Health inspection·January 19, 2023

F 0558 01/09/23 at 9:59 PM Level of Harm - Minimal harm or potential for actual harm 01/10/23 at 9:59 PM 01/11/23 at 9:59 PM Residents Affected - Few 01/12/23 at 1:31 PM 01/15/23 at 7:39 PM 01/16/23 at 9:59 PM 01/17/23 at 9:59 PM 01/18/23 at 3:41 AM and 9:49 PM In an interview on 01/18/23 at 10:14 am, Resident #329 stated after he had hip surgery at the hospital, he admitted to this facility early January 2023 and a few days later, at night CNA A was rough handling him and hurt his hip as she was trying to reposition him. He stated he had no problems getting repositioned, currently, because he told staff if they walked into his room by themselves and they looked too small, he requested for them to get a second person to assist him, so that his hip would not get hurt again. In an interview on 01/18/23 at 2:53 pm, CNA A stated on 01/07/23 around 9:30 pm, after Resident #329 was repositioned by her and LVN E, LVN E left the room, but Resident #329 said he still was not comfortable. She stated she repositioned his wedge cushions the way he wanted under his right side by his hip. She stated he was repositioned often and wanted his wedges to the right side under his buttocks and upper back. She stated she pushed the wedge cushion the way he wanted and while doing so he said she hurt his hip. She stated she apologized. She stated she had repositioned him several times in the past with CNA D with her, but that time she repositioned him by herself and readjusted his wedge cushions. She stated she was only putting the wedge cushions like he wanted them and added she would not hurt anyone. In an interview on 01/19/23 at 12:39 pm, CNA J stated Resident #329 was a 2 person staff assist because he recently had hip surgery and was very, very tall, 6'5 in height. In an interview on 01/19/23 at 2:00 pm, COTA F said she currently provided occupational therapy services to Resident #329 and that he was a 2 person staff assist with ADL care because he was not strong enough to extend his legs and could not stand up. In an interview on 01/19/23 at 2:09 pm, PTA G stated he currently provided physical therapy services and heard from co-workers that day someone hurt Resident #329's hip and added he was a 2 person assist with ADL care with very weak transitions from sit to stand. PTA G stated he was so tall with poor trunk control and too weak to stand. In an interview on 01/19/23 at 04:53 pm, MDS I stated she was Resident #329's MDS nurse and was not aware he preferred two person staff assistance. She stated since Resident #329 preferred having 2 person staff assist for his ADL's, she would change his care plan to 2 person staff assist. She stated Resident #329's care plan had not been updated for 2 person staff assist because it was an (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676466 If continuation sheet Page 2 of 21 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 676466 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cheyenne Medical Lodge 750 Highway 352 Mesquite, TX 75149 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 0558 oversight on her part with getting busy. Level of Harm - Minimal harm or potential for actual harm In an interview on 01/19/23 at 6:12 pm, the Admin stated he was unaware the staff was caring for Resident #329 by themselves at times without a second staff member assisting with patient care. He stated he was unaware Resident #329 had a preference for two person staff assistance with his ADL care. Residents Affected - Few Record Review of Nursing Facility Residents' Rights dated November 2021 revealed, Freedom of choice: you have the rights to: Make your own choices regarding personal affairs, care .Participation in your care: You have the right to: Receive all care necessary to have the highest possible level of health. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676466 If continuation sheet Page 3 of 21 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 676466 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cheyenne Medical Lodge 750 Highway 352 Mesquite, TX 75149 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 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the resident had a right to personal privacy and confidentiality of medical records for 1 (Resident #67) of 3 residents reviewed for privacy and confidentiality, in that: Residents Affected - Few The facility failed to ensure LVN N logged out of her computer and protect Resident#67's PHI information. This failure could place residents at risk for low self-esteem, loss of dignity and decreased quality of life due to medical history being accessible to others. Findings include: Resident #67's quarterly MDS assessment, dated 11/17/22, reflected she was an [AGE] year-old female admitted to the facility on [DATE], with diagnoses including diabetes mellitus, elevated blood pressure, and dementia. She had a BIMS of 09 indicating she was cognitively moderately impaired. During an observation on 01/18/2023 at 7:55 AM, LVN N stepped away from the medication cart, she entered Resident #97 room with the blood pressure cuff to check the resident's blood pressure. LVN N left the computer screen (on top of the medication cart) unlocked where all the Resident#67's information was clearly displayed. Two residents observed in their wheelchairs passed by the medication cart. Also, a housekeeper was observed in the hallway close by the medication cart. During an interview on 01/18/2023 at 8:00 AM, LVN N said she forgot to lock her computer screen before she stepped away from it because she was in rush to check Resident#67's blood pressure. LVN N reported she had received training regarding resident rights to privacy and confidentiality of records, she stated she was supposed to provide privacy for all residents, as the failure could cause embarrassment and poor self-esteem for the resident. In an interview on 01/19/2023 at 4:30 PM, the DON stated all employees were expected to provide full visual privacy and confidentiality of information for all residents. The DON stated further that she would start an in-service training with the employees on residents right to privacy and confidentiality of information. Record review of the facility's policy titled Medical Information and Confidentiality not dated revealed the policy did not address the concern. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676466 If continuation sheet Page 4 of 21 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 676466 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cheyenne Medical Lodge 750 Highway 352 Mesquite, TX 75149 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to develop, review, and revise a care plan after each comprehensive and quarterly review assessment for one of 10 (Resident #329) residents reviewed for care plans. The facility failed to ensure Resident #329's Care Plan was updated after his MDS Assessment revealed he was a two person staff assist for bed mobility. This failure could place all residents at risks of injury, distress or pain which could result in a decreased physical and psycho-social well-being if the staff do not know how to care for the residents properly. Findings Included: Record review of Resident #329's Order Summary Report, dated 01/18/23, revealed a [AGE] year-old male who admitted [DATE] with diagnoses of hypertension (high blood pressure), hyperlipidemia (high level fat in blood), atrial fibrillation (irregular heart beat), seizures (electrical brain disturbance), spinal stenosis (narrowing spinal nerves), displaced intertrochanteric fracture of right femur (hip fracture), muscle weakness , reduced mobility (reduced movement), lack of coordination (muscle loss), need for assistance with personal care. He had doctor's orders for Aspirin 81 mg tablet chewable for medical diagnosis/condition, Gabapentin capsule 400 mg for (nerve pain), Oxycodone tablet 5 mg for pain and Tylenol tablet 325 mg for pain . Record review of Resident #329's admission MDS assessment, completed by MDS I and dated 01/10/23, revealed, Able to Make self-understood, with a BIMS score of 12 (Cognitively intact) and extensive Assistance with two person ADL physical assistance for bed mobility. Record review of Resident #329's care plan, dated 01/04/23, revealed, Resident requires assist with ADL's .Goals: dated 01/05/23: Resident is able to perform self-care to optimal level and maintains strength and endurance x 90 days .Interventions: 2P (person) transfer for patient comfort related to pain, date initiated 01/19/23 .encourage independence in performance of self-care and mobility within limitations .Provide level of support to complete dressing, toilet use, personal hygiene, and bathing needs Q [every] shift. Record review of Resident #329's CNA ADL Task Sheet: he received one-person physical assist for bed mobility: 01/07/23 at 12:17 PM and 8:57 PM 01/09/23 at 9:59 PM 01/10/23 at 9:59 PM 01/11/23 at 9:59 PM 01/12/23 at 1:31 PM (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676466 If continuation sheet Page 5 of 21 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 676466 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cheyenne Medical Lodge 750 Highway 352 Mesquite, TX 75149 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 0657 01/15/23 at 7:39 PM Level of Harm - Minimal harm or potential for actual harm 01/16/23 at 9:59 PM 01/17/23 at 9:59 PM Residents Affected - Few 01/18/23 at 3:41 AM and 9:49 PM In an interview on 01/18/23 at 10:14 am, Resident #329 stated after he had hip surgery at the hospital, he admitted to this facility early January 2023 and a few day later, at night CNA A was rough handling him and hurt his hip as she was trying to reposition him. He stated he had no problems getting repositioned, currently, because he told staff if they walked into his room by themselves and they looked too small, he requested for them to get a second person to assist him, so that his hip would not get hurt again. In an interview on 01/18/23 at 11:29 am, ADON B stated a day or two after Resident #329 admitted earlier that month, the DON asked her to go talk to him because [Resident #329] said while he was getting care, CNA A repositioned him using the draw pad and hurt his hip. Resident #329 said he told the CNA to please not to do that anymore and his right hip was hurting so bad and was not sure which nurse checked on him 30 minutes later. Resident #329 said CNA A was rough repositioning him and ADON B said he was a one person staff assist when he first admitted and still was because he could bear weight when standing. In an interview on 01/18/23 at 2:53 pm, CNA A stated she worked the 2:00 pm to 10:00 pm shift and assisted Resident #329, who had a broken right hip and stated, He liked his stuff perfect. She stated on 01/07/23 around 9:30 pm, after Resident #329 was repositioned by her and LVN E, LVN E left the room, but Resident #329 said he still was not comfortable. She stated she repositioned his wedge cushions the way he wanted under his right side by his hip. She stated he was repositioned often and wanted his wedges to the right side under his buttocks and upper back. She stated she pushed the wedge cushion the way he wanted and while doing so he said she hurt his hip. She stated she apologized. She stated Resident #329 could turn a little but was not able to move that well which was why she used the pad underneath him. She stated he was a 2 person assist but he called her to lift up the pad and push the wedge cushion because he said he was in pain and wanted to be repositioned to get pressure off of his right side. She stated she had repositioned him several times in the past with CNA D with her, but that time she repositioned him by herself and readjusted his wedge cushions. She stated she was only putting the wedge cushions like he wanted them and added she would not hurt anyone. She stated she pushed the wedge cushion downward and under him and was doing it as he requested and was not done in a jerking or fast way. She stated she knew if a resident was one or 2 person staff assist by looking at them to see if they could do for themselves and by asking them and the nurse what was the resident's functioning status. She stated if the staff could not completely move the residents by themselves, they had to seek getting a second staff member. In an interview on 01/19/23 at 11:10 am, RN C stated Resident # 329 had a fall at home, went to the hospital, and had surgery on his right hip which had to be immobilized when providing him care. He stated when they provided care for him, two staff were needed with one staff to hold his leg in place and the other staff to provide the care. He stated they used care plans, but he had not because he was not told to do so and that the MDS's, SW, DON used care plans. He stated care plans were needed for how to care for each resident based on the resident's functional level before with expectations and treatment to resolve an issue or medical condition. He stated the CNA's asked the nurses which (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676466 If continuation sheet Page 6 of 21 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 676466 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cheyenne Medical Lodge 750 Highway 352 Mesquite, TX 75149 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few residents were 1-2 person assist and stated it was a must that Resident #329 received 2 person staff assist and should never receive care from just one staff in order to prevent Resident #329 from increased hip pain. In an interview on 01/19/23 at 11:33 am, CNA D stated he cared for Resident #329 and had no problems caring for him by himself because he was strong enough to move him and stated Resident #329 was a 2 person staff assist because Resident #329 was pretty tall and kind of heavy and CNA A was short. He stated he could tell if a resident was a 1 or 2 person assist by just kind of looking at them and asking them what they could do and not do and if it looked like the resident could safely transfer, he would care for them without a second staff present. He stated they had no record or binder to refer