page 26 of 50 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 09/27/2023 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 0791 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few locally. The DON said an emergent dental service would be tooth pain, tooth infection, broken teeth. The DON said the Social Worker was responsible for referring the residents for dental services. The DON said Resident #60 had a tooth infection back in April 2023 and was seen by the mobile dentist on 05/14/2023. The DON said the mobile dentist would not do the extraction because Resident #60 was on blood thinners and recommended oral surgery for Resident #60. The DON said Resident #60 had an appointment at the local dentist office on 07/26/2023 and was told he needed clearance from the heart doctor to have the oral surgery. The DON said currently they were waiting for Resident #60 to go to the appointment with the heart doctor. The DON said it was important for the residents to receive dental services and emergent dental services because it was their right to be free of pain and for their overall health. During an interview on 09/27/2023 at 4:59 PM, the Administrator said the Social Worker was responsible for referring residents for dental care. The Administrator said if the residents required emergent dental care, they should be taken to a local dentist office for care. The Administrator said an example of an emergent situation would be if the resident had a tooth abscess or pain. The Administrator said it was important for the residents to receive prompt dental care because of the pain and it could cause weight loss. Record review of the facility's policy reviewed 05/02/2019, titled, Dental Services, indicated, Policy Statement The facility will assist residents in obtaining routine and emergency dental care that meets the person centered-care needs . Social Services/designee will arrange or obtain from an outside resource routine and emergency dental service to meet the needs of each resident . Provide assistance to residents who are eligible and wish to participate to apply for reimbursement of dental services as an incurred medical expense under the State plan as applicable . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676294 If continuation sheet Page 27 of 50 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 09/27/2023 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the meals served met the nutritional needs of residents for 1 of 1 meals (the lunch meal) reviewed for nutritional adequacy, as evidenced by: The facility served the residents on a pureed food consistency diet the wrong scoop size servings on the buttered broccoli florets for the noon time (lunch) meal on 9/26/23. This failure had the potential to affect all residents in the facility who required pureed food consistency by placing them at risk of not receiving adequate nutritive food value needed to promote/maintain health. Findings included: Record review of the facility diet and nourishment roster on 09/25/2023 indicated there were 8 residents in the facility on pureed food consistency diet. Record Review of the week 1 menu dated on 9/20/23, indicated the lunch meal (A) items included Fried Cod, Lemon Wedge, French Fries, [NAME] Slaw, Dinner roll, Margarine, Chocolate Brownie, whole milk, hot coffee or hot tea, tartar sauce lunch meal (B) ) hamburger patties with beef gravy, buttered broccoli florets, mashed potatoes, dinner roll, chocolate brownie; (Substitute) Chicken soup . Record Review of the facility extended menu on 9/26/23 indicated the pureed buttered broccoli florets were to be served with the 3ounce scoop size. During an Observation and interview on 926//2023 at 10:47a.m., [NAME] N in the facility only kitchen preparing to serve puree food on the lunch menu for 9/26/2023. [NAME] N was observed preparing Pureed food prior to serving puree foods for lunch on 9/26/23. After [NAME] N checked temperature for the puree food, [NAME] N proceeded to grab scoop inside the kitchen drawer, and she then placed each scoop inside the puree foods. When asked, How you know what scoop size to use per food item? [NAME] N replied, I just know, I checked the scoop size prior to preparing puree foods. During an Observation on 9/26/23 at 11:29 a.m., [NAME] N was informed by the Dietary manager to refer to the extended menu for checking the scoop sizes per servings. [NAME] N reviewed the extended menu to check scoop sizes per food item. [NAME] N informed the Dietary manager that she needed the 3- ounce scoop size to serve the buttered broccoli florets puree diet food. [NAME] N could not find the 3- ounce scoop size and proceeded to use the 2.5- ounce scoop to serve the pureed buttered broccoli florets. During observation and Interview on 9/26/23 beginning at 10:50a.m., the Dietary Manager stated the kitchen did not have 3-ounce scoops. The Dietary Manager stated she was made aware in August 2023 that no 3-ounce scoop sizes were available in the kitchen. The Dietary manager stated she informed the facility Regional Office and her supplier about her requests for 3-ounce scoops back in August of 2023. The Dietary Manager stated she did not an update regarding the status of her request for the 3-ounce scoops needed for the kitchen. During a phone Interview on 9/27/2022 at 3:07 p.m., [NAME] N stated she was responsible for making (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676294 If continuation sheet Page 28 of 50 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 09/27/2023 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some sure the correct scoop size was used prior to serving the residents on a pureed food consistency diet for lunch. [NAME] N stated she were not to use the same scoop size for all food items. [NAME] N stated she were to review the extended menu book that informed her of the scoop sizes required for each meal. [NAME] N stated that she did not have the correct 3-ounce scoop size for the buttered broccoli florets, so she used the 2.5-ounce scoop size. [NAME] N stated she was aware that the 2.5 scoop size was smaller than the 3-ounce scoop size. [NAME] N stated she had completed in services on scoop sizes and serving from the menus book but could not recall when in-services had been completed. [NAME] N stated it was important to serve with the correct scoop size to ensure the residents nutrition needs were met. During an Interview on 9/27/23 at 4:03 p.m., the Dietary Manager stated she and the cook were responsible for ensuring the correct portions sizes were served for every meal serving. The Dietary Manager stated the cook were to check the extended menu for the correct scoop size per food item. The Dietary Manager stated that she verbally trained the dietary staff on the extended menu but was not sure if she physically documented the in-services about scoop sizes. The Dietary Manager stated she observed the preparation and serving of meals every day. The Dietary Manager stated she did notice problems in the kitchen with the dietary staff not serving with the correct scoop sizes per food item. The Dietary Manager stated she would pick up each scoop size from the kitchen and show the dietary staff how to find the scoop sizes on the scoops. The Dietary Manager stated she would ask the dietary staff to direct her to the correct scoop per food items so that these issues could be addressed in the kitchen. The Dietary Manager stated she did expect the dietary staff to verify scoop sizes in the extended menu prior to serving each meal item. The Dietary Manager stated she was currently waiting on a reply from her vendor regarding the shipping status of the 3-ounce scoops. The Dietary Manager stated it was important to serve with the correct scoop size to ensure the residents get the right portion size for nutrition for their meals. During a second attempted phone interview on 9/27/23 at 6:30 p.m., the Dietician was unable to be reach by phone for an interview; voicemail was left for a return call and call not returned prior to exit. During a phone interview on 9/28/23 at 6:55 p.m., the Lead Dietician stated she only does the hiring for the facility dieticians. The lead Dietician stated the current Dietician had worked at the facility for a few months. The Lead Dietician stated the new Dietitian will start on October 1, 2023. During an interview on 9/28/23 at 4:43 p.m., the administrator stated that he was not aware of the kitchen needing 3-ounce scoops for meal servings. The Administrator stated he did expect the dietary staff to follow the facility policy. The Administrator stated that he was not aware of any in-services being completed in the kitchen. The Administrator it was important for the dietary staff to use the correct scoop sizes in the kitchen to prevent the residents from losing weight. Record review of facility's undated Pureed program policy indicated, When a variety of food is eaten the Pureed diet will provide the nutrients required to meet the current Recommended Dietary Allowances of the National Research Council. The Pureed diet provides similar calories and protein as the Regular diet. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676294 If continuation sheet Page 29 of 50 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 09/27/2023 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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. 