Inspection·October 20, 2022

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few revealed that she had a fall in the restroom the day prior and was unable to find a call light to pull so she had to yell for help. Interview on 10/18/2022 at approximately 10:20 AM with LVN A stated the call button should always be left in reach of the resident. LVN A stated that she tries to remember to hand it back to resident when she leaves the room. LVN A stated the call light was out of reach when she entered the room of Resident #36. Interview revealed that she was the Nurse usually assigned to the hallway resident is located. LVN A stated that she was not present on the hallway when resident had a fall the day prior. Interview on 10/18/22 at 10:50 AM, with CNA A revealed that she did not observe if Resident #36 call light was within reach when she went into her room this morning. Interview revealed that she went into resident's room to deliver her breakfast tray and not because her call light was on. Interview revealed that CNA A believed that a resident without a call light could place them at risk for harm or danger due to not being able to call for assistance if needed. Interview on 10/19/22 at 1:30 PM, with ADON D revealed she was not aware of Resident #36's call light was not being left in reach. Resident expressed her concern that her call light was often not left where she could locate it. Interview with ADON D revealed that she will periodically check on resident during the day and she also do an in-service training with her staff on the importance of making sure that all call lights be left in reach of the residents. ADON D stated that a resident without a call light could place them at risk for being neglected because they are unable to call for assistance as needed. Observation on 10/20/2022 PM at 9:10 AM of Resident #36's call light was laying across her midsection and she was asleep. Record review on 10/20/2022 at 10:00 AM revealed Section C of Facility Policy handbook entitled, Call Lights revealed Procedure #9 states, The call light must always be within resident's reach before you leave the room. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676485 If continuation sheet Page 2 of 18 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 676485 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Princeton Medical Lodge 1401 W. Princeton Dr. Princeton, TX 75407 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, including procedures for administering drugs via enteral feeding tube , for one (Residents #209) of one resident reviewed for feeding tubes. RN A failed to flush Resident #209's G-Tube with 30 ccs of water prior to medication administration, failed to flush with water between each medication given and failed to ensure Vit D 3 was adequately dissolved prior to administering through the resident's G-tube. These failures could affect residents by placing them at risk of abdominal discomfort, obstruction of the G-tube and incomplete medication administrations. Findings included: Resident #209's Annual MDS assessment, dated 09/09/22, reflected a [AGE] year-old female admitted to the facility on [DATE]. Resident #209 had a BIMs of 9 which indicated she was moderately cognitively impaired. Resident received 51% or more of total calories through tube feeding (G-tube - tube inserted through the abdomen that delivers nutrition directly to the stomach.). Active diagnoses included hemiplegia (paralysis of one side of the body), diabetes, dementia, and dysphagia (difficulty swallowing) Resident #209's Care Plan, revised on 08/26/22, reflected, .Resident requires a PEG tube for adequate nutritional intake-refuses tube feedings at times, wants food/hydration po .Goal .No s/sx aspiration through next review .Resident will not experience adverse effects from placement of a PEG tube . Review of Resident #209's Physicians Order Summary Report for October 2022, reflected, .Enteral Feed order every shift G-Tube- Med administration=Flush with 30cc of H2O Before med administration. Give Each medication separately, mixed with small amount H2O to mix/dissolve. Flush Between each med with 5-30 ml H2O. Flush with 30cc H2O after med administration . with a start date of 08/26/21. Review of Resident #209's MAR for October 2022 reflected, .Enteral Feed order every shift G-Tube- Med administration=Flush with 30cc of H2O Before med administration. Give Each medication separately, mixed with small amount H2O to mix/dissolve. Flush Between each med with 5-30 ml H2O. Flush with 30cc H2O after med administration . with a start date of 08/26/21. An observation on 10/19/22 at 09:05 a.m. revealed RN A at the medication cart pulling the following medications for G-tube administration for Resident #209: Potassium Chloride Liquid 20 meq/15 ml - 15 ml Gabapentin 100 mg 1 capsule Multi vitamin- 1 tablet Cholecalciferol (vitamin D3) 125 mcg (5,000 units) 1 tablet (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676485 If continuation sheet Page 3 of 18 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 676485 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Princeton Medical Lodge 1401 W. Princeton Dr. Princeton, TX 75407 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 Colace 100 mg 1 tablet Level of Harm - Minimal harm or potential for actual harm Buspar 10 mg 1 tablet Tramadol 50 mg 1 tablet Residents Affected - Few Norvasc 5 mg 1 tablet Coreq 12.5 mg 1 tablet Miralax Powder 17 gm/ scoop 1 scoop RN A placed each of the tablets into a plastic sleeve and crushed them and opened the one capsule and placed its contents into a plastic sleeve and placed the Miralax powder into a drinking cup and diluted it with approximately 8 ounces of water. RN A gathered the 9 plastic sleeves with the crushed medications and several plastic water cups and entered the resident's room. RN A filled a large plastic container with water, washed her hands and put on gloves and placed the enteral feeding pump on hold. She retrieved a stethoscope and a 60-cc piston syringe and drew up approximately 20 cc of air and placed the syringe in the end of the resident's