Health inspection·January 19, 2023

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 01/17/23 at 10:07 AM with CNA D revealed she and other direct care staff changed him and put his pants up on his waist. She stated every day he pulled his pants down below his waist on his own even when they pulled them up. She stated he preferred to have his pants below his waist, and he did not wear underwear or a brief. Interview on 01/18/23 at 10:37 AM and 2:05 PM with LVN C revealed for about the last two months daily Resident #24 used a urinal to urinate and preferred his pants below his waist. She stated he had a private room but Resident #24 would come out into hallway with his pants below his waist. She stated sometimes he would try to cover his private area with his shirt. She stated they would give him a towel to cover his private area when in public areas for dignity. She stated family had been notified about him pulling his pants below his waist. Interview on 01/18/23 at 10:40 AM with the DON revealed he was aware of Resident #24's preference of having his pants below his waist. He stated they had discussed this with Resident #24's family. He stated he thought it was care planned and should include the interventions regarding how staff addressed Resident #24's preference. He stated nursing or the Social Worker should have care planned the resident's preference to have his pants below his waist. Interview on 01/18/23 at 1:01 PM with MDS Coordinator A revealed social services or nursing did behavioral acute plans, and she did the initial comprehensive care plan based on MDS assessment. She was aware Resident #24 did pull down his pants below his waist sometimes. Interview on 01/18/23 at 1:58 PM with the SW revealed she knew about Resident #24's preference in liking his pants to be below the waist since she had been at facility since August 2022. She stated she overlooked it and should have care planned it. She stated she would care plan it and include interventions regarding how staff addressed his preference. 2. Record review of Resident #6's 5-day MDS assessment dated [DATE], reflected a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE]. He had a BIMS of 9 which indicated he was moderately cognitively impaired. Diagnoses included hypertension, obstructive uropathy (urine cannot drain through the urinary tract), dementia, depression, chronic obstructive pulmonary disease, and acute and COVID-19. Resident #6 had received oxygen therapy in the last 14 days. Record of Resident #6's Active Physician orders dated 01/18/23, reflected: oxygen 2 l/m via n/c prn to keep sat greater than 90% as needed .Check oxygen q shift and document every shift for S.O.B (shortness of breath) . Record review of Resident #6's care plan with a revision date of 11/06/22 did not address the resident's use of oxygen. An observation on 01/17/23 at 10:05 AM revealed Resident #6 had an oxygen mask in place and the oxygen flow rate was set to deliver 4 liters per minute via an oxygen concentrator. In an interview with Resident #6 on 01/17/23 at 10:07 AM stated he had been on oxygen continuously. He stated he had not been feeling well the past few days. An observation on 01/18/23 at 11:15 AM revealed Resident #6 had a nasal cannula in place and the oxygen flow rate was set to deliver 4 liters per minute. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455864 If continuation sheet Page 2 of 10 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 455864 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Life Care Center of Plano 3800 W Park Blvd Plano, TX 75075 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few An observation made with LVN B on 01/18/23 at 11:20 AM revealed the oxygen flow rate was set to deliver 4 liters. LVN B stated it should be set at 2 liters and adjusted the rate to deliver 2 liters per minute. In an interview with LVN B on 01/18/23 at 11:25 AM revealed any resident with oxygen had to have an order with the number of liters per hour to be delivered. She stated she had assessed Resident #6 when she came on duty and had checked his oxygen saturation level but did not look to see what the oxygen concentrator was set on. LVN B stated she should have checked the levels instead of assuming it was set on the correct rate. She stated providing inaccurate amounts of oxygen could make the residents breathing worse. In an interview with the DON on 01/18/23 at 1:45 PM revealed any resident who required oxygen had to have an order from the physician which stated the number of liters to be delivered. He stated it was a requirement that the physician determine how much supplemental oxygen someone needed and was not a nurse's judgement. He stated the nurses were supposed to assess the resident's respiratory status, including ensuring the oxygen was delivered at the prescribed rate. He stated giving to much oxygen could lead to oxygen toxicity to the resident. Review of facility's policy Comprehensive Care Plans and Revisions reviewed 08/17/22 reflected .the facility will ensure the timeliness of each resident's person-centered, comprehensive care plan .2. When these changes occur, the facility should review and update the plan of care to reflect changes to care delivery, this can include a. additional interventions on existing problems, b. Updating goal or problem statements, c. Adding a short-term problem, goal and interventions to address a time limited condition. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455864 If continuation sheet Page 3 of 10 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 455864 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Life Care Center of Plano 3800 W Park Blvd Plano, TX 75075 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents who needed respiratory care were provided such care, consistent with professional standards of practice and the comprehensive person-centered care plan for one (Resident #6) of two residents reviewed for respiratory care Residents Affected - Few The facility failed to ensure the supplemental oxygen was provided at the physician ordered liter amount for Resident #6. This failure could place residents who received oxygen therapy at risk of receiving an incorrect amount of oxygen and the risk of oxygen toxicity. Findings included: Record review of Resident #6's 5-day MDS assessment dated [DATE], reflected a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE]. He had a BIMS score of 9 which indicated he had moderate cognitive impairment. Diagnoses included hypertension, obstructive uropathy (urine cannot drain through the urinary tract), dementia, depression, chronic obstructive pulmonary disease, and acute and COVID-19. Resident #6 had received oxygen therapy in the last 14 days. Record of Resident #6's Active Physician orders dated 01/18/23, reflected: oxygen 2 l/m via n/c prn to keep sat greater than 90% as needed .Check oxygen q shift and document every shift for S.O.B (shortness of breath) . Record review of Resident #6s care plan with a revision date of 11/06/22 did not address the resident's use of oxygen. Record review of Resident #6's TAR dated January 2023 reflected, .Check oxygen Q shift and document . Resident #6 oxygen saturation level on 01/17/23 was at 96% on the 6:00 AM to 2:00 PM shift, 96% on the 2:00 PM to 10:00 PM shift and 95% on the 10:00 PM to 6:00 AM shift and on 01/18/23 was 98% on the 6:00 AM to 2:00 PM shift. There was no documentation for oxygen at 2 liters prn for the entire month from 01/01/23 through 01/18/23 indicating oxygen was being administered. An observation on 01/17/23 at 10:05 AM revealed Resident #6 had an oxygen mask in place and the oxygen flow rate was set to deliver 4 liters per minute via an oxygen concentrator. In an interview with Resident #6 on 01/17/23 at 10:07 AM stated he had been on oxygen continuously. He stated he had not been feeling well the past few days. An observation on 01/18/23 at 11:15 AM revealed Resident #6 had a nasal cannula in place and the oxygen flow rate was set to deliver 4 liters per minute. An observation made with LVN B on 01/18/23 at 11:20 AM revealed the oxygen flow rate was set to deliver 4 liters. LVN B stated it should be set at 2 liters and adjusted the rate to deliver 2 liters per minute. In an interview with LVN B on 01/18/23 at 11:25 AM revealed any resident with oxygen had to have an order with the number of liters per hour to be delivered. She stated she had assessed Resident #6 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455864 If continuation sheet Page 4 of 10 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 455864 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Life Care Center of Plano 3800 W Park Blvd Plano, TX 75075 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few when she came on duty and had checked his oxygen saturation level but did not look to see what the oxygen concentrator was set on. LVN B stated she should have checked the levels instead of assuming it was set on the correct rate. She stated providing inaccurate amounts of oxygen could make the residents breathing worse. In an interview with the DON on 01/18/23 at 01:45 PM revealed any resident who required oxygen had to have an order from the physician which stated the number of liters to be delivered. He stated it was a requirement that the physician determine how much supplemental oxygen someone needed and was not a nurse's judgement. He stated the nurses were supposed to assess the resident's respiratory status, including ensuring the oxygen was delivered at the prescribed rate. He stated giving to much oxygen could lead to oxygen toxicity to the resident. Record review of the facility's policy, Oxygen Administration/Safety/Storage/Maintenance, dated December 2022, reflected, Oxygen will be administered in accordance with physician orders and current standard of practice . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455864 If continuation sheet Page 5 of 10 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 455864 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Life Care Center of Plano 3800 W Park Blvd Plano, TX 75075 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure residents who used psychotropic drugs received gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs for one (Resident #32) of five residents reviewed for unnecessary medications. The facility failed to attempt a gradual dose reduction (GDR) for Resident #32's Risperdal and failed to have an adequate indication, and adequate behavioral interventions for the continued use of Risperdal. These failures could place residents at risk for possible adverse side effects, adverse consequences, decreased quality of life and dependence on unnecessary medications. Findings included Record review of Resident #32's