Inspection·December 14, 2023

F 0558 Reasonably accommodate the needs and preferences of each resident. 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 the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for two (Resident #70 and Resident #46) of eight residents reviewed for reasonable accommodation of needs. Residents Affected - Some The facility failed to ensure the call light system in Residents #70 and #46's rooms was in a position that was accessible to the residents. This failure could place the residents at risk of being unable to obtain assistance when needed and help in the event of an emergency. Findings included: Review of Resident #70's Face Sheet dated 12/12/2023 reflected resident was a [AGE] year-old female admitted on [DATE]. Relevant diagnoses included muscle weakness, lack of coordination, and cognitive communication deficit. Review of Resident #70's Quarterly MDS assessment dated [DATE] reflected Resident #70 had a severe cognitive impairment with a BIMS score of 00. Resident #70 required extensive assistance for bed mobility, transfer, toilet use, and personal hygiene. Review of Resident #70's Comprehensive Care Plan dated 09/20/2023 reflected Resident #70 ad a communication problem related to poor cognitive status and one of the interventions was ensure/provide a safe environment by putting the call light within reach of the resident. Review of Resident #70's Comprehensive Care Plan dated 09/20/2023 reflected Resident #70 had a risk for fall related to unsteady gait/balance and generalized weakness to lower extremities. One of the interventions was to be sure the resident's call light is withing reach and encourage the resident to use it for assistance as needed. Observation and interview with Resident #70 on 12/12/2023 starting at 10:17 AM revealed resident sitting on a chair located at the end of her bed. Resident #70's call light was noted on the floor between the bedside table and the top part of the bed. There was a trash can in front of the call light on the floor making the call light not visible. Resident #70 was unable to tell where her call light was nor was able to explain why the call light was on the floor. Observation on 12/12/2023 at 2:23 PM revealed Resident #70's call light was still on the floor between the bedside table and the top part of the bed. The trash can was empty. Observation on 12/13/2023 at 7:29 AM revealed Resident #70's call light was still on the floor between the bedside table and the top part of the bed. The trash can was not in front of the call light on the floor but was in front of the bedside table. Interview and observation with CNA M on 12/13/2023 starting at 7:39 AM, CNA M stated call lights were extremely important for the residents. CNA M said the call lights were inside the rooms of the residents for a reason. CNA M continued the call lights were used by the residents if they wanted to communicate with the staff like if they were wet, thirsty, in pain, or even had a fall. CNA M added (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675113 If continuation sheet Page 2 of 23 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 675113 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Park IN Plano 3208 Thunderbird LN 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 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some that for these reasons, the call lights should always be within the reach of the residents. She continued if the residents were on their beds, the call lights should be near the residents whether clipped on the pillows or blankets. If the residents were up, the call lights should be on top of the bed so the residents could easily reach it and call the staff for assistance. If the residents did not have the call lights, they won't be able to call the staff and their needs won't be met. CNA M acknowledged Resident #70's call light was not on the top of the bed and was on the floor between the side table. CNA M said she must had missed it when she made the bed. CNA M went inside the room, looked for the call light, picked it up from the floor, and placed it on top of the bed. CNA M concluded all residents should have their call light with them at all times whether the resident was mobile, or bed bound. Review of Resident #46's Face Sheet dated 12/14/2023 reflected resident was a [AGE] year-old male admitted on [DATE]. Relevant diagnoses included cerebral infarction and unspecified anxiety disorder. Review of Resident #46's Quarterly MDS assessment dated [DATE] reflected Resident #46 was unable to complete the interview to determine the BIMS score. Resident #46 required extensive assistance for bed mobility, transfer, eating, and toilet use. Review of Resident #46's Comprehensive Care Plan dated 11/12/2023 reflected Resident #46 had a communication problem and one of the interventions was to ensure/provide a safe environment by making sure the call light was within reach. Review of Resident #46's Comprehensive Care Plan dated 11/12/2023 reflected Resident #46 had a risk for fall and one of the interventions was to be sure the resident's call light was within reach and