Health inspection·March 7, 2024

F 0679 attended and participated in activities of choice 3 times a week. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #17's Comprehensive MDS assessment dated [DATE] revealed resident was a [AGE] year-old male admitted to the facility on [DATE] with an initial admission date of 02/28/2022 and had diagnoses of sepsis (blood stream infection), type-2 diabetes mellitus (high blood sugar), adjustment disorder (excessive negative reactions and emotions to stress), unspecified Alzheimer's disease (loss of cognitive functioning), depression (persistent feeling of sadness and loss of interest), and generalized anxiety disorder (a condition in which a person has excessive worry and feelings of fear or unease), and a BIMS score of 14 (intact cognition). Residents Affected - Some Record Review of Resident #17's Care Plan dated 04/04/2022 and revised on 04/04/2023 revealed Resident #14 was the Resident Council President and had a variety of activity interests and a general willingness to take part in group activity programs. The Care Plan for Resident #17 stated resident would express enjoyment of the group activity programs and would be invited, encouraged, and assisted to programs of interest and preferences. The Care Plan for Resident #17 dated 04/13/2022 revealed the resident was provided a program of activities that was of interest and empowered the resident by encouraging and allowing choice, self-expression, and responsibility. Record review of Resident #29's Quarterly MDS assessment dated [DATE] revealed resident was an [AGE] year-old male admitted to the facility on [DATE] and had diagnoses of Alzheimer's disease (loss of cognition), type 2 diabetes, hyperlipidemia (high level of fats in blood), hypertension (high blood pressure), and a BIMS score of 5 (severely impaired cognition). Record Review of Resident #29's Care Plan dated 09/24/2023 revealed the resident was provided a program of activities that was of interest and empowered the resident by encouraging and allowing choice, self-expression, and responsibility. Resident #29's Care Plan dated 09/18/2023 and revised on 09/24/2023 revealed the resident had a variety of activity interests and a general willingness to take part in group activity programs. Record review of the Resident Council minutes dated 12/14/2023, 01/19/2024, and 02/15/2024 revealed Residents #1, #14, #17, and #29 were in attendance. Review of Resident Council minutes dated 01/19/2024 revealed residents had concerns with activities and needed more entertainment. Resident Council minutes dated 12/14/2023 and 02/15/2024 revealed no concerns. Observation on 03/05/2024 at 2:12 PM of dining room D revealed residents #14 and #17 were sitting in electric wheelchairs and appeared alert, well-kept, and were participating in a painting activity with Activities Assistant G. Observation on 03/05/2024 on 3:15 PM of dining room D revealed Activities Assistant G standing in front of a table with residents #14 and #17 who were seated in electric wheelchairs at a table with other residents and were playing bingo. Interview with Activities Assistant G revealed the current Activities Director, Activities Director F, were not at the facility due to a medical issues. Observation 03/06/2024 at 10:23 AM in dining room D revealed the room had two doors and one connected hallway that opened into D hall and did not allow for privacy for the confidential group interview. Interview with Assistant Activities Director revealed dining room D was used for Resident Council meetings and stated she would move residents to the main dining room to allow for privacy. (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 03/07/2024 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 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Confidential group interview began on 03/06/2024 at 10:39 AM in the main dining room. Residents stated that entertainment was their biggest concern, and they noticed a change in activities about a year ago. Residents stated that there was a lack of variety of activities at the facility and their favorite activity of music performers and entertainers had stopped about a year ago. Residents stated that the facility used to have someone come sing to them or perform but then it went away. Residents stated they had asked Activities Director E about the change and was told that there was not enough funding to have entertainers come in and perform for residents. Residents stated the issue of lack of entertainment was brought up at every resident council meeting but that there was no further discussion on the matter, and no one had asked them their preferences for activities. Residents stated that they thought someone might volunteer but that had not happened. Residents stated there are activities like painting, bingo, and sit and fit but they need other activities. Interview on 03/06/2024 at 11:13 AM with Activities Assistant G revealed she had worked at the facility since October 2023 and was responsible for implementing the activities like bingo, painting, and coloring while Activities Director F was on leave due to medical issues. Activities Assistant G stated, Activities Director F had recently started on 02/22/2024 and had to go on leave due to a medical concerns, she was still feeling unwell, and was waiting for medical clearance to return in person. Activities Assistant G stated that she was not a certified Activities Director. Activities Assistant G stated she was in contact via phone with Activities Director F. Activities Assistant G stated she had not attended