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 provide food that was palatable, attractive and at a safe and appetizing temperature for 1 of 3 meals reviewed for palatability and temperature. Residents Affected - Some The facility failed to provide food that was palatable and appetizing temperature for 1 of 3 meal observed on 9/26/23 (lunch) meal. These failures could place residents at risk of decreased food intake, hunger, and unwanted weight loss. The findings included: During an interview on 09/25/23 at 9:45 AM, Resident #42 stated the food was usually cold and They act like they don't know how to cook. Resident #42 stated the Meat was bad, and sometimes she could not even cut it. During an interview on 09/25/23 at 9:59 AM, Resident #54 stated the food did not have any seasoning at all and that it was bland. During an interview on 09/25/23 at 10:16 AM, Resident #57 stated the food was not cold, but it was not warm enough. During an interview on 09/25/23 at 11:10 AM, Resident #60 stated the food was always cold. During an interview on 09/25/23 at 3:39 PM, Resident #15 stated the Meat was tough, the food did not have any flavor, and the food was cold most of the time. Record Review of the facility week 1 menu dated on 9/20/23, indicated the lunch meal (A) items included Fried Cod, Lemon Wedge, French Fries, [NAME] Slaw, Dinner roll, Margarine, Chocolate Brownie, whole milk, hot coffee or hot tea, tartar sauce lunch meal (B) ) hamburger patties with beef gravy, buttered broccoli florets, mashed potatoes, dinner roll, chocolate brownie; (Substitute) Chicken soup. During an observation on 9/26/23 at 11:21 a.m., observations of food temperatures were made on the steam table by [NAME] N. The results were as followed, regular Beef hamburger patties was 160°F; the regular mashed potatoes were 178°F; the pureed mashed potatoes was 150°F; the regular Fried Cod 152°F; the mechanical soft Fried Cod 166°F; french fries 199°F; the mechanically soft buttered broccoli florets was 202°F and the soup were 167°F. During an observation, interview and tasting from the Dietician Manager of the puree food diet for lunch meal served on 9/26/2023 at 11:38 a.m., the Dietician Manager was observed tasting the pureed mashed potatoes. The Dietician stated the pureed mashed potatoes were overly seasoned. The Dietician Manager was asked, Do you taste the food items prior to serving? The Dietary Manager stated she usually taste the foods prior to serving for each meal but forgot to taste the foods during survey observation from the surveyor. During an observation on 9/26/23 at 11:38 a.m., the Dinner roll was on the counter at the service (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676294 If continuation sheet Page 30 of 50 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 09/27/2023 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 0804 line at room temperature and not on any source of heating or cooling. No temperature was taken. Level of Harm - Minimal harm or potential for actual harm During an observation on 9/26/23 beginning at 12:35 p.m., the regular foods were sampled. The results of the test were as followed, the beef hamburger patties with beef gravy were not warm; the regular mashed potatoes needed more seasoning; the regular, buttered broccoli florets were bland, and the regular chocolate brownie had a good tasting consistency flavor. Residents Affected - Some During an interview on 9/27/23 at 3:07 p.m., [NAME] N stated she was responsible for making sure the food was palatable, attractive, and correct temperature prior to serving. [NAME] N stated she did not taste the food prior to serving lunch on 9/26/23. [NAME] N stated she stated she conducted temperature checks for hot food items but did not conduct temperature checks for cold food items because she did not know that she was required to do so. [NAME] N stated hot food temperatures should be 165 and above, and for cold foods, she could not remember the temperatures for serving cold food items. [NAME] N stated the reason why she did not taste the food items prior to serving lunch because she was nervous of being observed by surveyor. [NAME] N stated she had received food complaints in the past from a resident receiving burnt fried chicken in August of 2023. [NAME] N stated she fried the chicken in old cooking oil. [NAME] N stated she was made aware to change the cooking oil prior to cooking food items by the Dietary Manager. [NAME] N stated the Dietary Manager was made aware last month of the food complaint regarding the fried chicken being cooked in old cooking oil. [NAME] N stated the Dietary Manager verbally spoke with her about cooking in cooking oil. [NAME] N stated the food should be palatable, attractive and correct temperature so the resident will eat it. During an interview on 9/27/23 at 4:09 p.m., the Dietary Manager stated she and the cook were responsible for making sure the food was palatable, attractive and correct temperature prior to serving. The Dietary manager stated that she does taste the food prior to serving at every meal serving. The Dietary Manager stated she does expect food the taste good. The Dietary Manager stated she had received food complaints on yesterday about a resident not receiving what she had ordered. The Dietary Manager stated that the residents will be happier and feel at home if the food served was palatable, attractive, and cooked at a correct temperature. During a second attempted interview on 9/27/23 at 6:30 p.m., the Dietician was unable to reach by phone for an interview; voicemail was left for a return call and not returned prior to exit. During an interview on 9/27/23 at 4:43 p.m., the Administrator stated the Dietary Manager, and the cooks were responsible for ensuring the foods served were palatable, attractive, and correct temperature prior to serving. The Administrator stated he had heard of one complaint of burnt chicken. The Administrator stated he talked to the Dietary Manager about the burnt fried chicken and issue was corrected. The Administrator stated the Dietary Manager had spoken to the cook regarding the burnt fried chicken food compliant from a resident. The Administrator stated he randomly checked the tray line before the food was served to the residents. The Administrator stated nursing staff checked trays prior to the CNA's serving meal trays to the resident's rooms. The Administrator stated the food should be palatable, attractive, and at correct temperature prior to serving to prevent weight loss. Record review of the facility policy, titled, Menus and Nutritional Adequacy, revised Dated on 5/30/2012, indicated, Menus are planned to meet the average resident nutritional needs. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676294 If continuation sheet Page 31 of 50 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 09/27/2023 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 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure food was prepared in a form designed to meet individual needs for 2 of 9 residents (Resident #2 and Resident #25). 1. The facility failed to ensure Resident #2 received her health shake with her lunch meal as ordered by the physician. 2. The facility failed to ensure Resident #25 received a mechanical soft diet during the lunch meal as ordered by the physician. These failures could place residents with a therapeutic diet at risk for poor intake, weight loss, not meeting their nutritional needs and choking. The findings included: 1. Record review of the face sheet, dated 09/27/2023, revealed Resident #2 was an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of recurrent depressive disorders (episodes of depression after periods of time without symptoms), anxiety disorder (characterized by significant and uncontrollable feelings of anxiety and fear), and unspecified atrial fibrillation (disease of the heart characterized by irregular and often faster heartbeat). Record review of the MDS assessment, dated 06/30/2023, revealed Resident #2 had clear speech and was understood by staff. The MDS revealed Resident #2 was able to understand others. The MDS revealed Resident #2 had a BIMS of 5, which indicated severe cognitive impairment. The MDS revealed Resident #2 had no behaviors or refusal of care. The MDS revealed Resident #2 had no significant weight loss. Record review of the comprehensive care plan, revised on 07/14/2023, revealed Resident #2 was at nutritional risk. The interventions included: provide and serve diet as ordered. Record review of the order summary report, dated 09/26/2023, revealed Resident #2 had an order, which started on 06/06/2023, for Regular texture, thin liquids with mighty milk shake with meals and gravy to meat . Record review of the meal ticket for lunch, dated 09/25/2023, revealed Resident #2 should have been served a health shake. During an interview on 09/25/2023 at 9:36 AM, Resident #2 stated she had recently loss her appetite and was not eating well. Resident #2 stated she had some weight loss as well. Resident #2 stated staff was providing her with shakes during meals. Resident #2 stated she was also started on a medication to help with increasing her appetite. Resident #2 stated her appetite had not improved much. During an observation and interview on 09/25/2023 at 11:56 AM, Resident #2 was sitting up in her recliner with her meal tray placed on the bedside table located in front of her. Resident #2 did not have a health shake on her tray. Resident #2 stated the facility staff probably forgot about it. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676294 If continuation sheet Page 32 of 50 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 09/27/2023 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 0805 Level of Harm - Minimal harm or potential for actual harm 2. Record review of the face sheet, dated 09/27/2023, revealed Resident #25 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of unspecified dementia, without behavioral disturbance (group of symptoms that affects memory, thinking and interferes with daily life), essential (primary) hypertension (high blood pressure), and chronic atrial fibrillation (disease of the heart characterized by irregular and often faster heartbeat). Residents Affected - Few Record review of the MDS assessment, dated 07/29/2023, revealed Resident #25 had clear speech was understood by staff. The MDS revealed Resident #25 was able to understand others. The MDS revealed Resident #25 had a BIMS of 14, which indicated she was cognitively intact. The MDS revealed Resident #25 had no behaviors or refusal of care during the 7-day look-back period. The MDS revealed Resident #25 had no significant weight changes. Record review of Resident #25's comprehensive care plan, last revised on 07/27/2023, revealed she was at risk for weight loss. The interventions included serve diet and supplements per order. Record review of the order summary report, dated 09/27/2023, revealed Resident #25 had an order, which started on 07/17/2023, for Mechanical soft texture, thin liquids diet. Record review of the meal ticket for lunch, dated 09/25/2023, revealed Resident #25 should have been served ground backed chicken breast with chicken gravy and mashed potatoes. The meal ticket revealed Resident #25 was served a regular diet. During an interview on 09/25/2023 at 10:27 AM, Resident #25 stated she had her top teeth pulled and was having trouble chewing her food. Resident #25 stated the facility had not modified her diet texture and she had some weight loss. During an observation and interview on 09/25/2023 at 11:51 AM, Resident #25 was sitting up in her recliner with the lunch tray sitting on the bedside table located in front of her. Resident #25 had a regular tray that consisted of one flour tortilla with diced chicken fajita meat. Resident #25 also had a bowl with a salad. Resident #25 stated she unable to eat the meal as she was having trouble chewing it. Resident #25 stated she was going to fix her own lunch from items located in her personal refrigerator. Resident #25 stated the facility staff did not offer her a substitute. During an attempted telephone interview, on 09/27/2023 at 7:11 PM, to gather additional information, RN D did not answer the phone. A brief message was left, and the call was not returned upon exit of the facility. During an interview on 09/27/2023 at 7:46 PM, ADON V stated CNAs or nurses should have checked the meal ticket against the tray prior to entering the resident's room. ADON V stated if a meal ticket did not match the food on the tray, she expected staff to request the correct tray from the dietary staff. ADON V stated she expected the correct diet and all supplements to have been given. ADON V was unsure why Resident #2 did not receive her health shake. ADON V was unsure why Resident #25 received the incorrect diet texture. ADON V stated it was important to follow the physician orders regarding diet, so residents received the proper nutrition and did not choke. During an interview on 09/27/2023 at 8:06 PM, the DM stated it was her responsibility to ensure the meal tickets match the diet orders in the charting system. The DM stated the person putting the tray together was responsible for ensuring health shakes were included. The DM stated Resident #25's order was probably changed without a communication slip being given from the nursing department. The (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676294 If continuation sheet Page 33 of 50 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 09/27/2023 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 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few DM stated Resident #2's health shake was just overlooked. The DM stated it was important to ensure residents received the correct diet texture and supplements to prevent further weight loss or decline in nutritional status and to ensure residents did not choke. During an interview on 09/27/2023 at 8:35 PM, the DON stated she expected nursing staff to ensure the correct diet texture and supplements were served to the residents. The DON stated she was monitoring different meal services sporadically during the day. The DON stated the staff had improved during meal service and she felt they no longer required monitoring. The DON stated it was important to ensure residents were served the correct diet texture and supplements for their overall health and nutrition. The DON stated a resident could have choked or aspirated if they were served the incorrect diet texture. During an interview on 09/27/2023 at 9:07 PM, the Administrator stated he expected facility staff to ensure residents received the correct diet texture and supplements that were ordered by the physician. The Administrator stated the dietary staff was responsible for monitoring meal trays. The Administrator stated it was important to ensure residents received the correct diet texture and supplements to maintain nutritional status and prevent weight loss. Record review of the Diets, Nutrition and Hydration policy, revised August 2023, revealed Each meal will be provided according to physician orders . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676294 If continuation sheet Page 34 of 50 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 09/27/2023 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 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record reviews, the facility failed to ensure each resident received and the facility provided food that accommodates resident preferences 1 of 78 residents (Resident #29) reviewed for resident food preferences. The facility failed to ensure Resident #29 received her preferred meal choice. This failure placed residents at risk for not having their nutritional needs met and a decreased quality of life. Findings included: Record review of Resident #29 face sheet dated 9/26/2023 revealed resident was a [AGE] year-old female admitted to facility on 10/11/2021 had diagnosis of muscle weakness generalized (lack of muscle strength), dementia without behavioral disturbance (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life), type 2 diabetes mellitus without complications (chronic condition that affects the way the body processes blood sugar), iron deficiency anemia (a condition in which blood lacks adequate healthy red blood cells) hyperlipidemia (blood has too many lipids (or fats), unspecified constipation and essential hypertension (high blood pressure). Record review of Resident #29 MDS assessment dated [DATE] revealed Resident #29 had clear speech, made self-understood and was understood by others. The MDS Assessment indicated Resident #29 had a BIMS score of 8 which indicated resident #29 cognition was moderately impaired. The MDS Assessment indicated Resident #29 was assessed to have feelings of being feeling tired or having little energy 2-6 days during assessment period. The MDS assessment indicated Resident #29 was independent with eating and required setup help only. Record review of Resident #29 Comprehensive Care Plan initiated on 3/14/2023 and revised on 3/14/2023 indicated resident was on a Regular Diet. The Comprehensive Care Plan Indicated Resident #29 had nutritional and hydration risk related to diabetes, constipation and anemia. The Comprehensive Care Plan Intervention indicated staff were to provide, serve diet as ordered; Dietary Manager to discuss food preferences with resident or family upon admission and then as needed to meet resident's dietary needs; Registered Dietitian to evaluate and make diet/supplement change recommendations as needed and encourage the resident to follow dietary guidelines; explain the consequences of refusal and malnutrition risk factors. During observation on 9/25/23 at 11:53 a.m., lunch meal ticket for Resident #29 indicated Resident #29 was on a regular diet. Resident #29 did not receive milk for lunch as indicated on meal ticket. Resident #29 meal ticket for lunch indicated Resident #29 were to receive 1 tong each of chicken Fajitas, 1 teaspoon of chopped cilantro, half cup of shredded lettuce and diced tomato, 1 portion of flour tortilla, 1 portion of margarine, 1 portion of oatmeal raisin cookie, 8 fluid ounce of whole milk and 6 fluid ounces of hot coffee or hot tea. During an interview on 9/25/23 at 11:53 a.m., Resident #29 stated she had never received milk for lunch or supper. Resident #29 stated she did received milk every morning for breakfast. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676294 If continuation sheet Page 35 of 50 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 09/27/2023 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 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During Interview on 9/26/23 at 2:51 p.m., Resident #29 stated she preferred to receive milk for supper and not for lunch. Resident #29 stated she did not like to drink tea. Resident #29 stated she received tea and water on every lunch and supper serving. During an interview on 9/27/23 at 3:33 p.m., [NAME] Aide O stated she was responsible for ensuring the residents received their meal preferences as indicated on their meal tickets. [NAME] Aid O stated she was not aware of Resident #29 not receiving her milk for lunch on 9/25/23. [NAME] Aid O stated she was expected to make sure residents received his/her diet as ordered. [NAME] Aid O stated she was not aware of completing any in-services on serving meals as ordered. [NAME] Aid O stated it was important to ensure residents diets were being followed as directed to prevent weight loss. During an interview on 9/27/23 at 3:14 p.m., the Dietary Manager stated she and the dietary staff was responsible for ensuring the residents received their meal preferences as indicated on their meal tickets. The Dietary Manager stated she was aware of Resident #29 not receiving milk for lunch as indicated on her meal ticket. The Dietary Manager stated residents were required at least two beverages per meal serving. The Dietary Manager stated she was using a new tray card system. The Dietary Manager stated that she wasn't sure if the milk could be updated on the tray system because she needed more training on how to update the resident's preferences. The Dietary Manager stated she left notes on resident's meal tickets when documenting resident's meal preferences. The Dietary Manager stated she did expect her dietary staff to make sure the residents received his/her diet as ordered. The Dietary Manager stated she did not have documentation on staff in-services on serving meals as ordered. The Dietary Manager stated she did agree that her dietary staff should be reeducated on serving meals as ordered. The Dietary Manager stated it was important to ensure the resident were being served meals as ordered to ensure the residents were receiving the proper nutrition. During a second attempted interview on 9/27/23 at 6:30 p.m., the Dietician was unable to reach by phone for an interview; voicemail was left for a return call and not returned prior to exit. During an interview on 9/27/23 at 4:43 p.m., the Administrator stated he was not aware of Resident #29 not receiving her milk on 9/25/23 for lunch. The Administrator stated he did expect staff to ensure the residents were receiving his or her diet as ordered. The Administrator stated he was not aware of the dietary staff completing any in-services on serving meals as ordered. The Administrator stated it was important to ensure the residents were being served meals as ordered to ensure the resident did not have a decrease in nutrition intake and to prevent weight loss. Record Review of facility policy on Menus and Nutritional Adequacy with a revision date of 5/30/2012 indicated, The meal planning guide in the facility diet manual is used as the basis for menu planning. The Menus and Nutritional Adequacy policy indicated residents were to receive a minimum daily serving of 5 ounces of meat or equivalent, 2-3 servings of vegetables, 2 servings fruits, 5-6 servings of starches or grains and 2 servings of milk. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676294 If continuation sheet Page 36 of 50 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 09/27/2023 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in (1 of 1) kitchen reviewed for dietary services, in that: 1) The facility failed to label and date all food items. 2) Dietary staff failed to dispose of expired foods items. 3) Dietary Staff failed to store (1) dented can in a separate area. 4) Dietary Staff failed to effectively reseal, label and date frozen food items. 5) Dietary Staff failed to label and date beverage items in the dining room for resident use. These failures could place residents at risk for food contamination and foodborne illness. The findings included: During observations on 09/25/23 beginning at 9:26 am, the following observations were made in the kitchen walk-in freezer (1 of 1): -(1) pack of Pork Ribs had a prep date of 9/20/23 was missing the use by date. -(1) container of chicken breast had a prep date of 9/21/23 was missing the use by date. -(1) bag of french fries open and not sealed had a prep date of 9/14 and was missing the use by date. -(4) 6-pound bags of potatoes wedges had a prep date of 9/14/23 was missing a use by date. -(1) bag of cilantro open and not sealed was missing open and use by date. -(1) gallon of [NAME] salad dressing was received on 8/10/23, had an opened date of 9/6/23 and was missing the use by date. -(1) container of slice cheese was missing the use by date. -(1) gallon of thousand Island dressing had a received date of 11/5/22, was missing a use by date and open date. -(1) gallon of Teriyaki sauce had a received date of 3/9/22, open date of 9/1/22 and use by date of 9/3/23 (expired). During observations on 09/25/23 beginning at 10:00 a.m., the following observations were made in the kitchen dry storage (1 of 1 ): (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676294 If continuation sheet Page 37 of 50 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 09/27/2023 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 0812 Level of Harm - Minimal harm or potential for actual harm -(1) 6 quarts of food thicker in a container with a lid cover had a prep date 9/13/23 was missing the use by date. -(1) 8 quarts of bread crumps in a container with a lid cover had a prep date 9/14/23 was missing the use by date. Residents Affected - Many -(1) 8 quarts of graham cracker crumps in a container with a lid cover had a prep date 9/14/23 was missing the use by date. -(1) 2 quarts of bacon bits in a container with a lid cover had an open date 9/14/23 was missing the use by date. (1) 6.5-pounds of Sliced peaches in a can was dented and found in dry storage area with the undented cans. -(1) 4 ounce of Organic rubbed sage food seasoning was received on 8/1/23 was missing a use by date and open date. -(1) 3.5 ounce of Tarragon leave had no received date, use by date nor open date. -(1) 16 ounces of Paprika had a receive by date of 7/28/22, was missing the use date and open date. -(1) 16 ounces of Cayenne had a receive date of 10/29/18 was missing the use by date and open date. -(1) 16 ounces of Cumin had a receive date of 10/28/21 was missing the use by date and open date. -(1) 16 ounces of Mediterranean style ground oregano had a receive date of 7/30/23 was missing open and use by date. -(1) container of Corn meal in a bid had no receive date, use by date nor open date. -(1) 16 ounces of Ground nutmeg had a received date of 12/02/21, was missing the open date and had a use by date of 8/30/2023 (expired). During observations on 9/25/23 beginning at 11:28 a.m., the following observations were made in the facility dining room (1 of 1): - (1) pitcher of brewed sweet tea was missing a prep date and use by date. - (1) pitcher of brewed unsweet tea was missing prep date and use by date. During an interview on 9/27/23 at 3:07 p.m., [NAME] aide O stated the Dietary Manager was responsible for all activity in the kitchen. [NAME] Aide O stated the Dietary Manager was responsible for labeling and dating food items and discarding expired food item. [NAME] aide O stated she had not completed in-services on labeling and dating food items. [NAME] aid O stated she was expected to follow policies and procedures in the kitchen. [NAME] Aide O stated it was important to ensure all items were labeled, dated, frozen food items sealed, and expired items were disposed to prevent the residents from getting sick. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676294 If continuation sheet Page 38 of 50 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 09/27/2023 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many During an interview on 9/27/23 at 4:02 p.m., the Dietary Manager stated she was responsible for the overall activity in the kitchen. The Dietary Manager stated the entire team was responsible for labeling and dating food items in the kitchen. The Dietary Manager stated she labeled, dated, and discarded expired food items twice per week. The Dietary Manager stated she did expect staff to follow polices and procedure in the kitchen. The Dietary Manager stated she did expect food items in the kitchen to be labeled, dated, and expired items to be discarded. The Dietary Manager stated she did complete staff in-services on labeling and dating food items and would provide a copy of the in-services prior to exit. The Dietary Manager stated it was important to ensure expired items were discarded and food items were labeled and dated so the dietary staff could identify how long food items were to stay in the refrigerator or be discarded if expired and not served to residents. During an Interview on 9/27/23 at 7:00 p.m., the Dietary Manager later stated she did not have documentation to provide regarding in-services on labeling, dating, and discarding expired food items for the dietary staff. During a second attempted interview on 9/27/23 at 6:30 p.m., the Dietician was unable to reach by phone for