encourage the resident to use it. Review of Resident #46's Incident Report denoted Resident #46 had falls on 10/02/2023 and 10/25/2023. Observation on 12/13/2023 at 7:51 AM revealed Resident #46 was on his bed sleeping. The call light was noted on the floor mat at the side of the bed. Interview and observation with CNA Y on 12/13/2023 starting at 8:02 AM, CNA Y stated the call light should be placed within the reach of the residents at all times. CNA Y said the staff must make sure the call lights were with the residents before leaving the room. CNA Y added the resident used the call lights to call for assistance. If the call lights were not with the residents, they might try to stand up to do it by themselves. CNA Y said the residents might fall or might get frustrated if they could not call the attention of the staff. CNA Y said she was not aware Resident #46's call light was on the floor. She said she would go to Resident #46's room and pick up the call light and place it near Resident #46. CNA Y went inside the Resident #46's room and secured the call light at the side of the resident. Interview with LVN H on 12/13/2023 at 8:54 AM, LVN H stated she was not aware Resident #70 and Resident #46's call lights were on the floor. LVN H said the call lights should always be within the reach of the residents, at all times. LVN H said the call lights were used by the residents to call the attention of the staff if they needed something or if they needed help. LVN H added the call lights should be placed and secured within the reach of the residents. LVN H added aside from the needs not being met, the residents might fall if they tried to stand up to reach for what they needed. LVN H said she would go around to make sure the call lights were with the residents. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675113 If continuation sheet Page 3 of 23 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 675113 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Park IN Plano 3208 Thunderbird LN 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 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interview with DON on 12/13/2023 at 3:13 PM, the DON stated the call lights were used by the residents if they needed assistance from the staff. The DON said the residents might need a glass of water, a pain medication, or they needed to be changed. The DON added without the call lights, the residents would not be able to tell the staff they were thirsty, needed a snack, they were in pain, they need to go to the bathroom, or they were not feeling well. The DON further added that when the call lights were not within the reach of the residents, unfavorable incidents like falls, skin tears, and bumps could happen. The DON said the expectation was for the staff to ensure that the call lights were within reach of the residents. She also said she would do an in-service training with her staff about the importance of making sure that all call lights be left in reach of the residents. The DON concluded that moving forward, she would be on top of this issue to make sure the staff would make certain the call lights were with the residents at all times. Interview with LVN K on 12/13/2023 at 3:28 PM, LVN K stated the call light should not be on the floor or anywhere the residents could not reach it. LVN K said the call lights must always be by the residents at all times because the call lights were their form of communication. The residents used the call lights to let the staff know they needed something. LVN K added without the call lights, the needs of the resident won't be met and it could result to fall, injury, fear, and frustration. LVN A said she would check her residents if they had their call lights. Interview with LVN I on 12/13/2023 at 3:32 PM, LVN I stated the call lights were the resident's lifeline. LVN I said the residents use the call lights for basic reasons such as a glass of water, television remote, eyeglasses, or magazines. LVN I added the residents used the call lights if they were not feeling well or if they or if they need to go to the bathroom. If the call lights were far from the residents, the residents won't be able to call the staff and these needs won't be addressed. If the call lights were not with the residents, it could result to fall, dehydration, and annoyance. Interview with the Administrator on 12/14/2023 at 7:37 AM, the Administrator stated the call light must be within the reach of the residents or else the basic needs of the residents won't be addressed. The Administrator added not only the basic needs but also in times of emergencies. The Administrator added she would monitor the staff for this concern and would re-educate the nurses and the CNAs to ensure call lights were within the reach of the residents. Record review of facility's policy Resident Rights, revealed . respect and Dignity . 