G-tube and pushed the air and listened with the stethoscope to check for placement and then drew back to check for residual. RN A then removed the plunger from the syringe and poured 15 cc of water into the tube. RN A then added a small amount of water to the liquid Potassium chloride and administered the medication and flushed with a small amount of water. RN A then poured the crushed Norvasc tablet into a drinking cup and added some water and swirled it around and then poured it into the G-Tube. She did not flush the G-tube with water. She then poured the crushed Coreq tablet into another drinking cup, added water and poured it into the G-Tube. RN A then repeated this process, one pill at a time, with 4 more pills, flushing with water between each pill until she attempted to dissolve the Vitamin D3, which would no dissolve with just swishing. RN A closed of the G-Tube, left the room to retrieve a spoon, and came back and tried to dissolve the crushed Vitamin D3 by adding more water. RN A then administered the Vitamin D 3 which was still not completely dissolved. She then poured approximately 45 ccs of water into the Syringe to try and clear the residue that was stuck inside the syringe. RN A then proceeded with the remaining two medications, Buspar and the MVT, dissolving each one, one at a time, and failed to flush with water between to the two medications. The resident refused the Miralax. RN A then flushed the G-Tube with 15 ccs of water after the final medication administration. In an interview with RN A on 10/19/22 at 09:45 a.m., she stated it had not occurred to her to dissolve all the medication in water prior to starting the medication administration. When asked what the procedure was for water flushes during medication administration, she pulled up the medication administration order and stated she should have flushed the G-Tube with 30cc of water before and after, instead of 15 ccs. She stated she was also supposed to flush between each medication with a small amount of water. She stated she did not realize she had missed flushing between some of the medications. When asked what could happen if flushing with appropriate amount of water, or inadequate dissolving of medications, she stated it could cause the G-tube to clog and the resident could not receive the full dose of medication if it was not adequately dissolved. Review of RN A's Skills Checklist dated 10/25/21 reflected she was proficient in G-Tube medication administration. In an interview with the DON on 10/20/22 at 9:45 a.m. he stated the staff was to flush the G-Tubes (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676485 If continuation sheet Page 4 of 18 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 676485 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Princeton Medical Lodge 1401 W. Princeton Dr. Princeton, TX 75407 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 with the amount of water ordered before and after medications and always flush with water between each medication. He stated they were ensuring the medications were completely dissolved prior to administering them through the G-tube. He stated failing to flush with the ordered amount of water and not dissolving the medication could result in a clogged G-Tube and could prevent the resident from receiving the prescribed amount of medication. Residents Affected - Few Review of https://www.in.gov/isdh/files/l52.pdf - Administering medications via the Gastrostomy Tube, searched on 10/21/22, page 3, reflected, .Flush the tube with approximately 30cc of water. Administer the medication(s); flush with 30 ccs of water after the final medication is administered. Verify that medication cups are clear of any remnants of crushed pills or liquid medication Do not force any medication or fluid into the tube. Allow gravity to work as possible. Deliver the medication slowly and steadily. Don't allow the fluid to flow in too quickly .cramping could occur . Review of the facility's undated policy, Tube (Medication administration), reflected, .Confirm Physician's orders .Crush each medication, which is not in liquid form, and place each medication in a separate cup. Dissolve/mix each medication in a small amount of water .empty capsule contents into a small amount of tap water .dilute liquids with water, using up to 60 ml of water for highly concentrated solutions. Crush each medication separately and dilute separately .Check for correct placement of tube .Flush tube with at least 5 cc of water prior to medication administration. Mediations are never added directly to the feeding solution. Keep in mind any possible fluid restrictions the patient may have and adjust accordingly .Instill 50 cc of water .to be sure tube is patent .Follow water with dissolved medication, giving each medication separately .Administer the diluted crushed tablets first, then the liquid medications .Flush the tube with water and clamp to prevent mediation from clogging tube . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676485 If continuation sheet Page 5 of 18 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 676485 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Princeton Medical Lodge 1401 W. Princeton Dr. Princeton, TX 75407 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and record review, the facility failed to ensure that it was free of medication error rate of 5 percent or greater. 36 opportunities were observed with a total of four errors, resulting in a 11 percent medication error rate. Two (MA B and MA C) of four staff observed administering medication made errors. Two (Residents #76 and Resident # 16) of four residents observed during the medication pass was affected. Residents Affected - Some 1. MA C administered Zinc 50 mg instead of Zinc 100 mg and failed to administer Cholecalciferol 1000 units 2 tablets per physician orders to Resident #76. 