to when determining if a resident was 1 or 2 person staff assist and said they had an EMR charting system, but it did not say if the residents was 1 or 2 person assist. He stated there was not a care plan or plan of care to determine their assist status and would normally ask the resident what they could do for themselves. In an interview on 01/19/23 at 11:56 am, LVN E stated Resident #329 was a 2 person assist and on 01/07/23 she had changed him by herself because he was able to move to some extent. She stated they used care plans when caring for the residents and looked at the care plan for how to care for the residents. She stated CNA's knew if a resident was 1 or 2 person staff assist by asking the nurses and looking at the resident's ADL profiles in the CNA tablet she thought. In an interview on 01/19/23 at 12:39 pm, CNA J stated Resident #329 was a 2 person staff assist because he recently had hip surgery and was very, very tall, 6'5 in height. She stated she worked the other end of the hall and assisted CNA A at times with Resident #329. In an interview on 01/19/23 at 2:00 pm, COTA F said she heard from the DON and Ombudsman about a CNA was rough handling Resident #329 that was reported to the administrator and stated she currently provided occupational therapy services to Resident #329 and that he was a 2 person staff assist with ADL care because he was not strong enough to extend his legs and could not stand up. In an interview on 01/19/23 at 2:09 pm, PTA G stated he currently provided physical therapy services to Resident #329 and heard from co-workers that day someone hurt his #329's hip and added he was a 2 person assist with ADL care and very weak with transitions from sit to stand. PTA G stated he was so tall with poor trunk control and too weak to stand. In an interview on 01/19/23 at 4:37 pm, MDS H stated she was the Long term care MDS nurse and not sure how the staff were able to tell when a resident was a 1 or 2 person assist and would have to check and get back with the surveyor. After review of Resident #329's care plan, she said Resident #329 had ADL assist on his care plan, but it did not say how many staff were to assist him. She stated when the nursing staff provided a resident 2-person staff assist at least 3 times, over a period of time by looking at the CNA's ADL task sheet, the resident's care plan should be changed to 2-person staff assistance. In an interview o 01/19/23 at 4:53 pm, MDS I stated she was the MDS nurse for Resident #329 and was not aware a CNA hurt Resident #329's hip. She stated the CNA's used a tablet to help them know how to care for the residents under the resident profile tab. She stated Resident #329 admitted to this facility for a right hip fracture. She stated he was a 1 person staff assist with ADL Care and stated it was a good idea to change him to 2 person assist since his ADL CNA task sheet showed 4 times where he received 2 person staff assist. She stated she was not aware Resident #329 preferred 2 person (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676466 If continuation sheet Page 7 of 21 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 676466 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cheyenne Medical Lodge 750 Highway 352 Mesquite, TX 75149 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few staff assistance and since his MDS Assessment was coded for 2 person ADL staff assist she would change his Care plan at this time. She stated the lookback on his MDS Assessment was overdue and was unaware his MDS Assessment was 2 person staff for ADL Care: Mobility. She stated it was an oversight on her part getting it changed and was due to being busy. In an interview on 01/19/23 at 5:11 pm, the DON stated Resident #329 was a 1-person staff assist with ADL's she guessed, but if his MDS Assessment was saying he was a 2 person assist, then he was a 2 person assist. She stated, after she reviewed Resident #329's admission MDS dated [DATE], it showed for ADLS, he was an extensive 2-person assist and had a care plan for 2 person staff assist also. She stated the care plans were done for the staff to know how to care for the residents. She stated she was not aware his care plan for 2 person staff assist was just added on 01/19/23. In an interview on 01/19/23 at 6:12 pm, the Admin stated for care plans he knew they had to get them done efficiently and knew at times they were not keeping up with completing them, but the MDS nurses and SW were working together to ensure none of the care plans were getting missed. He stated being unsure why Resident #329 had no 2 person staff assistance care plan despite his MDS being coded for 2 person staff assist for bed mobility. He stated he was unaware the staff was caring for Resident #329 by themselves at times without a second staff member assisting with patient care. Record review of the facility's Care Plan policy updated revealed, Use of Comprehensive Assessment: The results of resident comprehensive assessments shall be develop, review and revise each resident's plan of care .Comprehensive Person-centered resident care planning: .Each resident's plan of care shall be periodically reviewed and revised by an interdisciplinary team after each MDS assessment, including both the comprehensive and quarterly review assessments to reflect the resident's current care needs . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676466 If continuation sheet Page 8 of 21 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 676466 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cheyenne Medical Lodge 750 Highway 352 Mesquite, TX 75149 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. 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 the necessary services for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for 2 (Resident #125, Resident #335) of 8 residents reviewed for ADLs. Residents Affected - Few The facility failed to ensure: 1Resident #125 had her fingernails trimmed and cleaned. 2Resident #335 had her fingernails trimmed and cleaned. These failures could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections and a decreased quality of life. Findings include: 1- Review of Resident #125's Comprehensive MDS assessment dated [DATE] reflected Resident #125 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of muscle weakness, diabetes mellitus, blood cancer, and elevated blood pressure. She had a BIMS of 9 indicating she was moderately impaired. She required extensive assistance of two-persons physical assistance with bed mobility, toilet use, and personal hygiene. Review of Resident #125's Comprehensive Care Plan, dated 12/13/22, reflected the following: Focus: Resident requires assist with ADLs. Goal: Resident is able to perform self-care to optimal level and maintains strength and endurance. Interventions: Encourage independence in performance of self-care and mobility within limitations. Provide level of support to complete dressing, personal hygiene, and bathing needs every shift. Focus: The resident scratches to the point of bleeding and is at risk for further injury or infection. Goal: The resident will be free from skin tears through the review date. Interventions: If resident needs their nails trimmed, assisted to keep short to reduce risk of scratching or injury from picking at skin. An observation and interview on 01/19/23 at 9:45 AM revealed Resident #125 was lying in her bed. The nails on the left hand were approximately 0.5cm in length extending from the tip of her fingers. The nails were discolored tan, the underside had dark brown colored residue, and the bed of the nails had dark brown colored residue. Resident #125 said that he did not like her nails too long. 2Review of Resident #335's admission MDS assessment, dated 01/14/2023, reflected Resident #335 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of dementia, depression, limitation of activities and bed confinement. Resident#335 required extensive assistance of two-persons physical assistance with bed mobility, transfers and personal hygiene. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676466 If continuation sheet Page 9 of 21 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 676466 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cheyenne Medical Lodge 750 Highway 352 Mesquite, TX 75149 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident #335's Comprehensive Care Plan dated 01/16/23 reflected the following: Resident requires assist with ADLs. Interventions include Provide level of support to complete dressing, toilet use, personal hygiene, and bathing needs every shift. Observation on 01/19/23 at 09:50 AM revealed Resident #335 was laying in her bed. The nails on both hands were approximately 0.5cm in length extending from the tip of her fingers. The nails were discolored tan and the underside had dark brown colored residue. Resident #335 was unable to answer the questions. Interview on 01/19/23 at 09:55 AM, CNA J stated CNAs were allowed to cut the residents' nails if they were not diabetic. CNA J stated she would clean and trim Resident #125 and Resident #335's nails right then. Interview on 01/19/23 at 10:08 AM, RN C stated CNAs were responsible to clean and trim residents' nails during the showers. RN C stated only nurses cut residents' nails if they are diabetic. RN C stated no one notified her Resident #125 and Resident #335's nails were long and dirty, and he had not noticed the nails himself. RN C stated Resident#125 and Resident#335 were not diabetic and the CNA would clean and trim their nails. Interview on 01/19/23 4:30 PM, the DON stated nail care should be completed as needed and every time aides wash the residents' hands. The DON stated nails should be observed daily. The DON stated nurses were responsible for trimming the nails of residents who were diabetic, and CNAs could trim other residents' nails. The DON stated she expected CNAs to offer to cut and clean nails if they were long and dirty. The DON stated residents having long and dirty could be an infection control issue. Review of the facility's policy titled Activities of Daily Living, not dated, reflected . If a resident is unable to carry out activities of daily living, he/she shall receive the necessary services to maintain good nutrition, grooming, and personal an oral hygiene. For these residents, care plan goals may not be stated in terms of what the resident is able to achieve, but in terms of the outcome of care and/or services provided. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676466 If continuation sheet Page 10 of 21 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 676466 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cheyenne Medical Lodge 750 Highway 352 Mesquite, TX 75149 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure residents were adequately supervised and assisted to prevent accidents for one of 10 (Resident #329) residents reviewed for Incident and Accidents. The facility failed to follow its internal accident/incident policy after Resident #329 reported CNA A was rough after repositioning him in bed, resulting in him experiencing pain. These failures could place all residents at risk of injury, distress and pain if they are not assessed and treated for possible further injuries and continuity of care, which could result in a decreased psycho-social well-being and overall medical decline. Findings included: Record review of Resident #329's Order Summary Report, dated 01/18/23, revealed a [AGE] year-old male who admitted [DATE] with diagnoses of hypertension (high blood pressure), hyperlipidemia (high level fat in blood), atrial fibrillation (irregular heart beat), seizures (electrical brain disturbance), spinal stenosis (narrowing spinal nerves), displaced intertrochanteric fracture of right femur (hip fracture), muscle weakness , reduced mobility (reduced movement), lack of coordination (muscle loss), need for assistance with personal care. He had doctor's orders for Aspirin 81 mg tablet chewable for medical diagnosis/condition, Gabapentin capsule 400 mg for (nerve pain), Oxycodone tablet 5 mg for pain and Tylenol tablet 325 mg for pain . Record review of Resident #329's admission MDS assessment, completed by MDS I and dated 01/10/23, revealed, B0700: Able to Makes self-understood, - yes, C0500: with a BIMS score of 12 (Cognitively intact) , G0110: A. and Bed Mobility - Extensive Assistance with two person ADL physical assistance for bed mobility. Record review of Resident #329's care plan, dated 01/04/23, revealed, Resident requires assist with ADL's .Goals: dated 01/05/23: Resident is able to perform self-care to optimal level and maintains strength and endurance x 90 days .Interventions: 2P (person) transfer for patient comfort related to pain, date initiated 01/19/23 .encourage independence in performance of self-care and mobility within limitations .Provide level of support to complete dressing, toilet use, personal hygiene, and bathing needs Q [every]) shift. Record review of Resident #329's CNA ADL Task Sheet: he received one-person physical assist for bed mobility on 01/07/23 at 12:17 PM and 8:57 PM Record review of the facility's Incident/accident report for January 2023 printed 01/17/23 revealed Resident #329 had no incident/accidents since admitting to this facility. Records review of Resident #329's Nurses Notes from 01/03/23 to 01/18/23 revealed there were no nurses' notes documenting the resident's hip pain during resident care. Record review of Resident #329's Report of Grievance Form written by SW dated 01/09/23 revealed, [Resident #329] states the CNA assigned to him on 01/07/23 or 01/08/23 was rough when provided care and repositioning him causing pain near his suture/surgical site .Facility follow-up: Direct care (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676466 If continuation sheet Page 11 of 21 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 676466 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cheyenne Medical Lodge 750 Highway 352 Mesquite, TX 75149 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few staff will be in-serviced on patient turning, repositioning, care and service delivery .Narrative of