3. The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675113 If continuation sheet Page 4 of 23 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 675113 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Park IN Plano 3208 Thunderbird LN 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 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. Based on observations, interviews, and record review the facility failed to provide a safe, clean, comfortable, and homelike environment including but not limited to receiving treatment and supports for daily living safely for areas in the facility for 8 (Resident #'s 2, 10, 12, 31, 36, 38, 50, and 51's) of 27 resident rooms observed for a safe, clean, comfortable, and homelike environment. The facility failed to ensure that Resident #'s 2, 10, 12, 31, 36, 38, 50, and 51's rooms were cleaned, sanitized, and maintained, based on observations made on 12/12/23. This deficient practice could place residents at risk of infections and living in an uncomfortable environment leading to a decreased quality of life. Findings included: Observation of Residents #12 and #38's room on 12/12/23 at 11:22 AM revealed the wall alongside Resident's bed had light brownish stains going down the wall and there was a large circular scrap on the wall near the foot board. Both bed side tables in the room had dried-up brown stains and food crumbs in the drawer of the bed side tables. Observation of Residents #10 and #51's room on 12/12/23 at 11:26 AM revealed a white frame above the air-conditioned unit had brownish drop of stains on it. Observation of Residents #31 and #50's room on 12/12/23 at 11:31 AM revealed a mini fridge in the room that had displayed brown stains and black dirt particles on the inside bottom of fridge. The Resident bed frame had bright brownish stains along the bottom of the bed frames. One of the walls had dark stains along the top portion of the wall and brownish stains along the bottom of the wall. The wall alongside the resident's bed had light brownish stains and a wall nearing the entrance of the room had a circular brownish stain on the wall. Observation of Residents #2 and #36's room on 12/12/23 at 12:16 PM revealed a 12x12 inch square shaped, scraped wall. Both bed side tables in the room had dried-up brown stains and food crumbs in the drawer of the bed side tables. Interview on 12/14/23 at 10:16 PM with Housekeeping Manager, she stated she had been at the facility for three years. She stated she trained staff by showing them how to deep clean and how to daily clean. She stated for deep cleanings, they move furniture, wipe down walls, clean the vents on the air condition units, and thoroughly clean the bathrooms. She stated they deep clean two rooms a week. She stated she used a log to ensure that all rooms have been thoroughly cleaned. She stated for daily cleaning the staff are supposed to wipe down bed rails, bed side tables, sweep and mop, and clean the bathroom. She was shown pictures of the wall that had drywall damage, and she stated maintenance was aware of them and trying to make the repairs. She was shown pictures of the resident room walls, bed side tables, and others areas of the room that were of concerns and she stated that housekeeping should have cleaned those areas. She stated the risk of not thoroughly cleaning rooms could cause infections. Interview on 12/14/23 at 11:06 AM with Housekeeping M, she stated she had been at the facility for 4 years. She stated she was trained to clean the clean the entire room, including under the bed, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675113 If continuation sheet Page 5 of 23 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 675113 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Park IN Plano 3208 Thunderbird LN 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some wipe off items, and mopping and sweeping the floor. She stated she cleaned all rooms twice daily. She stated she started in the morning and returns in the afternoon to check for cleanliness. She stated they also clean the air filters. She stated she cleaned the 100 hall rooms. She stated she deep cleaned resident rooms daily. She stated she deep cleaned at least two rooms daily. She stated that a former co-worker had trained her to clean, and she had a history of cleaning homes and hotel rooms. She was shown the pictures of the concerns observed in the room and she stated that they should have cleaned, all of the areas mentioned by surveyor. She was asked the risk and she stated that all residents had the right to a clean room. She stated she was aware of the damaged walls in the rooms, but she had not reported it to maintenance. Interview on 12/14/23 at 11:40 AM with the Maintenance Director, stated he was made aware of the drywall damages in the resident rooms and stated that they are on his log for repair based on priority. He stated that maintenance concerns impacting Life Safety Code had priority and unfortunately these repairs were lower on the list. Interview on 12/14/23 at 01:00 PM with the DON, she stated she had been the DON at the facility for a year and two months. She stated that they complete Angel Rounds daily and the IDT conducts these daily and one of the things checked was the cleanliness of rooms and damages. The DON stated Angel Rounds were daily rounds conducted my members on the IDT team and the goal was