quarterly MDS assessment, dated 11/24/22, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident had a BIMS score of 4, which indicated she had severe cognitive impairment. She had no signs and symptoms of delirium, no hallucinations or delusion, no physical behavioral symptoms and had not rejected care. She had diagnoses which included non-Alzheimer's dementia, anxiety disorder, psychotic disorder (mental disorder characterized by a disconnection from reality), and schizophrenia (mental condition involving a breakdown between thought, emotion, and behavior). Resident had received Antipsychotic medications for the last 7 days or since admission. Gradual dose reduction attempts were left blank. Physician documented GDR as clinically contraindicated was left blank. Record review of Resident #32's care plan, revised on 12/20/22, reflected: .Resident is on Antipsychotic medication (Risperidone) .Interventions .staff will monitor all the side effect signs, if any notify the resident's physician. When clinically appropriate gradual dose reduction will be attempted by the resident's psychiatrist, in coordination with the resident's primary physician, nurses and other caregivers . Record review of Resident #32's active Physician orders, dated 01/18/23, reflected, .Risperidone (anti-psychotic) tablet 0.25 mg give 1 tablet by mouth at bedtime .0.25 mg 1 tablet by mouth in the afternoon related to unspecified psychosis not due to a substance or known physiological condition . The start date was 06/03/21. Further review of physician orders reflected Resident #32 had been on this same dose of Risperidone since 03/11/21. Record review of Resident #32's Medication Administration Records, dated November 2022, December 2022, and January 2023, reflected the resident received Risperidone 0.25 mg bid daily. Record review of Resident #32's behavior monitoring flow sheets reflected no behavior monitoring for November 2022 or December 2022. Behavior flow sheet for January 2023 listed Mood changes as the target behavior. There were no behaviors documented as observed from 01/01/23 through 01/18/23. Record review of the Nurses Notes, from 11/01/22 through 01/18/23, did not indicate any behaviors for Resident #32. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455864 If continuation sheet Page 6 of 10 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 455864 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Life Care Center of Plano 3800 W Park Blvd Plano, TX 75075 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of Resident #32's last documented Psychiatrist report dated 02/17/22 reflected: Resident was seen today for follow-up for delusional disorder, anxiety disorder, insomnia, impulsivity, and dementia. Resident was also seen for diagnostic clarification since resident is on Risperdal for a while. Resident continues to have periods of delusions and paranoia. She needs redirection. Resident was able to relate. She continues to have period of paranoia and delusion. Resident is tolerating medication with no reported side effects. Sleeps 6-8 hours at night. Appetite is adequate. Cognition is unchanged .Next follow up visit will be around 30 days or when need arises. There were no additional psychiatrist visits found past this date. Review of Resident #32's Pharmacy Consultation report dated 09/01/22 through 09/16/22 reflected: .[Resident #32] receives Risperidone 0.25 mg at noon and at bedtime for unspecified psychosis Please attempt a gradual does reduction (GDR), with the end goal of discontinuation .Please provide CMS REQUIRED patient -specific rationale describing why a GDR attempt is likely to impair function or cause psychiatric instability in this individual . The physician response for the rationale for the decline in the GDR was no change and was signed and dated by the MD on 10/21/22. An observation on 01/17/23 at 10:10 AM revealed Resident #32 sitting up in wheelchair in the dining room participating in a singing activity. Resident was appropriately dressed for the day. In an interview with the Social Worker on 01/18/23 at 10:15 AM revealed Resident #32 had not exhibited any behaviors of paranoia that she was aware of. She stated she would occasionally resist care but was easily re-directed and she participated in numerous activities. Interview with LVN B on 01/18/23 at 11:45 AM revealed Resident #32 used to be very paranoid and suspicious of people but stated this was when she first came to the facility. She stated she had not exhibited those behaviors in a very long time. She stated she will still occasionally refuse care but can be easily re-directed. She stated the resident enjoys activities and is up most of the day in the dining room or common area with other residents. In an interview with the DON on 01/18/23 at 1:45 PM revealed Resident #32 had been very stable for several months. He stated there was no reason why they should not have attempted a GDR. He stated it was just overlooked. He stated the nurses were supposed to document the behaviors they observed in the nurse's notes and the flow sheet and indicate what interventions had been attempted. He stated he was not sure when the last time the Psychiatrist had seen the resident. He stated he and the unit manager received the pharmacy recommendation for the physicians to sign and review. He stated he knew the physician had to write a clinical indication as to