Health inspection·May 23, 2024

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few documented on 05/17/2024. Review of Resident #50's progress notes revealed no evidence that Resident #50's tracheostomy shield was changed out by any facility staff between 05/10/2024 - 05/22/2024. Further review revealed no documentation of any refusals from Resident #50 for tracheostomy shield care by facility staff between 05/10/2024 - 05/22/2024. Review of Resident #50's TAR revealed Trach: Change trach shield . Q [per] week . with a start date of 01/30/2023 at 6:00 AM. Review of Resident #50's TAR revealed no evidence that Resident #50's tracheostomy shield was changed out by any facility staff between 05/10/2024 - 05/22/2024. In observation and interview on 05/22/2024 at 11:00 AM, Resident #50 was resting in bed in his room. His respiratory equipment was audibly functioning with the distal end of the tubing connected to Resident #50's tracheostomy shield. The date on Resident #50's tracheostomy shield was observed to be dated 5/10/24. Resident #50 stated RT J visited him at the facility every Friday and provided his tracheostomy care. Resident #50 denied refusing tracheostomy care from facility staff and stated that he has been cooperative with any intervention what was prescribed for his tracheostomy care. In telephone interview with RT J on 05/23/2024 at 9:19 AM and 9:31 AM, he stated that last Friday 05/17/2024, the facility was not stocked with tracheostomy shields, and he was not able to provide a new tracheostomy shield for Resident #50. He stated he informed Central Supply staff (CS S) and documented this request on an equipment request log. He stated he did not inform nursing leadership because he informed CS S of what he needed. He acknowledged that providing a new tracheostomy shield for Resident #50 was important for infection control purposes and stated the .[tracheostomy shield] can get dirty . anytime you have plastic and water, bacteria can grow . In interview with the facility staff responsible for Central Supply needs, CS S, on 05/23/2024 at 11:04 AM, she stated RT J reported to her on 05/17/2024 the facility was out of tracheostomy shields, and he then documented an equipment request on a request sheet. When documentation of this request sheet was requested from CS S, she stated she was not able to provide it because she shredded it. She further stated that supplies for the facility were ordered each Tuesday and that the tracheostomy shield had not arrived at the facility until today, 05/23/2024. She stated she was not aware Resident #50's tracheostomy shield had not been changed out, and it was RT J's responsibility to inform her when respiratory supplies get low and/or were not stocked at the facility. She stated it was ultimately her responsibility to ensure we don't run out of stuff, so the residents have what they need. She stated she did not inform anyone in nursing leadership that the facility did not have tracheostomy shields stocked after RT J informed her on 05/17/2024. In observation and interview with Resident #50's nurse for the day, LVN P, on 05/22/2024 at 12:17 PM, he observed Resident #50's tracheostomy shield and stated It was not acceptable that his tracheostomy shield was dated 05/10/2024. He stated this meant Resident #50 had not been provided a new tracheostomy shield since that date. He stated that RT J visited the facility each Friday and was responsible for physician ordered respiratory therapy equipment changes weekly, which included his tracheostomy shield. He acknowledged that facility nurses were able to change any respiratory therapy equipment; but stated he believed Resident #50 prefers RT J to provide this respiratory therapy intervention. When asked if he attempted to provide this care for Resident #50, LVN P stated he [Resident #50] refuses a lot of things, so he might have and further stated he did not report that Resident #50's tracheostomy shield was out of date to nursing leadership. He stated replacing Resident #50's tracheostomy shield was important for infection control. In an interview with ADON M on 05/22/2024 at 12:00 PM, she stated Resident #50 was the only (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675109 If continuation sheet Page 2 of 5 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 675109 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Richardson Nursing and Rehabilitation 1111 Rockingham Dr Richardson, TX 75080 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 resident with a tracheostomy at the facility. She stated that the facility's respiratory therapist, RT J, rounded on him every week on Friday and was responsible for replacing Resident #50's tracheostomy equipment at that time. She stated that facility nurses were responsible for tracheostomy care on the other days beyond Fridays. She stated she was aware of Resident #50 refusing tracheostomy care in the past; but the resident was receptive to the education provided by facility leadership and has been compliant with cares as of lately. In interview with the DON on 05/23/2024 at 11:17 AM, she stated that she was not aware the facility was out of tracheostomy shields, and further stated it was surprising to her as we are never out of anything. She stated she was not aware Resident #50's tracheostomy shield was not changed per physician order. She stated it was not acceptable and expected to be notified by her staff if the facility was out of supplies so I can get it taken care of. She stated she was not aware of any refusals from Resident #50 related to respiratory therapy cares. The DON stated there was a risk to the resident as it was best practice for a resident's tracheostomy shield to be changed out weekly for infection control purposes. Review of facility policy, Requesting, Refusing and/or Discontinuing Care or Treatment, dated 02/2021 revealed: Resident and resident representatives have the right to request, refuse and/or discontinue treatment . 1. Residents/representatives are informed (in advance) of: a. the care that will be furnished or made available to the resident based on his or her assessment and plan of care; b. the risks and benefits of the proposed care, treatment, treatment alternatives or treatment options . 