to make daily visits to all of the residents to see how they are doing and to also observe the resident's environment. They stated that if there were any concerns, they would present them to the housekeeping and maintenance departments during their IDT meeting. She stated Angels rounds are completed before the daily IDT meetings. She stated that it could impact their home like environment. Interview on 12/14/23 at 01:15 PM with the Administrator, she stated the leadership team completed Angel Rounds daily, before their IDT meetings. She stated that one of the things that were checked was the cleanliness of rooms and for any maintenance concerns. She was advised of the concerns observed in the rooms and she stated they were aware of the damages to the walls and are in the process of trying to place barriers over the wall alongside the resident's bed to protect the wall from damages and heavy stains, but had not gotten to that hall yet. She stated the risk of these concerns not being addressed was not good for the residents. Review of the facility's policy on Environmental Services (November 2021) revealed To provide a clean, attractive, and safe environment for residents, visitors, and staff. High Dust Wall Articles: Damp Dust the Doors and Wall the tops of items along the resident's room and restroom walls (door frames, picture frames, clocks, over bed lighting, door closures, etc.) that are at or above your shoulder height. Clean and Disinfect the Room Furnishings: A. Clean all furnishings in the resident's room including the bed rails, IV poles, doorknobs, wheelchairs, walkers, and all other high contact surfaces FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675113 If continuation sheet Page 6 of 23 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 675113 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Park IN Plano 3208 Thunderbird LN 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 0604 Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, the facility failed to ensure the resident was free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms for 4 of 8 (Resident #2, #26, #35 and #43) residents reviewed for restraints. Residents Affected - Some The facility failed to ensure Residents #2, #26, #35 and #43 had physician orders as of 12/12/2023 for the bolster side rails on their mattress . These failures could unnecessarily inhibit the residents' freedom of movement or activity. Findings included: 1. Record review of Resident #43's MDS assessment, dated 08/25/23, reflected she was an [AGE] year-old female who admitted to the facility on [DATE]. Her cognitive status was moderately impaired. Her diagnoses included stroke and seizure disorder. Record review of Resident #43's December 2023 Physician Orders reflected there were no orders for the bolster side rails ( a barrier attached to the side of a bed used to limit the ability to get out of bed) . An observation on 12/12/23 at 10:28 AM revealed Resident #43 was lying in bed. She had plastic, bolster side rails on both sides of her bed that limited her ability to get out of bed. An interview with the DON on 12/14/23 at 1:05 PM revealed Resident #43 had an air mattress and bed bolsters on each side of the bed to prevent her from falling out of bed. The DON said the resident did not have an order for the bed bolsters because it was an oversight and the resident had not been evaluated to have the bed bolsters. The DON said the resident had a fall from bed in March 2023 and the bed bolsters were placed at that time. The DON said she did not view the bed bolsters as a physical restraint. Record review of Resident #35's MDS assessment, dated 10/17/23, reflected she was a [AGE] year-old female who admitted to the facility on [DATE]. Her cognitive status was moderately impaired. Her diagnoses included end stage renal disease and non-Alzheimer's dementia. Record review of Resident #35's December 2023 Physician Orders reflected there was an order dated 12/13/23 for the bolster side rails. An observation on 12/12/23 at 11:00 AM revealed Resident #35 was lying in bed. She had plastic, bolster side rails on both sides of her bed that limited her ability to get out of bed. She also had a fall mat on the floor by her bed. An interview with the DON on 12/14/23 at 1:10 PM revealed Resident #35 had an air mattress and bed bolsters on each side of the bed to prevent her from falling out of bed. The DON said the resident had a history of falls from the bed. The DON said an order for the bed bolsters was not obtained until 12/13/23 because it was an oversight. The DON said she did not view the bed bolsters as a physical restraint. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675113 If continuation sheet Page 7 of 23 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 675113 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Park IN Plano 3208 Thunderbird LN 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 0604 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of Resident #2's face sheet, dated 12/13/23, revealed an [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included schizoaffective disorder (mood disorder), Diabetes (low insulin), and Stage 3 chronic kidney disease. Record review of Resident #2's Minimum Data Set (MDS) assessment, dated 11/25/23, revealed she had a BIM score of 00 (severe cognitive impairment), and required a two -person physical assist for all activities of daily living assistance (ADL). Record review of Resident #2's Care Plan on 12/13/23, revealed the resident's last quarterly assessment being completed on 09/07/23. Some of the Resident's plan of care included high risk for falls, ADL self-care, Risk for pressure ulcers, kidney disease, and mood problems. Observation made on 12/12/23 at 12:14 PM of Resident #2 revealed the resident was observed to be laying on an air pressured mattress that had raised sides on both sides of the mattress measuring at least 6 inches in height (scoop mattress). Observation made on 12/12/23 of Resident #2's orders revealed the resident had no orders for any restraint devices. Nor were there any orders for scoop mattresses or the use of bolster bumpers ( a barrier attached to the side of a bed used to limit the ability to get out of bed) . Record review of Resident #26's face sheet, dated 12/13/23, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included Alzheimer's disease (memory loss) and left artificial hip. Record review of Resident #26's Minimum Data Set (MDS) assessment, dated 12/05/23, revealed he had a BIM score of 00 (severe cognitive impairment), and required a two -person physical assist for all activities of daily living assistance (ADL). Record review of Resident #26's Care Plan on 12/13/23, revealed the resident's last quarterly assessment being completed on 10/02/23. Some of the Resident's plan of care included resident a risk for wandering, risk for falls, and ADL self-care. Observation made on 12/12/23 at 12:26 PM of Resident #26 revealed the resident was observed to be laying on an air pressured mattress that had raised sides on both sides of the mattress measuring at least 6 inches in height (scoop mattres). Observation made on 12/12/23 of Resident #26's orders revealed the resident had no orders for any restraint devices. Nor were there any orders for scoop mattresses or the use of bolster bumpers. Interview on 12/13/23 at 1:25 PM with LVN D, she stated that she was the nurse for Resident #2 and Resident #26. She stated Hospice provided added the booster bumper to the bed to prevent the resident from falling out of the bed. She stated the resident moved a lot while sleeping and Hospice had brought it in the booster bumper for the resident's bed. She stated there were orders for Resident #26 and she had to locate it. LVN D returned with a signed physician orders for the Booster bumper effective 12/13/23 at 01:45 PM. She stated the risk of the resident not having the proper risk assessment prior to the device being added to the bed could result in the resident hurting herself when trying to get out of bed. Interview on 12/14/23 at 01:00 PM with the DON, she stated she had been the DON at the facility for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675113 If continuation sheet Page 8 of 23 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 675113 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Park IN Plano 3208 Thunderbird LN 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 0604 Level of Harm - Minimal harm or potential for actual harm a year and two months. She stated that Resident#2 and #26 had the bed bolsters because they were falling out of the bed, but they did not obtain physician orders before applying the device because it was an oversite. She stated she was unsure how long each resident had the bolsters added to their mattress. She stated the risk to the resident not having physician orders could result in the resident getting injured while trying to get out of the bed. Residents Affected - Some Interview on 12/14/23 at 01:15 PM with the Administrator, she stated she was made aware by staff there were concerns with Residents having bed bolsters added to their beds but no physician orders. She stated that she had spoke with the DON and was advised that there was oversite and had gotten resolved. Record review of facility policy on Restraint/Seclusion, revised March 30. 2022, revealed Chemical/Physical restraints shall only be used upon the written order of a physician and after obtaining consent from the resident and/or representative, WITH THE EXCEPTION OF TEMPORARY BEHAVIORAL EMERGENCY. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675113 If continuation sheet Page 9 of 23 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 675113 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Park IN Plano 3208 Thunderbird LN 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure comprehensive care plans were reviewed and revised by the interdisciplinary team after each assessment, which included both the comprehensive and quarterly review assessments for 3 of 6 residents (Resident #2, #38, and #59) reviewed for Care Plans. The facility failed to ensure Resident #2, #38, and #59's Care Plan was reviewed and updated quarterly, based on record reviews made on 12/13/23. This failure could place residents at risk of their needs not being met. Findings included: Record review of Resident #2's face sheet, dated 12/13/23, revealed an [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included schizoaffective disorder (mood disorder), Diabetes (low insulin), and Stage 3 chronic kidney disease. Record review of Resident #2's Minimum Data Set (MDS) assessment, dated 11/25/23, revealed she had a BIM score of 00 (severe cognitive impairment), and required a two -person physical assist for all activities of daily living assistance (ADL). Record review of Resident #2's Care Plan, on 12/13/23, revealed the resident's last quarterly assessment being completed on 09/07/23. Some of the Resident's plan of care included high risk for falls, ADL self-care, Risk for pressure ulcers, kidney disease, and mood problems. Record review of Resident #38's face sheet, dated 12/13/23, revealed an [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included chronic kidney disease, dementia (memory loss), and schizoaffective disorder (mood disorder). Record review of Resident #38's Minimum Data Set (MDS) assessment, dated 10/04/23, revealed she had a BIM score of 00 (severe cognitive impairment), and required a two -person physical assist for all activities of daily living assistance (ADL). Record review of Resident #38's Care Plan, on 12/13/23, revealed the resident's last quarterly assessment being completed on 08/20/2023. Some of the Resident's plan of care included high risk for falls, ADL self-care, risk for pressure ulcers, and dementia. Record review of Resident #59's face sheet, dated 12/13/23, revealed an [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included acute kidney failure, dementia (memory loss), and schizoaffective disorder (mood disorder). Record review of Resident #59's Minimum Data Set (MDS) assessment, dated 11/29/23, revealed she had a BIM score of 08 (moderate cognitive impairment), and required a two -person physical assist for all activities of daily living assistance (ADL). Record review of Resident #59's Care Plan, on 12/13/23, revealed the resident's last quarterly assessment being completed on 08/27/2023. Some of the Resident's plan of care included communication (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675113 If continuation sheet Page 10 of 23 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 675113 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Park IN Plano 3208 Thunderbird LN 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 0657 problems, ADL self-care, risk for falls, and pain medication therapy. Level of Harm - Minimal harm or potential for actual harm Interview on 12/14/23 at 10:52 Am with ADON, she stated she had been at the facility for 4 months. She stated that everyone participates in Care plan meetings and the DON inputted the information. She stated that care plans are reviewed quarterly and as needed. She had her laptop with her, and she was asked to review Resident # 2, #38, and #59's Care plan. She stated that all three residents should have had a quarterly update. She stated that care plans are updated when there had been a change in condition and quarterly. She stated the DON and MDS Nurse normally updated the care plan. Residents Affected - Some Interview on 12/14/23 on 11:22 AM with MDS Nurse, she stated she had not been at the facility a month. She stated she was still in training. She stated care plans were to be updated quarterly or if there was a change in conditions. She was asked to review Resident # 2, #38, and #59's Care plans and she stated that all three residents should have had quarterly updates completed. She stated once she had completed training, she will be updating care plans, but she was unsure who was completing it prior to her starting at the facility. She stated the risk of care plans not being updated quarterly could result in the resident's care plan not being implemented accurately. Interview on 12/14/23 at 01:00 PM with the DON, she stated she had been the DON at the facility for a year and two months. She stated MDS updates the care plan quarterly. She was shown Resident # 2, #38, and #59's care plan and she stated that each resident did not have a quarterly update and it was because they were transitioning to a new MDS nurse, and she was trying to get caught up. She stated that the risk to the resident not having a current care plan could impact their care being received. Interview on 12/14/23 at 01:15 PM with the Administrator, she stated she was aware there were concerns with care plans not being updated quarterly. She stated that there was a performance improvement plan created to address the issue and now that they have a MDS nurse on staff, they hope to get caught up. She stated the risk of care plans not being updated could result in missed care. Record review of the Facility's policy on Care Plan Process reviewed March 27, 2023, revealed, The interdisciplinary team will coordinate with the resident and their legal representative an appropriate care plan for the resident's needs or wishes based on the assessment and reassessment process within the required time frames. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675113 If continuation sheet Page 11 of 23 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 675113 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Park IN Plano 3208 Thunderbird LN 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. 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 a resident who was unable to carryout activities of daily living received services to maintain grooming and personal hygiene for 1 of 8 residents (Resident #43) reviewed for quality of life. Residents Affected - Few The facility failed to ensure CNA B provided Resident #43 with timely incontinent care. These failures could place residents at risk for a decreased quality of life and pressure ulcers. Findings included: 1. Record review of Resident #43's MDS assessment, dated 08/25/23, reflected she was an [AGE] year-old female who admitted to the facility on [DATE]. Her cognitive status was moderately impaired. Her diagnoses included stroke and seizure disorder. Resident #43 required extensive assistance of two staff for toileting. Record review of Resident #43's Care Plan, dated 06/29/21, reflected: The resident had urinary incontinence and the facility intervention clean peri-area with each incontinent episode. The resident had bowel incontinence and the facility intervention was to check resident every two hours and assist with toileting as needed. An observation and interview on 12/12/23 at 11:26 AM revealed Resident #43 was lying in bed. The ADON said the resident needed incontinence care and CNA C assisted her. The ADON and CNA C performed hand hygiene and put on gloves. CNA C turned the resident to her left side. The resident's outer right thigh had dried bowel movement on it. The resident's brief was full of urine and leaking onto the mattress. The resident was rolled to her back. The brief was unfastened. The ADON provided peri-care to front area. The resident was rolled to her left side. The mattress was soaked with urine. CNA B entered the room and the ADON told CNA B that the resident was soaked down to the mattress. CNA B said she checked the resident earlier, but she had not changed her for the 6:00 AM - 2:00 PM shift because she had been busy and just finished showers. An interview on 12/12/23 at 1:44 PM with CNA B revealed the morning of 12/12/23 she made her first rounds at 6:30 AM. Two hours later she was busy with breakfast and did not check the resident. CNA B said 2 hours after that, at approximately 10:30 AM, she did not check the resident for incontinence because she was busy doing showers. She said she could call for help, but the other CNA and the nurse were all busy also. CNA B said it was important to perform timely incontinence care to prevent bed sores. An interview on 12/12/23 at 12:18 PM with the Administrator revealed incontinence care was to be provided as needed and staff were to round with residents every two hours. Review of the facility policy, Perineal Care, dated 05/11/22, reflected: An incontinent resident of urine and/or bowl should be identified, assessed, and provided (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675113 If continuation sheet Page 12 of 23 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 675113 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Park IN Plano 3208 Thunderbird LN 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 0677 appropriate treatment and services . 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: 675113 If continuation sheet Page 13 of 23 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 675113 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Park IN Plano 3208 Thunderbird LN 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 observation, interview and record review, the facility failed to provide appropriate treatment and services to prevent complications of enteral feeding for one (Resident #45) of three residents reviewed for feeding tube. The facility failed to ensure LVN H would cap the tip of Resident #45's gastrostomy tube (G-tube-a tube inserted through the abdomen that delivers nutrition directly to the stomach) when not in use. This failure could place residents with G-tubes at risk of infection. Findings included: Review of Resident #45's Face Sheet dated 12/12/23 reflected Resident #45 was a [AGE] year-old male admitted on [DATE]. Relevant diagnoses included oropharyngeal phase dysphagia (difficulty in swallowing), dysphagia following cerebral infarction (insufficient oxygen in the brain causing stroke), and hemiplegia (paralysis of one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction. Review of Resident #45's Quarterly MDS Assessment reflected resident had a severe cognitive impairment with a BIMS score of 00. Resident #70 was totally dependent for bed mobility, transfer, dressing, eating, toilet use, and personal hygiene. Review of Resident #45's Comprehensive Care Plan dated 11/12/2023 reflected resident was NPO (nothing by mouth) as per Dr's order and required G-tube feeding. One of the interventions was administer tube feeding as