why a GDR could not be attempted. He stated he was reaching out to the resident's physician today to request a GDR attempt. He stated failure to attempt a GDR reduction could cause a decrease in the resident's quality of life, but reducing her motor skills, decreased appetite and level of independence. Attempted to contact Resident #32's Psychiatrist on 01/18/23 at 2:14 PM No response. In an interview with Resident #32's MD on 01/19/23 at 10:11 AM she stated she had not attempted a GDR of resident Risperidone in over a year. She stated she had attempted one in 2020 and she was completely off the medication for several months. She stated and the resident started pacing the halls, becoming very suspicious of staff and difficult to comply with drawing labs etc. She stated she started her back on Risperidone and referred her to psych services. She stated she had been very stable for several months. She stated she did order the medication to be reduced from twice a day to one time a day yesterday (01/18/23) and monitor for paranoia. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455864 If continuation sheet Page 7 of 10 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 455864 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Life Care Center of Plano 3800 W Park Blvd Plano, TX 75075 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of Resident #32's physician orders revealed on 01/19/23 an order to reduce Risperidone 0.25 mg from twice a day to one time a bedtime was implemented. A return call received on 01/19/23 at 6:33 PM from Resident #32's previous Psychiatrist. She revealed she had provided care to Resident #32 for several years in the facility. She stated February 2022 was the last time she had seen the resident, but had been contacted by the facility today, for her to resume her services. She stated her goal would be to continue to attempt a GDR for the residents' Risperidone with the goal to completely discontinue the medication. Review of the facility's policy Psychotropic medication Use, dated October 2022, reflected .Facility should comply with the psychopharmacologic Dosage Guidelines created by the Centers for Medicare and Medicaid Services (CMS), the Stated Operations Manual, and all other Applicable Law relating to the use of psychopharmacologic medications including gradual dose reductions. The facility should not use psychotropic medication to address behaviors without first determining if there is a medical, physical, functional, psychological, social or environmental cause of the resident's behaviors Residents who exhibit new or worsening behavioral or psychological symptoms of dementia will be evaluated by a health care professional and the care team to identify contributing factors .All medications used to treat behaviors must have a clinical indication and be used in the lowest possible dose to achieved the desired therapeutic effect .Where Physician/Prescriber orders a psychotropic medication for a resident, Facility should ensure that Physician/Prescriber has conducted a comprehensive assessment of the resident and has documented in the clinical record that the psychopharmacologic medication is necessary .Physician/Prescriber should document the clinical rationale for why and additional attempted dose reduction at that time would be likely to impair the resident's function or increase distressed behavior .Facility staff should monitor the resident's behavior pursuant to Facility policy using a behavioral monitoring chart or behavioral assessment record for residents receiving psychotropic medication for organic mental syndrome with agitated or psychotic behavior(s). Facility staff should monitor behavioral triggers, episodes, and symptoms. Facility staff should document the number and/or intensity of symptoms and the resident's response to staff interventions . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455864 If continuation sheet Page 8 of 10 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 455864 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Life Care Center of Plano 3800 W Park Blvd Plano, TX 75075 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 observations, interview and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards in one of one kitchen reviewed for kitchen sanitation. Residents Affected - Some 1. The facility failed to label and date the refrigerator food items when opened. The facility failed to seal freezer food items. 2. Dietary [NAME] E and Dietary Aide F failed to perform hand hygiene during lunch meal preparation on 01/18/23. These failures could place residents at risk for food contamination and food-borne illness. Findings included: 1. Observation on 01/17/23 at 9:51 AM in facility's walk-in refrigerator revealed there was were two plastic wrapped breakfast meat patties not labeled with food item or dated when opened. Observation on 01/17/23 at 9:53 AM in facility's walk-in freezer revealed a box labeled southern style biscuits not sealed and open to air. A box labeled breadsticks not sealed and open to air. Interview on 01/17/23 at 9:54 AM with the Dietary Manager revealed the meat patties wrapped in plastic were breakfast sausage and the date/label may have come off. He stated they should be labeled as sausage and dated of when opened so they would know when items need to be discarded. He stated the biscuits and breadsticks should be