an interview; voicemail was left for a return call and not returned prior to exit. During an interview on 9/27/23 at 4:43 p.m., the Administrator stated he was not aware of food items in the kitchen were not labeled and dated. The Administrator stated he was not aware of expired food items found in the kitchen. The Administrator stated he did conduct random observation rounds in the kitchen a few weeks after being hired in September of 2023. The Administrator stated the dietary staff were all responsible for ensuring all food items in the kitchen were labeled, dated, or discarded if expired. The Administrator stated he did expect staff to follow the kitchen policy and procedures. The Administrator stated he was not aware of any dietary staff in-services for labeling, dating, and discarding expired food items. The Administrator stated he did expect the dietary staff to expose of expired food items. The Administrator stated that it was important to ensure all food items in the kitchen were labeled, dated, and expired food items were discarded to prevent the dietary staff from serving anything that will be expired making the residents sick. Record review of the facility's policy titled Dry Food and Supplies Storage, revised 11/15/17 indicated, (7) All storage bags must also be properly sealed and labeled with the common name of the food; (9) All opened products must be resealed effectively and properly labeled, dated and rotated for use. This may require storage in an approved NSF container or food grade storage bag; (10) Use by, Best by, and Sell by, dates should routinely be checked to ensure that items which have expired are discarded appropriately and (11) Canned goods that have a compromised seal with be removed from service and stored in a separate area, until they are picked up by the distributer of discarded. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676294 If continuation sheet Page 39 of 50 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 09/27/2023 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 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician, and others participating in the provision of care for 3 of 3 resident (Residents #31,#44 and #51) reviewed for hospice services. The facility did not ensure Resident #31, #44 and #51's hospice records were a part of their records in the facility. This failure could place residents who receive hospice services at-risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care and communication of resident needs. Findings included: 1. Record review of Resident #31's face sheet, dated 09/27/2023, indicated Resident #31 was a [AGE] year-old female, originally admitted to the facility on [DATE] with diagnoses which included cancer of right breast. Record review of the order summary report dated 09/27/2023 indicated Resident #31 had an order to admit to hospice with an order date 09/07/2023. Record review of the significant change in status MDS assessment, dated 09/06/2023, indicated Resident #31 made herself understood and understood others. The assessment indicated Resident #31 had a BIMS score of 15, which indicated her cognition was intact. The assessment indicated Resident #31 had a life expectancy of less than 6 months and received hospice services. Record review of the comprehensive care plan, revised on 09/13/2023, indicated Resident #31 had a terminal illness and was receiving hospice or palliative care. The care plan interventions included coordinate with hospice to ensure the resident's spiritual, emotional, intellectual, physician and social needs were met. Record review of Resident #31's hospice binder, accessed on 09/27/2023 at 8:15 a.m. revealed no CTI or updated nurses, aides, and chaplain notes since the last IDT meeting. During an interview on 09/27/2023 at 10:17 a.m., the Administrator for the hospice company stated Resident #31 was admitted to hospice on 08/31/2023 for cancer of the right breast. The Administrator stated the last visit was on 09/25/2023. The Administrator stated the nurses were required to see her two times a week, aides three times a week and chaplain once a week. The Administrator stated she was unaware that the contract included the interdisciplinary notes would be brought in every 14 days because it's not a condition pf participation for hospice. The Administrator stated the process for coordinating with the facility was completed verbally and written with the nurses. 2. Record review of Resident #44's face sheet, dated 09/27/2023, indicated Resident #44 was a [AGE] year-old male, admitted on [DATE] with diagnoses which included cerebral infarction (stroke). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676294 If continuation sheet Page 40 of 50 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 09/27/2023 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 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of the summary report dated 09/27/2023 indicated Resident #44 had an order to admit to hospice with an order date 09/26/2023. Record review of the significant change in status MDS assessment, dated 09/21/2023, indicated Resident #44 rarely/never made herself understood or rarely/never understood others. The assessment did not address the BIMS score. The assessment indicated Resident #44 had a life expectancy of less than 6 months and received hospice services. Record review of the comprehensive care plan, revised on 09/26/2023, indicated Resident #44 had a terminal illness and was receiving hospice or palliative care. The care plan interventions included coordinate with hospice to ensure the resident's spiritual, emotional, intellectual, physician and social needs were met. Record review of Resident #44's hospice binder, accessed on 09/27/2023 at 8:30 a.m. revealed no CTI (certification for terminal illness) or updated nurses and aides notes since the last IDT meeting. During an interview on 09/27/2023 at 10:17 a.m., the Administrator for the hospice company stated Resident #44 was admitted to hospice on 09/14/2023 for CVA (stroke). The Administrator stated the last visit was on 09/25/2023. The Administrator stated the nurses were required to see her two times a week, aides three times a week and chaplain once a week. The Administrator stated sometimes it take a minute before the CTI was placed in the chart due to the MD dictation was delayed. The Administrator stated she was unaware that the contract included the interdisciplinary notes would be brought in every 14 days because it's not a condition pf participation for hospice. The Administrator stated the process for coordinating with the facility was completed verbally and written with the nurses. 3. Record review of Resident #51's face sheet, dated 09/27/2023, indicated Resident #51 was a [AGE] year-old male, originally admitted on [DATE] with diagnoses which included nontraumatic intracerebral hemorrhage (ruptured blood vessel causes bleeding inside the brain). Record review of the summary report dated 09/27/2023 indicated Resident #51 had an order to admit to hospice with an order date 08/20/2022. Record review of the annual MDS assessment, dated 08/24/2023, indicated Resident #51 rarely/never made herself understood or rarely/never understood others. The assessment did not address the BIMS score. The assessment indicated Resident #51 had a life expectancy of less than 6 months and received hospice services. Record review of the comprehensive care plan, revised on 08/25/2022, indicated Resident #51 had a terminal illness and was receiving hospice or palliative care. The care plan interventions included coordinate with hospice to ensure the resident's spiritual, emotional, intellectual, physician and social needs were met. Record review of Resident #51's hospice binder, accessed on 09/27/2023 at 9:00 a.m. revealed no admission notes, consents, updated POC, nurses/aide's notes, and aide care plan since the last IDT meeting. During an interview on 09/27/2023 at 11:13 a.m., the Case Manager for the hospice company on 08/20/2022 for CVA. The Case Manger stated the last visit was on 09/26/2023. The Case Manager stated the nurses were required to see her once a week and the aides were required to see her daily. The Case (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676294 If continuation sheet Page 41 of 50 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 09/27/2023 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 0849 Level of Harm - Minimal harm or potential for actual harm Manager stated the updated POC, nurses/aide's visits, and aide care plan should be printed during the IDG meeting and the case manager should have brought it on the next visit which was 09/21/2023. The Case Manager stated the admission notes and consents should have been placed in the binder when the resident was admitted to the facility. The Case Manager stated the process for coordinating with the facility was completed verbally and written documents with the nurses. Residents Affected - Some During an interview on 09/27/2023 at 4:38 p.m., the DON stated she was unaware the binders were not updated. The DON stated she expected the binders to be updated after the IDT meetings. The DON stated the charge nurses communicated verbally one on one with the hospice. The DON stated it was important to ensure recent hospice documentation was in the facility for