2. MA B administered Zinc 50 mg instead of Zinc 100 mg and administered Calcium 500mg +D 1 tab, instead of administering Calcium 500 mg per physician orders to Resident #16. These failures residents at risk for not receiving the intended therapeutic benefit of their medications or receiving them as prescribed, per physician orders. Findings included: 1. Review of Resident #76's Face sheet dated 10/20/22 reflected a [AGE] year-old female with an admission date of 10/29/21. Residents #76's primary diagnoses include diabetes, malignant neoplasm (cancer) of right breast and COVID. An observation of the medication pass on 10/19/22 at 08:50 a.m., revealed MA C administered 1 tablet of Zinc 50 mg, (mineral used for immune health) along with nine additional medications to Resident #76. MA C did not administer Cholecalciferol (Vitamin D for bone strength) 1000 units 2 tablets. Review of Resident #76's Physician orders for October 2022, reflected .Zinc 100 mg 1 tablet by mouth for 10 days with a start date of 10/13/22 and a stop date of 10/23/22 Cholecalciferol Tablet 1000 unit 2 tablets by mouth for 10 days with a start date of 10/13/22 and a stop date of 10/23/22 . Interview with MA C on 10/19/22 at 8:30 a.m., when asked to review Resident #76's medications orders for Zinc she pulled up the Medication orders and stated she should have given 2 tablets of the Zinc 50 mg since the order was for Zinc 100 mg. She stated she saw the 1 tablet on the administration record and failed to check the dosage of the bottle. When asked why she had not given the Cholecalciferol 1000 units 2 tablets, she stated it had not popped up on the computer for her to administer it. She stated it showed up on the computer screen with the Resident's other medication but did not indicate she was supposed to administered it. She stated she had not asked anyone why the medication was showing up like this. Review of Resident #76's MAR for October 2022 reflected, Cholecalciferol tablet 1000 unit Give 2 tablet by mouth start date 10/13/22 It was coded with U-SA on all days from 10/13/22 to 10/19/22. Review of the reference codes on the MAR did not reflect what U-SA indicated. Interview with ADON C on 10/19/22 at 1:30 p.m. revealed she was unsure what U-SA code on Resident #76's MAR indicated. She stated MA C should have verified with the charge nurse when the Cholecalciferol 1000 units would not let her sign out for administration. She stated she would have to research to determine why U-SA was populating on the MAR. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676485 If continuation sheet Page 6 of 18 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 676485 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Princeton Medical Lodge 1401 W. Princeton Dr. Princeton, TX 75407 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 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interview with the Corporate Nurse on 10/19/22 at 3:30 p.m. revealed when the order for Cholecalciferol 1000 units 2 tablets had been put into the system, the staff had inadvertently checked Unsupervised -Self-administered, which would cause it to show up on the Mediation Administration but would not let the staff sign it out as administered. She stated it was a data entry error, which then led to the medication error. She stated MA C should have alerted the nurse or the ADON when she was not sure about the medication. She stated the error in the system had been corrected. 2. Record Review of Resident #16's Face Sheet dated 10/20/22 reflected a [AGE] year-old female with an admission date of 07/18/22. Her diagnoses included dementia, anxiety disorder, cerebral palsy (disorder of movement) and paraplegia (paralysis of the lower limbs). An observation of the medication pass on 10/19/22 at 09:50 a.m., revealed MA B administered 1 tablet of Zinc 50 mg, (mineral used for immune health) and Calcium (Mineral for bone health) 500 mg +D 1 tablet along with 14 additional medications to Resident #16. Record Review of Resident #16's Physician orders for October 2022, reflected, .Zinc 100 mg 1 tablet by mouth for 10 days with a start date of 10/14/22 and an end date of 10/23/22 .Oyster Shell Calcium 500 mg q tablet by mouth with a start date of 07/19/22 In an interview with MA B on 10/19/22 at 12:35 p.m. revealed her checking the bottle of Zinc in her medication cart, revealing it was only 50 mg. She stated she should have given 2 tablets of the Zinc 50 mg and had the nurse correct the order. She stated she saw the 1 tablet on the Medication administration record and failed to double check the dosage. She stated she only had Calcium 500 mg with D on her medication cart. She stated she had asked the Central Supply clerk for plain calcium and was told this was all they had, so that was what she had been giving to Resident #16. She stated she should have clarified it with the nurse, since it did not match the Medication administration order. In an interview with the Central Supply Clerk on 10/19/22 at 1:45 p.m. revealed the staff were supposed to clarify any discrepancy with the nurse on medication orders. She stated if the nurse determined they needed a specific over the counter medication after clarifying it with the physician, then they were to place it on a log sheet in central supply. She stated if it was not in their pharmacy formulary then she would go to the local pharmacy and pick up whatever was needed. She stated Oyster Shell Calcium 500 mg was never placed on her log sheet for her to request. She stated the only 500 mg Calcium she had in stock was Calcium 500 mg with D. In an interview with the DON on 10/20/22 at 09:35 a.m., He stated he expected the staff to follow the 5 rights of medication administration which are right drug, right dose, right route, right patient, and right time. He stated failing to follow these rights put residents at risk of not receiving all their medications or could lead to drug interactions if the correct medication or dosage was not given. He stated the MAs should always go to the Charge nurse, the ADON or himself if there were any question about a medication and they should clarify with the physician if they did not have a prescribed over the counter medication in stock. Review of the facility's undated policy titled, Medication Cart, Administration of Drugs, reflected, .Read medication orders on medication sheet and have medication cup ready .Remove mediation container (blister pack or bottle) and compare label and medication sheet. Place appropriate dosage into souffle 'cup. Re-Read label and medication sheet and return drug to its proper location .Administer medication to resident .Make appropriate entry on E-MAR . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676485 If continuation sheet Page 7 of 18 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 676485 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Princeton Medical Lodge 1401 W. Princeton Dr. Princeton, TX 75407 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 observations, interview, and record review, the facility failed to, in accordance with State and Federal laws, ensure all drugs were stored in locked compartments under proper temperature controls, and permit only authorized personnel to have access to these drugs, to meet the needs of each resident, for 1(Resident #) of 32 residents reviewed for medication storage. The facility failed to ensure Resident #87 did not have prescription pills and unsecured medication in his room on 10/18/22. This deficient practice could place residents at risk of, not being monitored for their medications, adverse reactions, and drug diversion. Findings included: Review of Resident #87's face sheet dated 10/20/22 reflected Resident #87 was a [AGE] year-old male admitted on [DATE] to the facility with diagnoses that included Parkinson's disease (disorder of the central nervous system that affects movement), Hypertension and Gastro-esophageal reflux disease. Review of Resident #87's quarterly MDS assessment dated [DATE] reflected he had a BIMS of 11 indicating he was moderately cognitively impaired. Review of Resident #87's Care Plan reflected on 01/20/22 with target date of 10/24/22 that Resident #87 had GERD (Gastroesophageal reflux disease). Intervention included to give medication as ordered. Monitor/document side effects and effectiveness. The comprehensive care plan did not reflect Resident #87 could self-administer his medications and keep medications in his room. Review of Resident #87's physician order dated 05/23/22 indicate to give Omeprazole 20 mg to give 1 capsule 5:30 AM in the morning for GERD - admin before breakfast. Review of Resident #87's MAR/TAR for October 2022 reflected the resident was given Omeprazole 20 mg on the following dates: Resident #87 was given his Omeprazole on *10/16/22 and 10/17/22 by LVN H ,and * 10/18/22 by RN J There was no other medications given by night shift. Further review of the MAR/TAR reflected Resident #87's next medication time was at 8 AM. Observation and Interview on 10/18/22 at 10:40 AM revealed Resident # 87 had an unknown pill in a plastic container with a pill inside on his bedside table, the pill had 12A written on it. There was no facility staff in resident room. Resident #87 stated he saw it in his room yesterday (10/17/22) after he woke up in the morning. He stated he was not sure who brought it in and maybe the pill was for his itching. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676485 If continuation sheet Page 8 of 18 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 676485 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Princeton Medical Lodge 1401 W. Princeton Dr. Princeton, TX 75407 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 Interview on 10/18/22 at 10:44 AM with RN F revealed he did not give Resident #87 any medications this morning, but medication aide would have given him medications. Interview on 10/18/22 at 10:47 AM with MA C revealed Resident #87 did tell her he would take his medications later and sometimes left the room without him taking all his medications . She did not recall seeing Resident #87 having a pill in his room when she gave him morning medications. In a Interview on 10/19/22 at 3:10 PM with MA C revealed this morning she saw Resident #87 had an unknown pill in the pill container on his bedside table when she came to give him his morning medications today. She stated the pill was his Omeprazole 20 mg pill Resident #87 had an order at 5 am. She stated Resident #87 took this Omeprazole pill along with the medications she was responsible for administering to him. Med Aide C stated she did not document about this pill and the night nurse was responsible for giving and documenting this medication in the morning. She stated she did not inform the nurse or any other staff about Resident #87 taking this pill which was not ordered at time he took it. She stated she was aware she had to stay in resident room to ensure resident took all medications and if resident did not she needed to take it with her to document refusal and dispose of medication . Observation and Interview on 10/18/22 at 10:51 AM revealed Resident #87 had an unknown pill in a plastic container with 12A on it on his bedside table in resident room. Resident #87 stated MA C gave him medication this morning and took his medication while MA C was in his room. He stated the pill was left from yesterday but not sure who brought it and what medication it was for. He stated he was asleep and woke up noticing it was there on bedside table . Observation on 10/18/22 at 10:53 AM revealed RN F took the pill container with unknown pill out of Resident #87's room. Interview on 10:58 AM with RN F revealed the unknown pill looked like it was Omeprazole and observation of Omeprazole 20 mg pill from pill bottle revealed it was the same pill. He stated according to Resident #87's physician order and MAR/TAR Resident #87 was given Omeprazole 20 mg daily at 5:30 AM so it would have to be night shift nurse giving medication since medication aide did not arrive until 6 am. He further stated he was not aware Resident #87 had medication in his room. He stated when administering resident medication the med aide or nurse should stay in resident room while resident takes medication. He stated if resident refuses to take medication then it should be taken out of room and be documented on MAR/TAR of resident refusal. Interview on 10/19/22 at 2:42 PM with RN J revealed when Resident #87 does