sealed to keep food items from freezer burn. He stated the items in the freezer not being sealed properly place the food items at risk of freezer burn which can affect cooking times and the taste of the food. Review of facility's policy Food Safety revised 12/17/21 reflected food is stored and maintained in a clean, safe and sanitary manner following federal, state and local guidelines to minimize contamination and bacterial growth. Under receiving it reflected 6. Food is labeled with the date received, if date received is not on the item. 2. Observation and interview on 01/18/23 at 11:47 AM revealed Dietary [NAME] E changed her gloves, did not wash her hands and scooped food on resident's plates for lunch. Dietary [NAME] E stated she went though a lot of gloves during meal service. At 11:51 AM Dietary [NAME] E changed her gloves, did not wash her hands and continued plating food for resident lunch touching the inside of the plate . Observation on 01/18/23 at 11:52 AM revealed the Dietary Manager washing his hands in the hand washing sink. Observation on 01/18/23 at 11:54 AM revealed Dietary Aide F washing dish at sink with gloved hands . She did not change gloves or wash hands. She put lids on lunch plates and placed the lids on resident meal trays. Observation on 01/18/23 at 11:59 PM revealed the Dietary Manager tried to wash his hands in hand (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455864 If continuation sheet Page 9 of 10 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 455864 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Life Care Center of Plano 3800 W Park Blvd Plano, TX 75075 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 washing sink but water was dripping from faucet. At 12:02 PM, an interview with the Dietary Manager revealed he just found out they shut off the water. He stated he knew they were coming today to fix the pipes but he should have been consulted so it is not during meal time. He stated he was not notified prior to them shutting off the water and unable to wash his hands properly. Interview on 01/18/23 at 12:06 PM with Dietary [NAME] E revealed she did change her gloves and did not wash her hands. She stated she should have washed her hands when changing gloves before putting on new gloves. She stated the water was turned off now so she cannot wash her hands. Interview on 01/18/23 at 12:10 PM with the Dietary Manager revealed dietary staff should wash their hands when they changed gloves before they put on new gloves. He stated dietary staff should wash their hands to prevent contamination. He stated the contractors had already started working on the pipes so they were unable to turn water back on until after the pipes were fixed. The Dietary Manager stated he and dietary staff would use hand sanitizer while water was off. Interview on 01/19/23 at 10:02 AM with Administrator revealed the contractors were already scheduled to come out to fix deteriorating pipes yesterday, but they were supposed to coordinate an appropriate time to shut off the water. He stated if they had coordinated with the facility they would have waited until after meal time to ensure the kitchen had working water to wash their hands. He stated they did not notify anyone at the facility before turning off the water and had already started dismantling the pipes once the facility became aware the water was turned off. He stated the Maintenance Director was not notified about the water being shut off. He stated he expected the dietary staff to wash their hands when changing gloves and when gloves get contaminated when water was on. Interview on 01/19/23 at 12:55 PM with the Maintenance Director revealed the contractors came yesterday to fix the pipes, did not notify him about shutting off the water, and he became aware the water was shut off after the contractors had already starting to dismantle the pipes. He stated he would have coordinated with the kitchen to ensure water was on during meal times. Review of facility's undated policy Washing Hands Properly from food and nutrition services in-service training manual reflected: As food service workers, our hands come into contact with many unsanitary things during the day. Some of these contacts are part of our job tasks and some are not. Harmful bacteria can pass from an infected person to a well person from objects such as food, dishes, eating utensils, glasses, etc. These bacteria, in turn, can make a person very ill. We can reduce the risk of being contaminated by washing our hands properly. The policy reflected to wash your hands at these times: when they become soiled, after handling soiled dishes, the trash can, etc, before handling food, clean dishes, or flatware, after completing any cleaning task. Review of facility's undated policy Proper Use of Gloves to Handle Food reflected: Gloves are not a substitute for hand washing .Wash hands each time new gloves are used .Wash your hands each time you change into new gloves .Be careful of cross-contamination while performing a task. Review of the US Public Health Service Food Code, dated 2017, retrieved 01/23/23 reflected the following regarding hand hygiene, .(H) Before donning gloves to initiate a task that involves working with food; and (I) After engaging in other activities that contaminate the Hands. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455864 If continuation sheet Page 10 of 10