previous resident council meetings, had not read the resident council minutes for previous months, and had not known where to find the resident council minutes. Activities Assistant G stated she was not aware residents had concerns about activities. Interview on 03/06/2024 at 11:52 AM with the Administrator revealed Activities Director F started working at the facility on 02/19/2024. The Administrator stated that Activities Director E had worked at the facility for about 6 years and her last day was 02/16/2024. The Administrator stated that Activities Director F had a medical emergency while at work on 02/21/2024 and had returned to the facility the next day but was still experienced health issues so she was not currently at the facility but was in contact via phone. The Administrator stated he expected Activities Director F would return on 03/11/2024, if she received medical clearance. The Administrator stated that he was not aware any residents had concerns of or requested more entertainment or activities and has never denied any supplies. The Administrator stated there was a budget for activities and the facility was open to volunteers or bake sales to fund activities. The Administrator stated that the Activities Director is responsible for assessing the activity needs and preferences of residents and creating the calendar of activities for the facility. Interview on 03/07/2024 at 10:17 AM with Activities Director E revealed she worked at the facility for about 7 years and had resigned about 3 weeks ago. Activities Director E stated she remembered attending the resident council meeting on 01/19/2024 and that residents had concerns about not having entertainment. Activities Director E stated she would organize and schedule activities for residents including arts and crafts, bingo, sit and fit (a movement and exercise activity), and entertainers that played musical instruments like bells, maraca's, accordion, or singers. Activities Director E stated she used to book about 4 to 5 entertainers a month and they would come about once a week. Activities Director E stated the entertainers would sing or perform for residents in a common area and the entertainers would also go to bed-bound resident rooms and perform to engage residents. Activities Director E stated residents enjoyed entertainer visits the most and they were effective and helpful to engage residents. Activities Director E stated there were changes in management on the corporate level which led to many changes including the activities budget, which was reduced by about half. Activities (continued on next page) 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 03/07/2024 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 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Director E stated she had to cancel her entire year of bookings with entertainers because there was not enough money in the budget for the activity. Activities Director E stated she always booked entertainers a year in advance because the budget had already been reduced in the past and it was more cost effective to book in advance. Activities Director E stated she had brought up concerns regarding the lack of budget and was told by management that some facilities did not have a budget for activities and to work with what she had. Activities Director E stated she attempted to compensate and would do many things herself. Activities Director E stated that residents noticed the change in activities and would ask her why the entertainers stopped coming. Activities Director E stated that she would bring up the residents' concern to management and was told to be a professional and not tell the residents there were budget cuts. Activities Director E stated that lack of activity options were repeatedly brought up as a concern in resident council meetings but sometimes she would not write the concern down because there was not anything she was be able to do about the concern. Interview on 03/07/2024 at 10:38 AM with Activities Assistant G revealed she thought the confidential group interview on 03/06/2024 was the March resident council meeting and had not planned the next meeting. Activities Assistant G stated she did not know how a confidential group interview was different from a resident council meeting or what the purpose was. Activities Assistant G stated she would immediately contact Activities Director F to reschedule the next resident council meeting. Activities Assistant G stated she had the March 2024 activity calendar and did not have the previous month's activity calendar. Activities Assistant G stated that the Activities Director was responsible for creating the activity calendar and assessed resident's activity needs and preferences. Interview on 03/07/2024 at 10:42 AM with Activities Director F revealed she had just started working as the Activities Director and had a medical emergency at the facility on her third day on the job on 02/22/2024 and had tried going back to the facility the next day but was still experiencing medical issues. Activities Director F stated that she was responsible for ensuring resident's had sufficient activity options to ensure psychosocial health. Activities Director F stated that she had assessed every resident in the three days she had been in the facility. Activities Director F stated she wasn't aware residents were not happy with the activities at the facility. Activities Director F stated she had not been in the facility for over a week but was available to Activities Assistant G via phone. Activities Director F revealed she was certified