continuity of care and so the residents received the correct care. During an interview on 09/27/2023 at 8:54 p.m., the Administrator stated he expected the hospice to update the binder. The Administrator stated it was important to ensure recent hospice documentation was in the facility for continuity of care. Record review of the Service Agreement, dated 09/12/2018, indicated, .1 Compilation of Records: Hospice shall ensure that the Nursing Facility's current clinical record includes the following: (A)Texas Medicaid Hospice Recipient Election/Cancellation form; (B)Minimum Data Set (MOS) assessments; (C) Physician Certification of Terminal Illness form; (D)Medicare Election Statement, if dually eligible; (E)verification that the recipient does not have Medicare Part A; (F)hospice interdisciplinary assessments; (G) hospice plan of care; and (H) and current interdisciplinary notes , which include the following (i) nurses notes and summaries (ii) physician orders and progress notes; and (iii) Medication and treatment sheets during the hospice period Record review of the Service Agreement, dated 06/09/2021, indicated, 5.1 Compilation of Records: Hospice shall ensure that the Nursing Facility's current clinical record includes the following: (A)Texas Medicaid Hospice Recipient Election/Cancellation form; (B)Minimum Data Set (MOS) assessments; (C) Physician Certification of Terminal Illness form; (D)Medicare Election Statement, if dually eligible; (E)verification that the recipient does not have Medicare Part A; (F)hospice interdisciplinary assessments; (G) hospice plan of care; and (H) and current interdisciplinary notes , which include the following (i) nurses notes and summaries (ii) physician orders and progress notes; and (iii) Medication and treatment sheets during the hospice period Record review of the facility's policy titled Coordination of Hospice Services implemented on 04/21/2021, indicated When a resident chooses to receive hospice care and services, the facility will coordinate and provide care in cooperation with hospice staff in order to promote the resident's highest practicable physical, mental, and psychosocial well-being 2. The facility and hospice provider will coordinate a plan of care and will implement interventions in accordance with the resident's needs, goals, and recognized standards of practice in consultation with the resident's attending physician/practitioner and resident's representative, to the extent possible FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676294 If continuation sheet Page 42 of 50 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 09/27/2023 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 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to promote antibiotic stewardship by ensuring the appropriate use of antibiotic therapy and providing written rationale, by the provider, when an antibiotic was used despite criteria, to determine the appropriate the use of an antibiotic for 4 of 4 residents and reviewed antibiotic use. (Resident #21, Resident #46, Resident #48, Resident #64) Residents Affected - Some The facility failed to ensure Resident #21, Resident #46, Resident #48, and Resident #64 had documented signs and symptoms, appropriate lab work, and diagnoses to support the use of prescribed antibiotics. These failures could place residents receiving antibiotics at risk for unnecessary antibiotic use, inappropriate antibiotic use, and increased antibiotic-resistant infections. The findings included: 1. Record review of the face sheet, dated 09/27/2023, revealed Resident #21 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of chronic kidney disease (condition characterized by a gradual loss of kidney function) and acquired absence of left leg below knee (amputation). There was no diagnosis to support antibiotic therapy. Record review of the MDS assessment, dated 07/03/2023, revealed Resident #21 had clear speech and was understood by staff. The MDS revealed Resident #21 was able to understand others. The MDS revealed Resident #21 had a BIMS of 15, which indicated she was cognitively intact. The MDS revealed Resident #21 had no behaviors or refusal of care. The MDS assessment did not address Resident #21's current antibiotic use. Record review of the comprehensive care plan, revised on 08/23/2023, revealed Resident #21 had a pressure ulcer to her right heel and was at risk for infection. The interventions included: monitor and document for signs and symptoms of infection . Record review of the order summary report, dated 09/27/2023, revealed Resident #21 had an order, which started on 09/15/2023, for metronidazole [antibiotic] 250mg - apply to right heel topically every day for wound care, crush and sprinkle on wound. There was no diagnosis to support antibiotic therapy. Record review of the MAR, dated September 2023, revealed Resident #21 received an antibiotic daily during wound treatment. Record review of the progress notes, from 09/10/2023 to 09/15/2023, revealed Resident #21 had no documentation of signs or symptoms of a wound infection to indicate antibiotic use. Record review of the Revised McGeer Criteria for Infection Surveillance Checklist, dated 09/15/2023, revealed Resident #21 did not meet the criteria for antibiotic use for skin and soft tissue infection. Record review of the Monthly Surveillance Log, dated September 2023, revealed Resident #21 had a skin/wound infection with no signs or symptoms documented that started on 09/14/2023. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676294 If continuation sheet Page 43 of 50 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 09/27/2023 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 0881 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of the Antibiotic Stewardship Surveillance Log, dated September 2023, revealed Resident #21's infection did not meet the definition guidelines. The log further revealed no lab work or cultures were obtained to confirm the presence of an infection. 2. Record review of the face sheet, dated 09/27/2023, revealed Resident #46 was a [AGE] year-old male who re-admitted to the facility on [DATE] with diagnoses of displaced fracture of right femur (broken right leg), hemiplegia and hemiparesis following a stroke affecting the right dominant side (weakness or paralysis to the right side of the body), and type 2 diabetes mellitus with diabetic neuropathy (high blood sugar with numbness and tingling to the feet). Record review of the MDS assessment, dated 08/18/2023, revealed Resident #46 had unclear speech and was sometimes understood by staff. The MDS revealed Resident #46 was usually able to understand others. The MDS revealed Resident #46 had a BIMS of 6, which indicated severe cognitive impairment. The MDS revealed Resident #46 had no behaviors or refusal of care. The MDS did not address Resident #46's antibiotic use. Record review of the comprehensive care plan, revised on 08/28/2023, revealed Resident #46 had a pressure ulcer and was at risk for infection. The interventions included: monitor and document for signs and symptoms of infection . Record review of the MAR, dated August 2023, revealed Resident #46 had an order, which started on 08/30/2023, for doxycycline hyclate (antibiotic) 100 mg - give one tablet by mouth two times a day for preventative. There was no diagnosis to support antibiotic therapy. Record review of the daily skilled note, dated 08/29/2023 at 7:05 AM, revealed Resident #46 had no signs of infection. The note further revealed the surgical incision to his right leg was slightly red. Record review of the Revised McGeer Criteria for Infection Surveillance Checklist, dated 08/31/2023, revealed Resident #46 did not meet the criteria for antibiotic use for skin and soft tissue infection. Record review of the Monthly Surveillance Log, dated August 2023, revealed Resident #46 had a skin/wound infection with the sign and symptom of redness that started on 08/30/2023. Record review of the Antibiotic Stewardship Surveillance Log, dated August 2023, revealed Resident #46's infection did not meet the definition guidelines. The log further revealed no lab work or cultures were obtained to confirm the presence of an infection. 