not take his morning medication of Omeprazole she will leave the medication pill with MA C to give at a later time. She stated she did not know how Resident #87's morning pill was found in his room on 10/18/22 and should not be left in resident room unless he takes the medication. She stated there was no medication aide on night shift when Resident #87's Omeprazole pill was ordered so the nurse on night shift was responsible for administering this medication to Resident #87. Interview on 10/19/22 at 2:53 PM with LVN H revealed Resident #87 did have a 5 AM medication of Omeprazole and usually Resident #87 was asleep so she will have to wake him up and if not able to give it to him due to sleeping she will come back later to give it to resident. She stated Resident #87 took his medication when LVN H was in room. She stated Resident #87 would ask them to leave the medication in room and take later but she would not do that. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676485 If continuation sheet Page 9 of 18 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 676485 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Princeton Medical Lodge 1401 W. Princeton Dr. Princeton, TX 75407 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 Interview on 10/19/22 at 3:33 PM with Resident #87 revealed his morning medication pill that was his room earlier was Zantac. He stated he sometimes was awakened as early as 4:30 AM for the 5:30 AM by night nurse to take this pill and expressed interest in wanting to see if he could take it a little later. Interview on 10/19/22 at 3:37 PM with ADON D revealed Resident #87 should not have medications in his room and did not self-administer his medications. She stated Resident #87 did tell her before he would take medications later when she worked the floor, but she would tell Resident #87 she had to watch him take medication. She stated she expected the Med Aide or Nurse to administer Resident #87's medications as ordered and stay in room while resident takes the medication. She stated they should not leave resident room without taking medication pill out of room with them if resident refuses or did not want to take it. She stated medications should not be passed along to next shift and be given as ordered by physician. She stated MA C should have reported it to the nurse this morning Resident #87 had a pill in his room and take it out of resident room. She stated she would follow-up with Resident #87 and physician to see about Resident #87's medication being given a little later. Review of the facility's policy Storage of Drugs undated reflected All drugs and biologicals are stored in locked compartments under proper temperature .Only authorized personnel are permitted to have access to the medication keys. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676485 If continuation sheet Page 10 of 18 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 676485 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Princeton Medical Lodge 1401 W. Princeton Dr. Princeton, TX 75407 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 Based on observation, interview, and record review the facility failed to provide food that was palatable, served at an appetizing temperature, and prepared by methods which conserved the nutritive value, flavor, and appearance for one (Lunch 10/19/22) of one meals observed for food texture and palatability. Residents Affected - Some The facility failed to provide lunch hall trays with bread that was palpable and in a form to meet the needs of individual residents on 10/19/22. This failure placed residents at risk of possibly choking and create a potential for weight loss and a decline in their quality of life. Findings included: In an interview on 10/18/22 at 11:05 a.m. Resident #64 was in his room and stated, The food is over cooked. The resident showed the surveyor the bacon from breakfast. Observation revealed the bacon was hard. Interview on 10/18/22 at 10:28 a.m. , Resident # 55 revealed food was overcooked and can be tough to eat. Observation on 10/19/22 at 12:50 p.m revealed the last hall and meal tray for residents was served on 100 hall. In an observation on 10/19/22 at 12:58 p.m. revealed a regular lunch test tray with bread that was extremely hard. It would break and crumble. Surveyor was unable to bite into the bread. Interview on 10/19/22 at 1:28 PM, the Dietary Manager revealed the garlic bread toast served for lunch today could be more difficult on residents to swallow and chew since the bread was hard. She stated she would have to look into cooking temperature times of the garlic bread toast to ensure it is not overcooked. In an interview on 10/19/22 at 01:05 p.m. the ADON revealed the bread was hard. She stated the bread would be hard and difficult to eat. She stated the residents could choke or maybe cause teeth pain. Review of the facility's policy, Preparation of Foods, revised 4/9/19, reflected, .all food will be prepared by methods In a form to meet the individual needs of the resident .food is not overcooked . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676485 If continuation sheet Page 11 of 18 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 676485 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Princeton Medical Lodge 1401 W. Princeton Dr. Princeton, TX 75407 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, interview and record review, the facility failed to provide each resident with a diet taking into consideration the preferences of each resident for one (Resident #27) of eight residents reviewed for dietary preferences. The facility failed to provide Resident #27 with double portions as requested. This failure placed residents at risk of not having an opportunity to exercise choices for meals and created a potential for weight loss and a decline in their quality of life. Findings included: Review of Resident #27's Face Sheet dated 10/19/22, revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses including diabetes mellitus type 2, overactive bladder, and hypertension. Review of Resident #27's Care Plan dated 