as an Activities Director and worked 40 hours a week at the facility. Activities Director F stated she was not sure when she would be able to come back in person because it would depend on her doctor's consent. Activities Director F stated Activities Assistant G had been implementing the activities schedule. Activities Director F stated she was unaware that the March resident council meeting did not occur and thought the confidential group interview was the resident council meeting. Activities Director F stated she would speak with Activities Assistant G and figure out a time for the March resident council meeting. Activities Director F stated she had spoken with every resident in the facility, and she was not aware that residents were concerned with a lack of variety of activities. Activities Director F stated she had not read any of the previous resident council meeting minutes. Activities Director F stated that the activities budget did seem low and that it was a concern. Activities Director F stated she would need to see how much money per month was being spent before she could determine if the budget would allow for entertainers or performers. Activities Director F stated a lack of activities that engaged residents could put them at risk of emotional harm. Observation and interview on 03/07/2024 at 12:00 PM revealed Resident #17 was sitting in his room in an electric wheelchair and was dressed in a t-shirt, shorts, and shoes with a bedside table in front of him with the television on. Interview with Resident #17 (Resident (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 03/07/2024 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 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Council President) revealed there used to be a lot of activities and entertainers in the past and that they had gone a long time without a variety of activities. Resident #17 stated he was told the reason the entertainers stopped coming was due to a lack of funds. Resident #17 stated the residents were disappointed when the music performances and entertainers stopped coming because they were the most impactful for himself and other residents. Resident #17 stated the concern regarding lack of activity options was frequently brought up at resident council meetings but there was not anything to be done about the issue. It was just how things were now. Resident #17 stated that not having the entertainers and music anymore had left a big hole in his life and he and other residents felt bored. Resident #17 stated no one had talked with him about his activities or preferences. Resident #17 stated that the activities he participated in were resident council, bingo, painting, and an exercise class. Observation and interview on 03/07/2024 at 12:05 PM revealed Resident #29 was sitting in his room in an electric wheelchair wearing a t-shirt, shorts, and shoes, and appeared well-kept and alert and was speaking with his new roommate. Interview with Resident #29 revealed he participated in bingo, resident council, and an exercise class and would like to learn chess, computers, Spanish, and have entertainers come back to the facility. Resident #29 stated that the activities used to be good here and that a woman used to come to the facility and sing to residents but that didn't happen anymore. Resident #29 stated not having a variety of activities that were of interest to him and varied had made the days feel long. Resident #29 stated that no one had asked what he was interested in participating in and he did not know who else to talk to about the concern. Observation and interview on 03/07/2024 at 12:10 PM revealed Resident #14 was in her room sitting in an electric wheelchair wearing a blouse, pants, and shoes, and was alert and appeared well kept. Resident #14 stated she noticed a change in activity options about a year ago. Resident #14 stated that she enjoyed bingo, painting, resident council, church, and music. Resident #14 stated that she enjoyed music activities and performances the most and she noticed about a year ago that music performances didn't happen anymore, and it made her feel like not participating in other activities. Resident #14 stated that she was told there wasn't a budget for entertainers anymore. Resident #14 stated she felt bored now and that other residents mention being bored with the same activities. Resident #14 stated that she would like to be a part of planning activities that are of interest to her, and no one had asked her about what activities she would like to participate in. Observation and interview on 03/07/2024 at 12:20 PM revealed Resident #1 was sitting in her room in a wheelchair watching television and eating lunch. Resident #1 stated she participated in resident council and church services, and she did not know what other activities were available. Resident #1 stated music activities were what she enjoyed the most, especially when people would come and sing or perform music for residents. Resident #1 stated she was bored frequently and spends a lot of time watching television. Resident #1 stated she could not recall if someone talked with her about her preferences for activities. Record review of facility's activity policy titled Therapeutic Activities Program and dated 09/21/2023 revealed The facility should implement an ongoing resident centered activities program that incorporates the resident's interests, hobbies, and cultural preferences which is integral to maintaining and/or improving a resident's physical, mental, and psychosocial well-being, and independence. To create opportunities for each resident to have a meaningful life by supporting his/her domains of wellness (security, autonomy, growth, connectedness, identity, joy and meaning). 