5. If a resident/representative requests, discontinues or refuses care or treatment, an appropriate member of the interdisciplinary team will meet with the resident/representative to: a. determine why he or she is requesting, refusing or discontinuing care or treatment; b. try to address his or her concerns and discuss alternative options; and c. discuss the potential outcomes or consequences (positive and negative) of the decision . 8. Detailed information relating to the request, refusal or discontinuation of treatment are documented in the resident's medical record. 9. Documentation pertaining to a resident's request, discontinuation or refusal of treatment includes at least the following: a. The date and time the care treatment was attempted; b. The type of care or treatment; c. The resident's response and stated reason(s) for request, discontinuation or refusal; d. The name of the person who attempted to administer the care or treatment e. That the resident was informed (to the extent of their ability to understand) of the purpose of the treatment and the potential outcome of not receiving the medication/or treatment. Review of facility policy, Tracheostomy Care, dated 08/2013, revealed General Guidelines . 4. Tracheostomy tubes should be changed as ordered . Procedure Guidelines . Preparation and Assessment . 1. Check physician order . Site and Stoma Care: 8. Replace supplemental oxygen mask over tracheostomy . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675109 If continuation sheet Page 3 of 5 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 675109 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Richardson Nursing and Rehabilitation 1111 Rockingham Dr Richardson, TX 75080 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for one of one facility reviewed for environment. 1. The facility failed to ensure the foundation, walls, and ceiling were in good repair in the hallway to the right of the secretary's desk. 2. The facility failed to ensure the carpets were clean and stain free throughout the facility. These failures could affect all residents, resulting in falls and cross contamination which could lead to a decline in the resident's health and physical functioning. Findings included: Review of the quarterly MDS assessment for Resident #1, dated 04/23/24, reflected he was an [AGE] year-old male admitted on [DATE]. His cognitive status was moderately impaired. His diagnoses included Alzheimer's Disease and heart failure. An observation on 05/21/24 at 9:25 AM revealed on the right side of the facility, close to the receptionist desk there were foundation problems. There was a downward slope on the floor. The walls had separated from the floor. The floor was lower than the wall. There were large cracks on the walls that were close to the ceiling on the right side of the hallway that traveled from one door to the next. There were additional cracks that traveled from the ceiling down to the door frames. There was a large open hole in the ceiling where pieces in the ceiling were hanging out. There were three cones with caution yellow tape in front of the area. The carpet at the entrance to the facility and down the resident halls was gray colored with large areas of brown/black discoloration. The carpets appear to be stained with unknown substances. An interview with the Administrator on 05/21/24 at 11:25 AM revealed a new company took over the facility on 05/10/24. The Administrator said he had worked at the building for 2 weeks. He said he was not sure when the facility foundation repair would be fixed. He said there were vendors looking at it and it would need a lot of repair and foundation work. An interview on 05/21/24 at 2:10 PM with the CEO revealed an engineering survey started after the last facility survey (10/17/23). The CEO said she received the engineering report on 04/08/24 and the facility was working to get the work done. An observation on 05/21/24 at 2:15 PM revealed Resident #1 was walking on the right side of the building where the damage was. He was on the other side of the cones walking toward the front desk. The Surveyor notified the Administrator. The Surveyor attempted to interview the resident, but the resident was confused. The Administrator approached the resident, and the resident told the Administrator, Bang, bang. An interview with the DON on 5/22/24 at 1:55 PM revealed she had worked at the facility for one year. She said she did not know when the foundation damage first occurred, but she said it had been that way since she started employment. The DON said the facility had been through change of ownerships, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675109 If continuation sheet Page 4 of 5 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 675109 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Richardson Nursing and Rehabilitation 1111 Rockingham Dr Richardson, TX 75080 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 0921 Level of Harm - Minimal harm or potential for actual harm but none of the companies fixed it. She said the previous owners were going back and forth with trying to figure out who was supposed to repair it. The DON said something was currently being done with soil testing and she was told the repair process would take 2 years. The DON said residents did not go to that side of the building and no staff or residents had been injured in the area. The DON said the carpet was cleaned daily, but there were no plans to replace it until the foundation work was completed. Residents Affected - Many An interview on 5/22/24 at 2:45 PM with the SW revealed she had worked at the facility since 09/06/22. The SW said the damage to the foundation started when she was hired. She said during the summer the ground dried up and the damage would worsen. When the facility got rain the damage was not too bad, but during summer it would worsen. The SW said the facility went through a CHOW on 08/01/23. She said at that time, she was told there were 3-4 foundation companies that were going to look at the issues. The Foundation companies said they needed information from structural engineers who said the foundation would require more than just a foundation company to repair. The SW said the carpet was cleaned with a commercial carpet shampooer but would not be replaced until the foundation work was completed. Review of the facility policy, Homelike Environment, revised February 2021, reflected: Policy Statement Residents are provided with a safe, clean, comfortable and homelike environment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675109 If continuation sheet Page 5 of 5