Health inspection·February 19, 2025

F 0550 shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675109 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 675109 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/19/2025 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure residents had the right to a safe, clean, comfortable, and homelike environment including but not limited to receiving treatment and supports for daily living safely for 4 of 6 resident rooms (room [ROOM NUMBER], #2, #3, and #4) and all the facility hall floors reviewed for environment. 1. The facility failed to ensure resident rooms #1, #2, #3, and #4 were thoroughly cleaned and sanitized. 2. The facility failed to ensure the facility hallway floors were cleaned and sanitized. These deficient practices could place residents at risk of living in an unclean and unsanitary environment which could lead to a decreased quality of life. Findings include: An observation on 02/18/25 at 08:19 AM of the facility hallways revealed large dark stains on the carpet areas and dark brown and black stains on the tiles, especially along the edges of the floor, near the walls. An observation on 02/18/25 at 08:20 AM of resident room [ROOM NUMBER] reflected the bathroom floor had dirty clothes on the floor under the sink. The bathroom floor had black stains under the sink and along the corners of the floor. The room floor had black stains all over it. An observation on 02/18/25 at 08:25 AM of resident room [ROOM NUMBER] reflected the floor had brown stains under a sink in the resident's room and along the corners of the floor. An observation on 02/18/25 at 08:33 AM of resident room [ROOM NUMBER] reflected white shredded papers and dirt between the resident bed and nightstand. The bathroom floor had black and brown stains, especially around the toilet and corners of the floor. The air condition unit had vents filled with black and brown debris. An observation on 02/18/25 at 08:33 AM of resident room [ROOM NUMBER] reflected the bathroom floor had back and brown stains, especially around the toilet and corners of the floor. The air condition unit had vents filled with black and brown debris and there was no filter observed. The resident's room floor had dark stains under the air condition unit and large [NAME] stains along the front of the bathroom door. In an interview on 02/19/25 at 12:00 PM, the Administrator was shown pictures of the concerns observed in the facility hallways and resident rooms #1, #2, #3, and #4. He stated the floors were old and their floor cleaning machine had broken down and was just recently repaired. He stated he agreed there was still an opportunity for them to do a better job cleaning. He stated the facility was scheduled for a revamp. He stated they planned to reconstruct one side of the facility and once they were done, they would move the residents to the newly rebuilt area and then work on the other side. He stated the project was scheduled to take 9 months. He stated this was the resident's home and it should be clean. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675109 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 675109 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/19/2025 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 0584 Level of Harm - Minimal harm or potential for actual harm In an interview on 02/19/25 at 02:00 PM, the Housekeeping Supervisor was shown the pictures of the concerns observed in the facility hallways and resident rooms #1, #2, #3, and #4. He stated the floors were old and not really stained. He was advised the floors observed were stained and were observed to be built up dirt that required extensive cleaning. He stated the risk for the residents was the facility was their home, and they should be in a safe and clean place. Residents Affected - Some Record review of the facility's policy on Homelike Environment (February 2021) reflected Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible . 2. The facility staff and management maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: a. clean, sanitary and orderly environment FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675109 If continuation sheet Page 4 of 4