3. Record review of the face sheet, dated 09/27/2023, revealed Resident #48 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of hydronephrosis with renal and ureteral calculous obstruction (condition of excess urine accumulation in kidney(s) that causes swelling of kidneys) and cellulitis (infection of the skin). Record review of the MDS assessment, dated 06/30/2023, revealed Resident #48 had clear speech and was understood by staff. The MDS revealed Resident #48 was able to understand others. The MDS revealed Resident #48 had a BIMS of 15, which indicated no cognitive impairment. The MDS revealed Resident #48 had no behaviors or refusal of care. The MDS revealed Resident #48 had a diagnosis of sepsis (infection in the blood stream). The MDS revealed Resident #48 received antibiotics during the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676294 If continuation sheet Page 44 of 50 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 09/27/2023 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 0881 look-back period. Level of Harm - Minimal harm or potential for actual harm Record review of the comprehensive care plan, revised on 07/14/2023, revealed Resident #48 was at risk of bowel and bladder incontinence. The interventions included: monitor for and report to MD s/sx UTI . The care plan did not address potential for skin infections. Residents Affected - Some Record review of the MAR, dated June 2023, revealed Resident #48 had an order, which started on 06/15/2023, for meropenem (antibiotic) - use 1 gram intravenously two times a day for UTI, sepsis. The order ended on 06/24/2023. Record review of the Revised McGeer Criteria for Infection Surveillance Checklist, dated 06/16/2023, revealed Resident #48 did not meet the criteria for antibiotic use for UTI. Record review of the progress notes, between 06/13/2023 to 06/16/2023, revealed Resident #48 had no documented signs or symptoms of an UTI. Record review of the Monthly Surveillance Log, dated June 2023, revealed Resident #48 had an UTI with signs and symptoms from the hospital. Record review of the Antibiotic Stewardship Surveillance Log, dated June 2023, revealed Resident #48's infection did not meet the definition guidelines. The log further revealed no lab work or cultures were obtained to confirm the presence of an infection. Record review of the MAR, dated July 2023, revealed Resident #48 had an order, which started on 07/20/2023, for Macrobid (antibiotic) 100 mg - give one capsule by mouth in the evening for prophylactic for 60 days. Record review of the Revised McGeer Criteria for Infection Surveillance Checklist, dated 07/24/2023, revealed Resident #48 did not meet the criteria for antibiotic use for UTI, respiratory infection, skin or soft tissue infection, or gastrointestinal tract infection. Record review of the progress notes, between 07/17/2023 and 07/21/2023, revealed Resident #48 had no documented signs or symptoms of an infection. Record review of the Monthly Surveillance Log, dated July 2023, revealed Resident #48 had an unspecified infection with signs and symptoms prophylactic. Record review of the Antibiotic Stewardship Surveillance Log, dated July 2023, revealed Resident #48's infection did not meet the definition guidelines. The log further revealed no lab work or cultures were obtained to confirm the presence of an infection. Record review of the MAR, dated September 2023, revealed Resident #48 had an order, which started on 09/17/2023, for doxycycline monohydrate (antibiotic) 100 mg - give one capsule by mouth two times a day for cellulitis for 10 days. Record review of the Revised McGeer Criteria for Infection Surveillance Checklist, dated 09/18/2023, revealed Resident #48 did not meet the criteria for antibiotic use for skin or soft tissue infection. Resident #48 had warmth and redness to the affected site but must have had at least 4 signs and symptoms. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676294 If continuation sheet Page 45 of 50 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 09/27/2023 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 0881 Level of Harm - Minimal harm or potential for actual harm Record review of the progress note, dated 09/17/2023 at 2:47 PM, revealed Resident #48's bilateral lower extremities were red and warm to the touch. Record review of the Monthly Surveillance Log, dated September 2023, revealed Resident #48 had skin/wound infection with signs and symptoms of heat and pain. Residents Affected - Some Record review of the Antibiotic Stewardship Surveillance Log, dated September 2023, revealed Resident #48's infection did not meet the definition guidelines. The log further revealed no lab work or cultures were obtained to confirm the presence of an infection. 4. Record review of face sheet, dated 09/27/2023, revealed Resident #64 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of surgical aftercare following a surgery on the digestive system, injury of duodenum (small intestine), perforation of intestine, abscess of lung with pneumonia, and urinary tract infection. Record review of the MDS assessment, dated 08/16/2023, revealed Resident #64 had clear speech and was understood by staff. The MDS revealed Resident #64 was able to understand others. The MDS revealed Resident #64 had a BIMS score of 15, which indicated no cognitive impairment. The MDS revealed Resident #64 had no behaviors or refusal of care. The MDS revealed Resident #64 had an active infection and diagnosis of pneumonia. The MDS revealed Resident #64 received antibiotics during the look-back period. Record review of Resident #64's comprehensive care plan, revised on 08/28/2023, did not address risk for infection. Record review of the MAR, dated June 2023, revealed Resident #64 had an order, which started on 06/02/2023, for vancomycin (antibiotic) oral suspension - give 125 mg by mouth four times a day for c-diff positive. Record review of the Revised McGeer Criteria for Infection Surveillance Checklist, dated 06/05/2023, revealed Resident #64 did not meet the criteria for gastrointestinal tract infection. Record review of the progress notes, between 06/01/2023 and 06/04/2023, revealed Resident #64 had no documented signs or symptoms of a gastrointestinal tract infection. Record review of the c. difficile (infectious organism that can cause severe diarrhea) test results, dated 06/01/2023, revealed positive test results. Record review of the Monthly Surveillance Log, dated June 2023, revealed Resident #64 had a gastrointestinal tract infection with no documented signs and symptoms. Record review of the Antibiotic Stewardship Surveillance Log, dated June 2023, revealed Resident #64's infection did not meet the definition guidelines. Record review of the MAR, dated August 2023, revealed Resident #64 had an order, which started on 08/11/2023, for amoxicillin-pot clavulanate (antibiotic) 875 - 125 mg - give one tablet by mouth tow times a day for hospital orders for 10 days. Record review of the Revised McGeer Criteria for Infection Surveillance Checklist, dated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676294 If continuation sheet Page 46 of 50 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 09/27/2023 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 0881 08/21/2023, revealed Resident #64 did not meet the criteria for skin or soft tissue infections. Level of Harm - Minimal harm or potential for actual harm Record review of the progress notes, between 08/05/2023 and 08/10/2023, revealed Resident #64 had redness and swelling to right jaw and neck. Residents Affected - Some Record review of the Monthly Surveillance Log, dated August 2023, revealed Resident #64 had skin/wound infection with signs and symptoms of redness and swelling. Record review of the Antibiotic Stewardship Surveillance Log, dated August 2023, revealed Resident #64's infection did not meet the definition guidelines. The log further revealed no lab work or cultures were obtained to confirm the presence of an infection. During an interview on 09/27/23 at 9:14 AM, ADON C stated she was responsible for completed the antibiotic stewardship reports and logs. ADON C stated she had taken the Infection Control Preventionist training and was acting as the infection control preventionist. ADON C said the process for antibiotic stewardship started with completing a facility map and color coordinating infection categories. ADON C stated she completed the antibiotic log to include the signs and symptoms, type of infection, and antibiotic information. ADON C stated a separate form was completed by hallways for antibiotic stewardship to include whether the antibiotic meets the definition guidelines. ADON C stated she then completed a McGeer criteria form for each resident who was prescribed antibiotics. She stated the facility policy was to use the McGeer's criteria. ADON C stated no interventions were implemented for a resident who doesn't meet the criteria for antibiotic use. ADON C stated the residents would have continued to the take the antibiotics as prescribed by the physician until completed. ADON C stated she did not notify the doctor or perform an antibiotic timeout to assess continued use of the antibiotic prescribed if the criteria were not met. ADON C stated antibiotic stewardship was reviewed monthly in the QAPI meetings with the Medical Director. ADON C stated no plans had been implemented to prevent or reduce the use of antibiotics that were prescribed with the criteria not met. ADON C stated she suspected the criteria was actually met but the nursing documentation was insufficient and did not reflect the appropriate charting. ADON C stated the facility staff did perform some training with the nurses regarding documentation, but it was ineffective. During an interview on 09/27/2023 at 11:23 AM, the Medical Director stated he was new to the position and had only attended two QAPI meetings. The Medical Director stated antibiotic stewardship was discussed during the meeting, but he did not notice any trends or issues. The Medical Director stated he was unaware that all antibiotics prescribed during June, July, August, and September did not meet the criteria for antibiotic use. The Medical Director was unaware of any processes in place to monitor antibiotic use at the facility. The Medical Director stated it could have been happening during the night while using the telemedicine service. The Medical Director stated the doctors used on the telemedicine