report: Resident with very low pain threshold. Does not tolerate repositioning well, will consult with pain management and educate staff related to his sensitivity .Date resolved: 01/10/23 and signed by SW and Admin. In an interview on 01/18/23 at 10:14 am, Resident #329 stated after he had hip surgery at the hospital he admitted to this facility and earlier this month, at night CNA A was rough handling him and hurt his hip as she was trying to reposition him. He stated he was not assessed by the nurses after he reported this incident and no x-rays done. He stated he had no problems getting repositioned currently because he told staff if they walked into his room by themselves and they looked too small, he requested for them to get a second person to assist him, so that his hip would not get hurt again. In an interview on 01/18/23 at 11:29 am, ADON B stated a day or two after Resident #329 admitted , the DON asked her to go to talk to Resident #329 because he said while he was getting care CNA A repositioned him using the draw pad and hurt his hip. He stated not being sure which nurse checked on him 30 minutes after his hip was hurt. She stated Resident #329 said CNA A was rough repositioning him and added he was a one person staff assist when he first admitted and still was because he could bear weight when standing. She stated she did not report his allegation to his charge nurse on duty, she said she assessed him for pain and assessed his leg and hip but did no incident/accident report or document the findings of his assessment and did not complete a nurses note because Resident #329 was not in any pain. She stated the DON just told her to talk to Resident #329 about what happened. In an interview on 01/18/23 at 1:17 pm, the DON stated Resident #329 complained about a CNA turning him and hurt his hip then the Admin and SW completed a Grievance Report. She stated they in-serviced the staff to ensure they moved him very delicately because he had an extremely low pain tolerance. She stated Resident #329 was evaluated by a pain management specialist and was not sure which CNA the resident was referring to who hurt his hip and stated she did not talk to the resident because ADON B did. She stated he told ADON B the lady wore blue and used the draw pad and turned him causing him pain. She stated there was no Incident report done because he had not fallen, had a skin tear, and his allegation did not fall under accidents to do an incident/accident report. She stated she was not sure why there was not any nurses notes or assessments after Resident #329 made the allegation about the CNA. She stated Resident #329 had a skin assessment on 01/12/23 and weekly nurses note for 1/10/23 but there was no documentation in the nurses note or weekly nurses' assessment about the allegation of the CNA hurting his hip and steps to assess and monitor the resident. She stated she was not sure which CNA hurt Resident 329's hip. In an interview on 01/18/23 at 1:34 pm, the SW stated the Admin wanted her to talk to Resident #329 on Wednesday 01/09/23 because he said the previous weekend (01/07/23) during the 2:00 pm to 10:00 pm shift, a lady wearing blue, hurt his hip. He stated CNA A came in after he pressed his call light and stated based on the description, she interviewed CNA A and she denied being rough with Resident #329 and had her complete 1:1 education with her to be gentler when turning the resident and to pay attention with what the resident was saying and if the resident needed more assistance, she should have asked. She stated CNA A had no other complaints about her being rough with the residents. In an interview on 01/18/23 at 1:52 pm, the Admin stated CNA A provided care to Resident #329 who said CNA A was rough with him. He stated there was probably an incident report and nurses notes in Resident #329's EMR and he was not sure if x-rays were done and would have to check with nursing because he was not having any pain issues. He stated they were able to determine it was CNA A, who was not very big and in her 60's, and strength-wise, she may not have had enough strength to turn him. He (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676466 If continuation sheet Page 12 of 21 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 676466 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cheyenne Medical Lodge 750 Highway 352 Mesquite, TX 75149 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few stated CNA A said she turned him like she normally did and was not being rough with Resident #329 and was just trying to turn him. In an interview on 01/18/23 at 2:53 pm, CNA A stated she worked the 2:00 pm to 10:00 pm shift and had taken care of Resident #329 in the past. She stated he had a broken right hip and said, He likes his stuff perfect. She stated he wanted his wedges positioned under the right side of his buttock and his upper back area. CNA A stated on 01/07/23 around 9:30 pm LVN E initially assisted her with repositioning Resident #329 earlier, then LVN E left, but he said he still was not comfortable. So she started repositioning the wedges the way he wanted it by pushing the wedges up under him and was trying to adjust his wedge cushions then he said she hurt his hip. She stated she apologized and for the remainder of the shift, CNA D took over caring for him. She stated Resident #329 could turn a little and was not able to move too well which was why she used a pad underneath him. She stated Resident #329 was a 2-person assist, but he wanted her to lift up the pad and push the wedge cushion, because he said he was in pain and needed to get pressure off of that side. She stated she repositioned him normally in the past with CNA D but that time, she repositioned him by herself and stated she would not hurt anyone. She stated she spoke to his Charge nurse about Resident #329 saying she hurt him but could not remember which nurse she spoke to. She stated the SW told her she needed to be as gentle as she could caring for the residents and the SW had her sign papers about the meeting. She stated she knew if a resident was a one or 2 person assist by looking at them to see if they could do for themselves and by asking the resident and the nurse. She stated if the staff could not completely care for the residents by themselves, they had to have 2 people to assist. She stated she normally went to the Admin if she had to report something, but he was not at the facility, so she reported this incident to the nurse. In an interview on 01/18/23 at 4:46 pm, Admin stated the DON was responsible for ensuring incident/accidents and nurses notes were completed. In an interview on 01/18/23 at 5:56 pm, the Regional Director stated the previous week, none of the nurses did an incident report because there was no concern of Resident #329 being injured. In an interview on 01/19/23 at 11:10 am, RN C stated Resident #329 had a fall at home, went to the hospital for right hip surgery and needed his leg immobilized during care and when they turned him, 2 staff was need with one person to hold his leg and the other to clean him