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 03/07/2024 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure a resident who was fed by enteral means received the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding for 1 of 3 residents (Resident #40) reviewed for reviewed for feeding tubes. The facility failed to ensure Resident #40's feeding bag was labeled and dated. This failure could result in complications of enteral feedings such as receiving the wrong feeding or outdated feeding. The findings were: Review of Resident #40's Quarterly MDS assessment dated [DATE] revealed that Resident #40 was an [AGE] year-old male admitted to the facility on [DATE]. Relevant diagnoses included cerebrovascular disease (interruption in the flow of blood to cells in the brain), dysphagia (difficulty swallowing), gastrostomy status (a surgical procedure used to insert a tube, through the abdomen and into the stomach to deliver nutrition), and Parkinson's disease (brain disorder that causes unintended or uncontrollable moments). Resident #40 required assistance with ADLs. Resident #40 had BIMS score of 7 suggesting severe cognitive impairment. Review of Resident #40's comprehensive care plan dated 1/10/2024 revealed, Focus: The resident requires tube feeding related to Dysphagia. Goal: o The resident will be free of aspiration through the review date. o The resident will maintain adequate nutritional and hydration status. o The resident will remain free of side effects or complications related to tube feeding. Intervention: The resident needs the head of bed elevated 45 degrees during and thirty minutes after tube feed. o Discuss with the resident/family/caregivers any concerns about tube feeding, advantages, disadvantages, potential complications. o Listen to lung sounds. o Observe and report signs and symptoms of aspiration. Review of Resident #40's Physician order dated 2/8/2024 revealed Jevity 1.2 @ 65 milliliters per hour x 12 hours from 6pm - 6am via pump. Flush with 120 milliliters purified water every 4 hours. In an observation on 03/05/24 at 10:21 AM, Resident #40 was lying in bed. He could not answer questions. Resident #40 had an enteral feeding pump at his bedside which was not running into his G-tube (a tube inserted through the belly that brings nutrition directly to the stomach). The feeding pump had 2 bags hanging; one was marked as water dated 03/04/2024, and the second had a tan colored liquid. The tan colored liquid bag did not have a label with contents, date it was hung, or the resident's name. In an observation and interview with LVN A on 03/05/24 at 01:53 PM revealed that Resident #40 continued to have the feeding pump next to his bed with one bag marked as water and the other bag did not have a label or date on it. Per LVN A, Resident #40 received nocturnal tube feeding from 7 pm- 6am. She stated that the 2-10 Shift LVN was responsible for starting Resident #40 on tube feeds and LVN on 10 pm-6am shift was responsible for discontinuing the feeds. She stated that the tube feed formula came in 8-ounce containers and needed to be poured in the tube feeding bag to administer the feeding to the resident. She further stated that all Enteral feeding bags should be dated and labeled (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 03/07/2024 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few each time before administering the feeds . She stated that the risk of not dating the tube feed bag was an increased risk of infection related to an unknown hung date and risk of not labeling the bag was probably hanging an incorrect tube feed formula. In an interview with LVN B on 03/05/24 at 02:34 PM revealed that she worked on the 2 pm-10 am shift on 3/4/24 and hung the tube feed bag for Resident #40 around 6 pm on 3/4/24. She stated that she always dated and labeled residents tube feed bag since it was standard nursing protocol, but she did not have a marker with her to label the bag and may have forgotten to label and date it afterwards. She stated that the risk for not dating and labeling was incorrect feedings, microbial growth, and potential for decreased quality of care. In an interview with the DON on 03/06/24 at 11:56 AM revealed that it was a standard nursing protocol to date and label tube feed formula, and it was his expectation that all nursing staff follow standard protocols. He stated that risk of not dating and labeling tube feed formula was a possibility of the same formula being used for the resident for multiple days and spread of microbial infection. He stated that if the nursing staff saw any tube feed formula that was not labeled, he expected them to throw it out, and restart the tube feeds with a formula bag that was dated and labeled appropriately. Record review of the facility's Enteral Nutrition Therapy policy dated 8/8/2023 revealed, the facility will provide intermittent enteral nutrition therapy in accordance with physician orders and professional standards of practice. Recommendation from American Society for Parenteral and Enteral Nutrition Safe Practices for Enteral Nutrition Therapy dated January 2017 Practice Recommendations Standardize the labels for all Enteral formula containers, bags, or syringes to include who prepared the formula, date/time it was prepared, and date and time it was started. 