service were unaware of the antibiotic stewardship policies of the nursing facilities. The Medical Director stated the policy at the facility in order to prescribe antibiotics was to ensure the McGeer's criteria was met. The Medical Director stated antibiotic stewardship was a complex situation and was a systemic problem in all nursing facilities. The Medical Director stated it was important to ensure the correct antibiotic was given for the correct situation. The Medical Director stated he did not believe the antibiotics that were prescribed did not meet the criteria. The Medical Director stated the charting was inappropriate and did not reflect the actual resident status. The Medical Director stated his next project was to implement new processes for the antibiotic stewardship program. During an interview on 09/27/2023 at 7:38 PM, RN U stated she was aware the facility had an (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676294 If continuation sheet Page 47 of 50 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 09/27/2023 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 0881 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some antibiotic stewardship program. RN U stated she received training on antibiotic stewardship but was unable to specify dates. RN U stated part of the antibiotic stewardship program was checking the antibiotic again the order when it arrived from the pharmacy. RN U stated she normally worked during the evening and was not familiar with the McGeer's criteria. RN U stated the physician was notified when lab results were available. RN U stated she documented signs and symptoms and notification of the physician in the progress notes. RN U stated signs and symptoms might not have been documented in the progress notes related to getting busy and forgetting. RN U stated it was important to ensure antibiotic stewardship policies were followed to ensure residents did not get an antibiotic they did not need. RN U stated antibiotics that were given unnecessarily could put the residents at risk for super infections and multi-drug resistant organisms. During an interview on 09/27/2023 at 7:59 PM, ADON C stated the nurses were verbally given in-servicing on appropriate documentation regarding signs and symptoms of infection and antibiotic use. ADON C stated she had personally given them a copy of the McGeer's criteria she used to ensure criteria was met. ADON C stated she also educated them on non-pharmacological interventions such as increasing fluids. ADON C stated during her monitoring and tracking of infections she noticed the lack of documentation included all nurses, across all shifts. ADON C stated she had seen some improvement. ADON C stated antibiotic stewardship was important to ensure the medications were effective, the proper dosage was given, signs and symptoms were improved, and residents were not continuously having the same issues. ADON C stated it was important to ensure policies on antibiotic stewardship were followed to prevent residents receiving unnecessary medication. ADON C stated receiving unnecessary antibiotics could have caused super infections, multi-drug resistant organisms, dehydration, and side effects. ADON C stated residents could build up a resistant intolerance to antibiotics that would have caused them to become ineffective. During an interview on 09/27/2023 at 8:35 PM, the DON stated part of the antibiotic stewardship program was to monitor antibiotics for side effects and resident condition during treatment. The DON stated antibiotics were monitored and tracked on an antibiotic log that was filled out by ADON C. The DON stated no antibiotic time outs were performed. The DON stated antibiotic stewardship was part of the monthly QAPI meetings, but she was unaware all the antibiotics for June 2023, July 2023, August 2023, and September 2023 did not meet the McGeer's criteria. The DON stated education regarding antibiotic stewardship had not been provided to her knowledge. The DON stated it was important to ensure antibiotic stewardship policies were in place and followed so residents did not get multi-drug resistant organisms. During an interview on 09/27/2023 at 9:07 PM, the Administrator stated he expected the antibiotic stewardship program to have been appropriately implemented and monitored. The Administrator stated the DON was responsible for monitoring the antibiotic stewardship program. The Administrator stated the importance of the antibiotic stewardship program was to prevent multi-drug resistance organisms, super infections, and unnecessary medication. Record review of the Antibiotic Stewardship policy, reviewed on 12/12/202, revealed .committed to safe and appropriate antibiotic use that includes: .promoting and overseeing antibiotic stewardship, .accessing pharmacists and other with experience or training in antibiotic stewardship, . implement policies or practices to improve antibiotic use, .regular reporting on antibiotic use to relevant staff, . educate staff and residents about antibiotic stewardship. The policy did not address antibiotic use when the definition guidelines were not met. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676294 If continuation sheet Page 48 of 50 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 09/27/2023 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 0940 Develop, implement, and/or maintain an effective training program for all new and existing staff members. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to develop, implement, and maintain annually an effective training program for existing staff, consistent with their expected roles for 12 of 20 employees (RN D, Dietician, Occupational Therapist F, Physical Therapist G, Dietary Manager, Social Worker, CNA H, CNA K, CNA L, CNA M, Maintenance Director, Housekeeping Supervisor) reviewed for required trainings. Residents Affected - Some The facility failed to ensure the Maintenance Director, the Housekeeping Supervisor, Occupational Therapist F, Physical Therapist G, CNA H, CNA K, CNA L, and CNA M received HIV and restraint training upon hire. The facility failed to ensure RN D, the Dietary Manager, the Social Worker, received annual HIV and restraint training. The facility failed to ensure the Dietician received annual restraint training. This failure could place residents at risk for inappropriate restraints and exposure to HIV. Findings included: Record review of the employee files revealed there was no HIV or restraint training completed upon hire for the following staff: Maintenance Director hire date 06/09/2023 Housekeeping Supervisor hire date 03/30/2021 Occupational Therapist F hire date 02/09/2023 Physical Therapist G hire date 05/08/2023 CNA H hire date 08/23/2023 CNA K hire date 06/20/2023 CNA L hire date 08/21/2023 CNA M hire date 06/29/2023 Record review of the employee files revealed there was no HIV or restraint training completed annually for the following staff: RN D hire date 03/31/2022 Dietary Manager hire date 02/08/2010 Social Worker hire date 06/15/2018 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676294 If continuation sheet Page 49 of 50 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 09/27/2023 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 0940 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of the employee files revealed there was no restraint training completed annually for the following staff: Dieticians hire date 11/29/1999 During an interview on 09/27/2023 at 7:45 PM, the Payroll Coordinator said she was responsible for ensuring the staff completed the HIV and restraint trainings. The Payroll Coordinator said the HIV and restraint trainings were supposed to be completed upon hire and annually. The Payroll Coordinator said she did not have a system in place to monitor for the completion of the HIV and restraint trainings. The Payroll Coordinator said the staff say they do not have time to complete the trainings because they are too busy working on the halls. The Payroll Coordinator said it was important for the HIV training to be completed annually and upon hire to prevent the spread of infection. The Payroll Coordinator said it was important for the restraint training to be completed upon hire and annually to prevent abuse. During an interview on 09/27/2023 at 9:08 PM, the Administrator said he expected for the staff to complete the HIV and restraint training annually and upon hire. The Administrator said the Payroll Coordinator was responsible for ensuring these were completed timely. The Administrator said it was important to complete the HIV and restraint trainings as required to keep the staff educated. Record review of the facility's policy dated 11/29/2022, titled, Training Requirements, indicated, It is the policy of this facility to develop, implement, and maintain an effective training program for all new and existing staff, individuals, providing services under a contractual arrangement, and volunteers, consistent with their expected roles . Training requirements should be met prior to staff and volunteers independently providing services to residents, annually, and as necessary based on the facility assessment. 6. Training content includes, at a minimum . g. Restraints h. HIV . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676294 If continuation sheet Page 50 of 50