or reposition him. He stated they used care plans, but he had not because he was not told to do so and that the MDS, SW, and DON used them. He stated care plans was for how to care for the resident's and know what their level of care was before providing care with expectations and treatment to resolve an issue or medical condition. He stated the CNAs asked the nurses if a resident was 1 or 2 person staff assist. He stated for Resident #329 it was a must that he received 2 person assist and there should not be just one person assisting him. He stated Resident #329 was alert and oriented X 4 and added if a resident complained of pain he would assess, to determine where was the pain was and the level of pain, give medication, document and 30 minutes later follow up to see if the medication was effective. In an interview on 01/19/23 at 11:33, CNA D stated he cared for Resident #329 and had no problems caring for him by himself because he was strong enough to move him and stated Resident #329 was a 2 person staff assist because Resident #329 was pretty tall and kind of heavy and CNA A was short. He stated he could tell if a resident was a one or 2 person assist by just kind of looking at them and by asking the resident what they could do. He said if it looked like he could safely transfer a resident he would do and added they had a medical record charting system, but it did not say if the residents were one or 2 person assist. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676466 If continuation sheet Page 13 of 21 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 676466 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cheyenne Medical Lodge 750 Highway 352 Mesquite, TX 75149 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few In an interview on 01/19/23 at 11:56 am, LVN E stated Saturday 01/07/23 she worked, and Resident #329 pressed his call light saying he needed to be turned and she started turning him by herself and he did not complain about his hip hurting. Then she stated CNA A came into his room, but she had already repositioned him then CNA A left his room. She stated being unaware CNA A had gone back into his room to reposition him and hurt his hip. She stated on Sunday 01/08/23 CNA A said she re-assigned herself and would not be taking care of Resident #329. LVN E stated she did not know why CNA A re-assigned herself from caring for Resident #329 and did not ask CNA A or Resident #329 why. She stated Resident #329 was a 2 person assist but changed him by herself because he could move to some extent. She stated they used care plans when caring for the residents and said she looked at the care plans for how to care for the residents. She stated the CNAs knew if a resident was a 1 or 2 person assist by asking the nurses and looking at the resident's ADL tablet, she thought. She stated if a resident was injured she would assess the resident, call the resident's doctor for further instructions, carryout the order, call the responsible party ,and complete an incident/accident report to check their vitals and pain level. In an interview on 01/19/23 at 2:00 pm, COTA F stated Resident #329 was a 2 person staff assist for ADL care and was not strong enough to extend his legs and could not stand up. She stated the CNA's asked her at times if a resident was a one or 2 person assist. In an interview on 01/19/23 at 2:09 pm, PTA G stated Resident #329 was a 2 person assist for ADL care because he was very weak transitioning from sit to stand and was so tall, had poor trunk control and too weak to stand. In an interview on 01/19/23 at 4:37 pm, MDS H stated she was the long term care MDS Nurse, after reviewing Resident #329's care plan, he needed assist with ADL care plan, but it did not say how many staff was needed to assist him. She stated when the nursing staff provided a resident 2 person staff assist at least 3 times, over a period of time on the CNA ADL task sheet, the resident's care plan should be changed to 2 person staff assistance. In an interview o 01/19/23 at 4:53 pm, MDS I stated she was the MDS nurse for Resident #329 and was not aware a CNA hurt Resident #329's hip. In an interview on 01/19/23 at 5:11 pm, the DON stated she found out just recently it was CNA A who caused Resident #329's hip injury when repositioning him. She stated Resident #329 was a 1 person assist she guessed but if his MDS Assessment was saying he was 2 person assist, then he was 2 person assistance. After review of his admission MDS assessment dated [DATE] she stated Resident #329 was an Extensive 2 person assist and had a Care Plan for 2 person staff assist for comfort. She stated she was not aware his Care Plan was just changed to 2 person assistance today (01/19/23). She stated Resident #329 had no Incident/Accident report done because he was not injured by CNA A but when CNA A moved him he said she hurt his hip. She stated on 01/07/23 they did a grievance report to address the issue and added from 01/07/23 to 01/09/23 there were no nurses notes and was not sure why his charge nurse at the time of the allegation was not made aware of his statement and documented and contacted his doctor and Responsible Party. She stated she was not sure why ADON B did not complete an Incident/accident report on Resident #329. In an interview on 01/19/23 at 6:12 pm, the Admin stated He stated he was not aware of any issues with the nurses not completing incident accidents and nurses notes and that Resident #329 did not have an incident/accident report and nurses notes from his 01/07/23 incident. He stated he was unaware the staff was caring for Resident #329 by themselves at times without a second staff member (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676466 If continuation sheet Page 14 of 21 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 676466 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cheyenne Medical Lodge 750 Highway 352 Mesquite, TX 75149 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 0689 assisting with patient care. Level of Harm - Minimal harm or potential for actual harm Record review of the facility's Incident/Accident Policy undated stated, Incident/Accident Policy: 1. The facility details in the medical record every accident or incident, including of mistreatment or residents by facility staff, medication errors, and drug reactions, 2. Accidents, whether or not resulting in injury, and any unusual incidents or abnormal events including allegations of mistreatment of residents by staff or personnel or visitors, shall be described in a separate administration record and reported by the facility in accordance with the licensure Act and this section .4. The facility investigates incidents/accidents and complaints for trends which may indicate resident abuse. Trends that might be identified include but are not limited to type of incident, type of injury, time of day, staff involved, staffing level and relationship to past complaints, Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676466 If continuation sheet Page 15 of 21 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 