01/08/22, revealed the resident was at risk for dehydration and/or weight loss .will maintain current weight x 90 days . It did not reflect double portions for Resident #27. Review of Residents #27's breakfast meal ticket for 10/19/22 reflected, Alerts: Double Portions. Interview with Resident #27 on 10/19/22 at 10:11 am revealed she was not given enough food. The resident stated the fruit plate was not a double portion. Interview revealed she was told that the facility would provide double portion of her food. The resident stated, they haven't been doing it. It is on my meal ticket for double portions. In an observation and interview on 10/19/22 at 12:45 p.m. revealed one plate with approximately half the plate with cottage cheese, six orange slices, four strawberry slices, and six grape slices. The meal ticket stated double portions. The Corporate nurse, stated she was not sure if the meal provided was double portions. At that time, she stated she was going to talk to the dietary manager. The Corporate Nurse came back with a second plate. She stated it was one serving, so the dietary manager gave her another plate. The Corporate nurse stated the way it was served made it difficult to be able to tell if it was a single or double portion and that was why it might have been missed . Interview on 10/19/22 at 1:28 PM, the Dietary Manager revealed Resident #27 did have an order for double portion on her meal tray. She stated for lunch on 10/19/22 Resident #27 ordered alternative of cottage cheese with fruit. She stated double portions for Resident #27 should have been 2 plates of cottage cheese and fruit. The Dietary Manager stated since Resident #27 ordered an alternate food option it was missed to give her double portions. She stated going forward she would ensure when Resident #27 ordered food alternates she received double portions for her meals . In an interview on 10/19/22 at 01:05 p.m. the ADON stated nursing should be helping check trays to make sure what it looks like. The ADON stated that maybe there needs to be an inservice to discuss what the portions should look like. The ADON stated education was always important. Interview revealed the ADON was not sure why the resident did not receive double portions. The ADON stated that she (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676485 If continuation sheet Page 12 of 18 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 676485 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Princeton Medical Lodge 1401 W. Princeton Dr. Princeton, TX 75407 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 had not received a complaint from Resident #27. Level of Harm - Minimal harm or potential for actual harm Review of the facility's policy, Preparation of Foods, revised 4/9/19, reflected, .all food will be prepared by methods In a form to meet the individual needs of the resident . Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676485 If continuation sheet Page 13 of 18 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 676485 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Princeton Medical Lodge 1401 W. Princeton Dr. Princeton, TX 75407 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. Based on observations, interviews and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for the facility's only kitchen reviewed for kitchen sanitation. 1. The facility failed to ensure grease trap in oven was not full of food debris and grease buildup. 2. The facility failed to ensure the fryer with grease was covered and clean when not in use. 3. Dietary Aides K and L failed to wash hands during lunch preparation of meal trays. These failures could place residents at risk for food contamination and food-borne illness. Findings included: 1. Observation on 10/18/22 at 9:42 AM of grease trap on stove top was difficult to open but Dietary Manager was able to open it after forcing it open. The grease trap was covered on outside sides with sticky and hard brownish and black buildup. The inside bottom of grease trap about 1 inch of yellowish, brownish and blackish buildup of grease and food buildup. There was 2 fries along with 1 inch white plastic piece on top of hard blackish buildup at least ½ inch. Interview on 10/18/22 at 9:43 AM, Dietary [NAME] M revealed she last cleaned the grease trap about 3 weeks ago. Interview on 10/18/22 at 9:44 AM, the Dietary Manger revealed the Dietary Cooks were responsible for cleaning the grease trap. She further stated she did not have it listed on the cleaning schedule and thought it was getting done. She moved the grease trap to 3 compartment sink to be cleaned. She stated the grease trap needed to be cleaned up with that much buildup. Review of the facility's policy on Cleaning Ranges/Grills revised 01/01/2010 reflected Ranges/grills will be kept clean and free of spills and grease. Under procedure for each shift about range reflected .4. Remove grease trap and wash in hot detergent water. Use a stiff bristle brush to remove hard to remove spills. Rinse in fresh, hot water. 2. Observations on 10/18/22 at 9:37 AM revealed 2 fryer basket had food and grease particles on the inside of them and on the handles. The fryer had uncovered dark oil with sediment particles on top of the oil. Particles of grease were above the oil on the edges. The top front of fryer had food particles and grease particles on it. There were food particles and stains covering the bottom door of the fryer which was sitting on the ground. Interview on 10/18/22 from 9:39 AM and 9:48 AM with Dietary Manager revealed she did not have a lid for fryer grease to cover it but stated it should be covered by a flat pan when not in use. Observation revealed Dietary Manager moved a flat pan and covered the grease. She stated it was due to be cleaned today and expected it to be cleaned weekly as part of deep cleaning. She stated the fryer baskets should have been cleaned after last use. She stated she did not have a deep cleaning schedule for the kitchen. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676485 If continuation sheet Page 14 of 18 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 676485 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Princeton Medical Lodge 1401 W. Princeton Dr. Princeton, TX 75407 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 Review of the facility's policy on Cleaning the Fryer revised 05/15/2015 reflected The fryer will be maintained clean and in good repair. The oil in fryer should be kept cool and covered when not in use. When oil darkens in color or changes viscosity .it is time to thoroughly clean the fryer and change the oil .Procedure: after each use: .2. Remove any food particles using filter tool. 3.Wipe down front, sides, back and cover with warm soapy water. Residents Affected - Many 3. Observations of Dietary aide L on 10/19/22 revealed the following: * At 11:32 AM, Dietary Aide L took his gloves off, put new gloves on and did not wash his hands. He then put lunch plates on trays along with drinks on hall trays. * At 11:51 AM, Dietary Aide L changed gloves but did not wash hands. He continued putting completed lunch plates on meal tray along with drinks and silverware on tray. * At 11:55 AM he took his gloves off and did not wash hands. Dietary Aide L put one glove on right hand and left hand no glove. He put drink on lunch meal trays and put the tray in hall cart. Interview on 10/19/22 at 11:58 AM, Dietary Aide L stated he did take his gloves off and should have washed his hands prior to putting on new gloves. He stated he usually put two gloves on his hands and not just the one glove . Observations of Dietary aide K on 10/19/22 revealed the following: * At 11:50 AM Dietary Aide K came in from dining room and did not wash hands. She put gloves on and put lunch plates on trays. She placed the lunch trays on hall cart. *At 11:52 AM she went to freezer to get a magic cup and placed on meal tray. She took her gloves off and put new gloves on without washing her hands. Interview on 10/19/22 at 11:56 AM, Dietary Aide K stated she should have washed hands when changing gloves before putting on new gloves. She stated she was supposed to wash hands when she entered the kitchen before doing any tasks . Interview on 10/19/22 at 11:59 AM, the Dietary Manager stated Dietary Aides K and L should have washed hands when they take gloves off and before putting on new gloves. She stated they were nervous. She stated they should wash hands when entering kitchen before starting any tasks . She stated they should have washed their hands to prevent cross contamination. Review of the facility's policy Hand Washing revised 01/01/2010 reflected hand hygiene is the most import component for preventing the spread of infection. Proper hand washing technique will be used at all times that hand washing is indicated. Employees will keep their hands and exposed portions of their arms clean. Procedure: 1. Employees are to wash hands .g. prior to returning to food production areas .j. Before putting on gloves, when changing into fresh pair of gloves and immediately after removing gloves. The US Public Health Service, Food Code, dated 2017, retrieved on 10/25/22, reflected the following regarding Equipment, Food-Contact Surfaces and Nonfood-Contact Surfaces, equipment food-contact surfaces and utensils shall be clean to sight and touch .the nonfood contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676485 If continuation sheet Page 15 of 18 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 676485 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Princeton Medical Lodge 1401 W. Princeton Dr. Princeton, TX 75407 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 designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for two (Resident #59 and Resident #76) of six residents observed for infection control in that: Residents Affected - Some 1. Facility staff failed to place Resident #59 in isolation after the resident was diagnosed with parainfluenza virus on 10/13/22. 2. MA C failed to handle Resident # 76's medication in a manner to prevent cross contamination. Theses failure could place residents at risk for infection and cross contamination. Findings included: 1. Review of the Facilities undated Emergency Guidance plan for the management of Seasonal Influenza(flu) and/or Pandemic Viruses reflected, .If a Resident Develops Influenza-Like Illness (ILI) .In the absence of definitive diagnosis, influenza-like illness (ILI) is often used as an indicator of flu activity. ILI is defined as having a fever (temperature >100 degrees F) .AND either cough or sore throat or both with no other known cause for these symptoms .All ill resident should be separate from other in a single room until asymptomatic, if possible .Facilities should have signage at entry points instructing residents and visitors about facility policies including the need to notify staff immediately if they have signs and symptoms of influenza-like or other illness .Employees should wear N-95 respirators when in direct or close contact (within 6 feet) with ill individuals. Physical contact with the individual should be avoided, but if contact must be made, the employee should follow standard and contact precautions (including gown and gloves) and eye protection. Visitors may be offered N95 respirators for director or close contact with ill individuals. Physical contact should be avoided, but if contact must be made, the visitor may be offered respirators, gowns, gloves, and eye protection, and if used, should be instructed on their use . Review of Resident #59's Face Sheet dated 10/19/22 reflected a [AGE] year-old female with an admission date of 07/28/22. Resident #59's primary diagnoses included Influenza due to other identified influenza virus with other respiratory manifestations with an onset date of 10/14/22. Other diagnoses included urinary tract infection and dementia. Record Review of Resident #59's hospital discharge record dated 10/13/22 reflected, .Admit 10/12/22 .Chief Complaint Shortness of breath Fever .Patient is noted to have some cough and wheezing. She is also febrile in ER with fever of 101. Her COVID is negative .Lab results .10/13/22 .Parainfluenza (virus that causes respiratory symptoms) detected . Review of Resident #59's admission orders for 10/14/22 did not reflect an order for isolation. Review of Resident #59's admission Nursing Entry dated 10/14/22, reflected, .A [AGE] year-old Female is readmitted back to this facility . Went to the hospital with a DX: Hypoxia and was admitted for flu and UTI. Pt is on isolation for FLU X 5 days . In an observation 10/18/22 at 1:30 p.m. revealed Resident #59 in her room. There was no signage (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676485 If continuation sheet Page 16 of 18 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 676485 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Princeton Medical Lodge 1401 W. Princeton Dr. Princeton, TX 75407 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 posted outside her room indicating the resident was in any form of isolation. Level of Harm - Minimal harm or potential for actual harm In an interview with RN F on 10/18/22 at 1:35 p.m. stated he was unsure if Resident #59 was supposed to be in isolation or not. He stated the resident had tested positive for flu at the hospital. He stated he would have to follow up with the physician. He stated Resident #59 had been on antibiotics and had not had any fever since her return to the facility. Residents Affected - Some In an interview with ADON D on 10/18/22 at 1:40 p.m. stated any resident who was diagnosed with the flu was supposed to be in isolation. She stated she had done the admission orders on Resident #59 and did not see an order for isolation. She stated she called the physician and asked if they needed to put her isolation now, and he stated since she was asymptomatic, and it had been five days since her initial diagnosis she did not need to go into isolation now. ADON D stated the resident should have been placed in isolation when she re-admitted on [DATE]. She stated since the facility was already in outbreak mode due to COVID all staff were wearing N95's but stated they should have been wearing full PPE (gown, N95, goggles and gloves) when caring for Resident #59 when she had returned from the hospital. She stated they just missed it. She stated failing to place her in isolation could pose the risk of spreading infection to staff and other residents. She stated at this time there were no other residents in the facility who had tested positive for flu. 2. Review of Resident #76's Face sheet dated 10/20/22 reflected a [AGE] year-old female with an admission date of 10/29/21. Residents #76's primary diagnoses include diabetes, malignant neoplasm of right breast and COVID. Review of MA C's undated skills checks reflected she had been skills checked on medication proficiency, which included Proper hand washing techniques/gloves at appropriate times. During a medication pass observation on 10/19/22 at 8:50 revealed MA C pulling medications for Resident #76. Resident #76 had six over the counter medications; Acidophilus (probiotic to promote growth of good bacteria), Vitamin C ( antioxidant) 500 mg, Colace (laxative) 100 mg, Ferrous Sulfate ( iron supplement) 325mg, Simethicone (reduces gas) 80 mg and Zinc ( mineral for immune health) 50 mg; which were utilized for multiple residents. MA C was observed holding her un-gloved finger over the top of the open bottle of each of the over-the-counter medication bottles to prevent more than one pill from coming out of the bottle. While pouring one of the over-the-counter medications into the medication cup, the pill bounced out of the cup and fell on top of the medication cart. MA C proceeded to pick up the pill with her bare hands and placed it back into the medication cup with the remainder of Resident #79's morning medications and then entered the Resident's room and administered her medications. In an interview with MA C on 10/19/22 at 9:00 a.m. revealed she was not supposed to touch medications with her bare hands. She stated she should wear gloves when pouring medications from over-the-counter medication bottles to prevent from touching the remaining medication in the bottle. She stated she should have thrown the pill away that fell onto the medication cart and gotten another pill. She stated by touching the medications with her bare hands she could spread germs to the resident. In an interview with the DON on 10/20/22 at 09:30 a.m. he stated staff were never supposed to touch a resident's medication with their bare hands. He stated if they had to touch a medication, they were performed hand hygiene and put on gloves. He stated by not following standard precautions with hand hygiene it placed residents at risk of infections and cross contamination. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676485 If continuation sheet Page 17 of 18 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 676485 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Princeton Medical Lodge 1401 W. Princeton Dr. Princeton, TX 75407 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 Review of the facility's guidelines titled, Your 5 moments for hand hygiene, obtained from the World Health Organization, dated October 2006, reflected, 1. Before patient contact .Clean your hands before touching a patient when approaching him or her .2. Before an aseptic task .Clean your hands immediately before any aseptic task to protect the patient against harmful germs, including the patients' own germs, entering his or her body .3. After body fluid exposure risk .Clean your hands immediately after an exposure risk to body fluids (and glove removal .4. After patient contact .Clean your hands after touching a patient and his or her immediate surroundings when leaving .5. After Contact with Patient surroundings .Clean your hands after touching any object or furniture in the patient's immediate surroundings, when leaving-even without touching the patient Review of the facility's undated policy titled, Medication Cart, Administration of Drugs, reflected, .Properly wash hands if contact has been made with the resident or any procedure that would cause infected hands . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676485 If continuation sheet Page 18 of 18