Health inspection·May 2, 2024

F 0689 stated the risk to the resident was injury if he fell out of the bed without the fall mat. Level of Harm - Minimal harm or potential for actual harm Interview on 05/01/2024 at 11:30 AM with LVN B revealed Resident #1 was supposed to have floor mats on both sides of his bed because he was a fall risk and floor mats reduce injury if he fell out of bed. LVN B stated Nurse Aide A should have placed the fall mats back on the floor if she had to leave the room to get assistance. LVN B stated the resident could have been injured if he fell without a floor mat. LVN B stated it was Nurse Aide and Nurses responsibility to ensure floor mats were used for residents at risk of falls. Residents Affected - Few Interview on 05/03/2024 at 2:01 PM with the DON revealed Resident #1 was at high risk for falls and should always have floor mats on both sides of his bed. The DON stated if a nurse aide needed the assistance of another staff member when caring for a resident then they should ask another staff member ahead of time, before picking up the fall mats. The DON stated if the nurse aide needed to leave the room then they should have put the fall mats back down before leaving the resident's room. The DON stated the resident could have fallen out of bed and been injured. The DON stated the nurse aide was a newer employee and would be in-serviced immediately. Interview on 05/03/2024 at 3:10 PM with the Administrator revealed if a staff member rolled fall mats up but realized they didn't have assistance with the resident then they should put the fall mats back down while they left the room to get assistance. Review of the policy titled Area of Focus: Fall Management dated reviewed 12/04/2023 reflected the facility was to promote patient safety and reduce patient falls by proactively identifying, care planning, and monitoring of patients fall indicators. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455864 If continuation sheet Page 2 of 4 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 05/02/2024 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 Residents Affected - Some 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 free of grease buildup. 2. The facility failed to ensure the sides of the stove were clean from food residue and grease build up. These failures could place residents at risk for food contamination and food-borne illness. Findings included: Observation at 04/30/2024 10:00 AM of the kitchen revealed grease trap with thick black build up that covered the outside handle of stove and a thick and sticky black build up on the inside corners and along the sides of the trap. Interview on 04/30/2024 at 10:45 AM with [NAME] C revealed that the stove and grease trap were supposed to be cleaned at the end of every shift, but she did not clean it or check it if she did not use the griddle top. [NAME] C stated it generally was cleaned by which ever cook used the griddle top, which was usually the morning shift for breakfast foods like bacon. [NAME] C stated she did not remember if she checked the grease trap at the beginning of her shift or before she started cooking because she did not use the griddle top for the lunch meal. [NAME] C observed the grease trap and stated it was not sufficiently cleaned and that the side of the oven had food residue and was unable to say if there was a risk to residents. [NAME] C stated it was her responsibility to clean any spills on the top of the stove that occurred on her shift during the cooking process. Observation and interview on 04/30/2024 at 3:52 PM with the Food Services Director revealed there was thick black build up that covered the outside handle of the grease trap, at the inside corners, sides, and there was food residue and grease build up on both sides of the oven and the fryer next to the oven. The Food Services Director stated the grease trap and stove were not fully cleaned and they should not have any residue or grease. The Food Services Director stated it was the cook's responsibility to clean the stove including scraping any thick areas of greasy residue and cleaning the sides of the oven. The Food Services Director stated it was his responsibility to ensure the equipment was cleaned properly. The Food Services Director stated he had taken down the cleaning checklist to review it, could not currently locate the document, and the current cleaning check list posted was for the previous week dated 04/15/2024 through 04/22/2024. The Food Services Director stated the cleaning schedule was posted in the kitchen and staff check off tasks they completed at the end of every shift, including cleaning the stove and did not currently check routinely that staff were cleaning thoroughly. Interview on 05/01/2024 at 9:12 AM with the Food Services Director revealed the risk to residents when stoves and grease traps were not cleaned were food contamination and it could be a hazard. The Food Services Director provided the cleaning check list and stated he added the cleaning task cleaning grease traps and in-serviced staff on cleaning kitchen equipment. The Food Services Director stated he took the stove out completely the evening of 04/30/2024 and degreased the grease trap. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455864 If continuation sheet Page 3 of 4 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 05/02/2024 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 Residents Affected - Some Observation on 05/01/2024 at 12:30 PM of the kitchen stove revealed there was food residue and grease on both sides of the stove and grease trap had same amount of thick black residue on inside corners. Interview on 05/01/2024 at 12:33 PM with [NAME] D revealed the stove had food residue on both sides and grease trap had thick grease build up on the inside corners. [NAME] D stated she does not clean certain areas of the stove, such as the flat top and grease trap, because she does not use them when she cooks lunch. [NAME] D stated that whichever cook uses the flat top was responsible for cleaning it after each use. [NAME] D was unable to say if there was a risk to resident by having food residue on sides of stove and uncleaned grease traps. Interview on 05/01/2024 at 12:45 PM with [NAME] E revealed he usually worked on the morning shift and used the flat top regularly for items like sausage or bacon. [NAME] E stated he empties the grease trap at the end of each shift, and it currently was sufficiently cleaned. Interview on 05/01/2024 at 1:25 PM with the Food Services Director revealed the grease trap had been scrapped clean and he had to use a putty knife to get the substance free and expected Cook's to check the grease trap and clean it including scrapping if needed to ensure it was free of any residue. Review of the posted cleaning schedule titled Daily Cleaning Week of 4/15-4/22 reflected cleaning stove top and grill were the cook's responsibility. Review of the facility's policy on cleaning titled Cleaning Schedule dated 10/04/19 and reviewed on 04/25/2023 reflected The Director of food and Nutrition Services develops a cleaning schedule . to ensure that the Food and Nutrition Services department remains clean and sanitary at all times. Review of 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: 455864 If continuation sheet Page 4 of 4