676466 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cheyenne Medical Lodge 750 Highway 352 Mesquite, TX 75149 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide pharmaceutical services to ensure the accurate acquiring, receiving, dispensing, administering, and securing of medications for 1 (Med Aide Cart) of 3 medication carts reviewed for pharmacy services. The facility failed to ensure MA K reported one damaged blister pack of Resident#98's Hydroco APAP tab 7.5-325 mg (controlled medication) and one damaged blister pack of Resident #116's Tramadol 50 mg tablet (controlled medication). This failure could place resident at risk of not having the medication available due to possible drug diversion and at risk of not receiving the intended therapeutic benefit of the medication. Findings included: Review of Resident #98's Quarterly MDS Assessment, dated 11/17/22, reflected Resident #98 was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses of muscle weakness, diabetes mellitus, arthritis, and dementia. Resident#98 had a BIMS of 11 indicating he was moderately impaired. Review of Resident #116's Comprehensive MDS Assessment, dated 10/24/22, reflected Resident #116 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of muscle weakness, diabetes mellitus, and pressure ulcer of sacral region. Resident#116 had a BIMS of 10 indicating she was moderately impaired. Observation on 01/17/2023 at 2:35 PM of the Med Aide Cart Hall 100 revealed the blister pack for Resident #98's Hydroco APAP 7.5-325 mg (pain reliver) had 1 blister seal broken and taped over, the pill was still inside the broken blister. The blister pack for Resident #116's Tramadol 50 mg (pain reliver) had 1 blister seal broken and taped over, the pill was still inside the broken blister. Interview on 01/17/23 at 2:44 PM, MA K stated she was unaware when the blister pack seals were broken (Resident #98's Hydroco APAP 7.5-325 mg and Resident #116's Tramadol 50 mg), MA K stated she was not aware of who might have damaged the blisters. She stated the risk of a damaged blisters was a potential for drug diversion. She stated the nurses and med aides were responsible for checking the medication blister packs for broken seals during the count of narcotics during the change of the shifts. MA K stated the count was done at shift change and the count was correct. She stated she did not see the broken blister during the count. At that time the count was done by the surveyor and was compared to the blister packs and the count was correct. Interview on 01/19/23 at 4:30 PM, DON stated if a blister pack medication seal was broken, the pill should have been discarded. DON stated it would not be acceptable to keep a pill in a blister pack that was opened. DON stated the risk would be losing the medication because the seal was broken. DON stated nurses were responsible for checking the medication blister packs for broken seals. DON stated the ADON were responsible to check the carts randomly and the pharmacy consultant checks the carts monthly. Record review of facility's policy titled Drug Security not dated, reflected the following: . The facility will be responsible for medication security, accurate information, and medication compliance FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676466 If continuation sheet Page 16 of 21 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 676466 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cheyenne Medical Lodge 750 Highway 352 Mesquite, TX 75149 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. Based on observation, interview, and record review, the facility failed to assure that medications were secure and inaccessible to unauthorized staff and residents for 1 (nurses medication cart) of 3 medication carts reviewed for medication storage. The facility failed to ensure: The medication supplies were secured or attended by authorized staff when the nurses cart in hall 100 was left unlocked and unattended in the hall way 100. This failure could place residents at risk to access and ingest of medications leading to a risk for harm, and could lead to missing medication. The findings include: Observation and interview on 01/18/2023 at 7:55 AM, LVN N stepped away from the medication cart, she entered Resident #97 room with the blood pressure cuff to check resident's blood pressure. LVN N left the nurses medication cart in hallway 100, by room117, unlocked. The lock was in the out position and the drawers were able to be opened, leaving the medications accessible. The following medications were in the cart: Losartan 50 mg, amlodipine 10 mg, Januvia 50 mg, citalopram 10 mg, and other medication. One resident was observed in the hallway in his wheelchair during the observation. LVN N stated they did not normally leave the cart unlocked. LVN N stated she was taught medication carts should be locked when not in use or out of sight because a resident could take the medications. Interview on 01/19/23 at 4:30 PM, DON stated it was her expectation that medication and treatment carts were locked when not in use. DON stated if they were not locked, residents and staff could get into the cart and there would be opportunities for harm and medication to go missing. Record review of facility's policy titled Drug Security not dated, reflected the following: . A drug distribution cart is used by the facility and when not in use it will be locked and secured in the locked medication room FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676466 If continuation sheet Page 17 of 21 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 676466 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cheyenne Medical Lodge 750 Highway 352 Mesquite, TX 75149 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 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food safety in the facility's only kitchen. Residents Affected - Some The facility failed to ensure that food items past their expiration date were discarded. This failure could place residents at risk for food borne illness. Findings included: In an observation and interview with Kitchen Manager on 1/17/23 at 9:22 a.m., while conducting a tour of the facility's refrigerated walk-in storage area an open box of Otis-Spunkmeyer Cookie Dough was discovered to be open to the air. The box stated, Keep Frozen, there was no opened by date, and no expiration date that could be easily located on the box. The box was found in the refrigerator and not the freezer area. The Kitchen Manager was then observed immediately discarding the box of Otis-Spunkmeyer Cookie Dough The Kitchen Manager relayed that the box should have been kept in the freezer and that the box should have been marked with an opened date and expiration date. She further relayed that if expired foods were served to residents, it could cause the residents to become sick. In an observation and interview with Kitchen Manager on 1/17/23 at 9:26 a.m. while conducting a tour of the facility walk-in refrigerated area an unmarked stainless-steel container covered with aluminum foil was discovered on one of