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 03/07/2024 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, 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. Residents Affected - Some 1. The facility failed to label and date food stored in the reach-in refrigerator that should no longer be consumed. 2. The facility failed to label and date food in the dry storage. 3. The facility failed to date food stored in the walk-in refrigerator that should no longer be consumed. 4. The facility failed to store food in a sanitary manner in the walk-in refrigerator. 5. The facility failed to date food in the general storage area. These failures could affect residents who received their meals from the facility's only kitchen, by placing them at risk for food-borne illness if consumed, and food contamination. Findings included: Observations on 03/05/24 at 09:32 AM revealed mixed cut fruit in a container, whipped cream in a piping bag and grated cheese in the reach-in refrigerator were not labeled or dated. Observations on 03/05/24 at 09:35 AM revealed two bags of [NAME] Krispies in the dry storage were not labeled or dated. Observations on 03/05/24 at 09:41 AM revealed one big block of American cheese on the floor in the walk-in refrigerator. Observations on 03/05/24 at 09:42 AM revealed one big container of fruit juice and several cups of Kool-Aid in the walk-in refrigerator were not labeled or dated. Observations on 03/05/24 at 09:58 AM revealed several cans of canned goods in the general storage area were not labeled or dated. (continued on next page) 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 03/07/2024 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 Interview with Dietary Aide D on 03/06/2024 at 11:06 AM revealed that everyone in the kitchen was responsible for dating and labeling foods. She stated as an aide, she usually prepared daily desert and prepared drinks and labeled and dated those items. She stated that not dating and labeling items can lead to risk of feeding foods to residents that could be spoiled. She stated that she had not received in-services for dating and labeling for last few months. Residents Affected - Some Interview with [NAME] C on 03/06/2024 at 11:15 AM revealed that the cooks were responsible for dating and labeling all food items in the refrigerator/ freezer. He stated that if he found any food that was not dated or labeled, he would inform the food service manager and throw away that food. He stated that he knew all food should be stored at least 6 inches away from the floor. He was not able to explain why a block of cheese was on the floor. He stated he had not seen the cheese on the floor when he reported to the shift and checked the refrigerator that morning. He had received in-services re: handwashing and food hygiene, but he does not remember in-services about food storage. He stated that not storing food properly could lead to food borne illness. Interview with Food Service Manager on 03/06/2024 at 11:30 AM revealed that had been working in the facility for the last 8 months. He stated that the cooks and the dietary aides, including himself, were responsible for food storage including labeling and dating foods. He stated that he found inconsistent labeling and dating on various food items yesterday. He stated that he had not provided any in-services to the kitchen staff on food storage and safe food handling during his 8-month tenure. He stated that they provided in-services to dietary staff only when they saw a problem and there were no planned in-services that were to be conducted. He stated that being a dietary manager he was ultimately responsible for ensuring food safety and food storage in the facility kitchen. He stated that not storing food properly could lead to food borne illness. Interview with the Dietitian on 03/06/2024 at 01:20 PM revealed that cooked food should not be stored in the refrigerator for more than 72 hours. She stated that all the foods in the kitchen should be dated and labeled. She stated that it's an expectation from the corporate team to round the kitchen at least monthly to check on food temperatures, food dating and labeling, and perform taste trays. She stated that the cooks and food service manager were responsible for dating and labeling all food items. She stated that she provided monthly in-services on various topics and the last in-service on food storage, labeling, and dating was provided to the kitchen staff in April 2023. She stated that it was her expectation that all food items be labeled, dated, and always covered. She added risk of not dating or labeling can lead to food borne illness. Record Review of the Facility's Food Safety revised 04.26.2023 revealed Food is stored and maintained in a clean, safe, and sanitary manner following federal, state, and local guidelines to minimize contamination. Review of the Food and Drug Administration Food Code, dated 2022, reflected, .3-302.12 Food Storage Containers, Identified with Common Name of Food. Except for containers holding food that can be readily and unmistakably recognized such as dry pasta, working containers holding food, or food ingredients that are removed from their original packages for use in the food establishment, such as cooking oils, flour, herbs, potato flakes, salt, spices, and sugar shall be identified with the common name of the food 3-305.11 Food Storage.(B) .refrigerated, ready-to eat time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day (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 03/07/2024 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 the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455864 If continuation sheet Page 10 of 10