the walk-in refrigerator shelves. The container appeared to contain yellow liquid and what appeared to be tan noodles in it. The item was immediately removed and discarded by Kitchen Manager. Kitchen Manager stated that: Our policy is that we must mark what the food is and the expiration date, if we don't then we don't know when foods might expire and that could make our residents sick. In an observation and interview with Dietary Manager on 1/18/23 at 4:50 p.m., while conducting a tour of the facility's walk-in refrigerated area, an unmarked clear plastic container was discovered on a shelf in the walk-in refrigerator that appeared to contain cheese slices wrapped in plastic. Dietary Manager was observed immediately discarding the container of cheese slices and stated that: It is our policy here that we mark all leftovers and opened foods with the opened date and the discard date. If we do not have opened on and expiration dates, we could expose our residents to food borne illnesses. Review of the undated facility's policy entitled Operational/Resident Care Policies page IX.8 under the subtitle Sanitary Conditions the policy stated that Food in unlabeled or damaged containers shall not be accepted or retained. The Food and Drug Administration Food Code dated 2017 reflected, 3-305.11 Food Storage. (A) .food shall be protected from contamination by storing the food: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination .(B) .refrigerated, ready-to eat time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676466 If continuation sheet Page 18 of 21 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 676466 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cheyenne Medical Lodge 750 Highway 352 Mesquite, TX 75149 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete section and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking . Date marking is the mechanism by which the Food Code requires active managerial control of the temperature and time combinations for cold holding. Industry must implement a system of identifying the date or day by which the food must be consumed, sold, or discarded. Event ID: Facility ID: 676466 If continuation sheet Page 19 of 21 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 676466 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cheyenne Medical Lodge 750 Highway 352 Mesquite, TX 75149 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain an infection prevention and control program designated to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 3 (Resident #52, Resident #97, and Resident#114) of 5 residents reviewed for infection control. Residents Affected - Some The facility failed to ensure MA L disinfected the blood pressure cuff in between blood pressure checks for Residents #52, #97, and #114. This failure could place residents at-risk of cross contamination which could result in infections or illness. Findings included: Review of Resident 52's Quarterly MDS, dated [DATE], revealed the resident was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included elevated blood pressure, muscle weakness, and anxiety. Review of Resident #52's physician orders dated 01/19/23 reflected, telmisartan tablet; 40 mg, give 1 tablet by mouth, one time per day - Special instruction: Hold for systolic blood pressure less than 100 and or diastolic blood pressure less than 60. Review of Resident #97's Quarterly MDS, dated [DATE], revealed the resident was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses including elevated blood pressure, hypercholesterolemia (an abnormal high concentration of fats or lipids in the blood), and muscle weakness. Resident#97 had a BIMS of 5 indicating she was severely impaired. Review of Resident #97's Physician Orders dated 01/19/23 reflected, losartan potassium tablet 100 mg, give 1 tablet by mouth, one time a day - Special instruction: Hold for systolic blood pressure less than 100, diastolic blood pressure less than 55, and when the heart rate is less than 55. Review of Resident #114's Quarterly MDS Assessment, dated 10/19/22, reflected she was a [AGE] year-old female admitted to the facility on [DATE], with diagnoses including elevated blood pressure, dementia, and muscle weakness. Resident#114 had a BIMS of 8 indicating she was moderately impaired. Review of Resident #114's Physician Orders dated 01/19/23 reflected, Norvasc tablet 5 mg give 1 tablet by mouth one time a day - Special instruction: Hold for systolic blood pressure less than 110. Observation on 01/18/23 at 7:40 AM revealed MA L performing morning medication pass, during which time MA L checked the blood pressures on Resident #114. MA L did not sanitize the blood pressure cuff before or after using it on Resident #114. MA D put the blood pressure cuff on top of the medication cart after use. Observation on 01/18/23 at 7:51 AM revealed MA L continued to perform morning medication pass, during which time she checked the blood pressure on Resident #97. MA L used the same blood pressure cuff right after using it on Resident#114. MA L did not sanitize the blood pressure cuff before or after using it on Resident #97. She left the blood pressure cuff on top of the medication cart. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676466 If continuation sheet Page 20 of 21 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 676466 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cheyenne Medical Lodge 750 Highway 352 Mesquite, TX 75149 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Observation on 01/18/23 at 8:16 AM revealed MA L continued to perform morning medication pass, during which time she checked the blood pressure on Resident #52. MA L used the same blood pressure cuff right after using it on Resident#97. MA L did not sanitize the blood pressure cuff before or after using it on Resident #52. Interview on 01/18/23 at 8:25 AM, MA L stated reusable equipment, like blood pressure cuffs, should be sanitized with wipes between each resident use (before and after use on each resident) in order to prevent transmitting of infection from one resident to another. MA L stated she forgot to wipe the cuff this time. Interview on 01/19/23 at 4:30 PM, DON stated that her expectation was that staff would sanitize all reusable equipment between each resident use. DON stated that not doing so placed residents at risk of cross contamination of infections from one resident to another. DON stated she was responsible for training staff on infection control. DON stated that she did routine rounds in the floor to ensure the nurses and med aids were following proper infection control procedures. Record review of facility's policy Cleaning Multi Use Medical Equipment, dated August 2012, reflected Policy - Multi use medical equipment such as glucometers, blood pressure cuffs, stethoscopes and other medical equipment that goes in and out of Patient's rooms will be disinfected before and after using the equipment with an antiviral wipe or approved disinfectant solution. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676466 If continuation sheet Page 21 of 21