ordered by MD. Review of Resident #45's Physician Orders dated 11/23/2022/ reflected, every shift administer Jevity or Isosource 1.5 65 cc/hr (milliliter per minute) per GT (g-tube) with downtime (a pause from feeding) from 1000 - 14--. Provide 1950 kcal (kilo calorie), 88 gm (gram) protein and 2000 cc free water from feeding and flush. Observation on 12/12/2023 at 11:07 AM revealed Resident #45 was on his bed resting. It was noted the tube for the feeding formula was disconnected from the feeding port on Resident #45's left upper abdomen. The feeding tube was hanging on a pole with the tip uncovered and touching the pole of the feeding formula. The pole where the end of the feeding tube touched showed a small drop from the feeding formula. Observation and interview with LVN H on 12/12/2023 at starting at 11:19 AM, LVN H stated Resident #45 had a G-tube that runs for twenty hours. LVN H said the feeding formula was disconnected because it was his downtime. LVN H said the feeding formula will continue at 2:00 PM. LVN H acknowledged the tip of the feeding tube was touching the pole of the feeding tube. LVN H said she did not notice the tip was touching the pole when she disconnected and hanged the feeding tube. LVN said they do not use a cover for the tip when they disconnect the feeding tube. LVN said she would get a new one and change the tip. LVN H left the room and came back holding a package with a tip for the feeding tube inside. LVN H said the tip of the feeding tube should not be touching anything because it could result to infection. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675113 If continuation sheet Page 14 of 23 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 675113 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Park IN Plano 3208 Thunderbird LN 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 Observation and Interview with DON on 12/13/2023 starting at 3:13 PM, the DON stated the tip of the feeding tube should be covered when disconnected to prevent infection. The DON said their feeding tube kits come with covers. The DON showed a box filled with feeding tubes package with cover for the tip of the feeding tube included. The DON said she was made aware about the issue by LVN H, and she already started an in-service for the nurses pertaining to feeding tubes. The DON concluded the expectation was to cover the feeding tube tip when not in use. The DON said she would oversee the staff to make sure the right feeding tube care was done. Interview with LVN K on 12/13/2023 at 3:28 PM, LVN K stated the tip of a disconnected feeding tube must not be in contact with anything because it might catch anything that was dirty. If a dirty feeding tube tip will be connected again, it could cause the germs to go inside the body and could cause infections. She said the tip should be covered during downtime. LVN K added the feeding tube kit included a cover and she would usually set it aside to use when the feeding tube was disconnected. Interview with the Administrator on 12/14/2023 at 7:37 AM, the Administrator said she was not familiar with the procedure for tube feeding but said it was a basic knowledge that the tip should be kept clean because the tube was a conduit of Resident #45's food. The Administrator added if the tip of the feeding tube was touching the pole, it could cause infection. The Administrator said the expectation was for the staff to have a conscious effort when doing the tube feeding. Review of the facility's policy on Gastrostomy Tube Care, Nursing Policy & Procedure manual 2003 rev. February 13, 2007, revealed Gastrostomy is a surgically created abdominal opening into the stomach for the purpose of administering feedings. Goals 2. The resident will be free from infection . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675113 If continuation sheet Page 15 of 23 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 675113 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Park IN Plano 3208 Thunderbird LN 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, interviews, and record review, the facility failed to ensure that a resident who needed respiratory care was provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one (Resident #67) of two residents reviewed for respiratory care. Residents Affected - Few The facility failed to ensure Resident #67's oxygen concentrator had a humidifier. Findings included: Review of Resident #67's Face Sheet dated 12/12/2023 reflected resident was an [AGE] year-old female admitted on [DATE]. Relevant diagnoses included unspecified chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs) and shortness of breath. Review of Resident #67's Quarterly MDS assessment dated [DATE] reflected Resident #67 had a moderately intact cognition with a BIMS score of 10. Resident #67's required limited assistance for bed mobility, transfer, and dressing. Review of Resident #67's Comprehensive Care Plan dated 11/26/2023 reflected Resident #67 had Oxygen Therapy and one of the interventions was oxygen at 2 liters per minute per nasal cannula. Review of Resident #67's Physician Order dated 05/05/2023 reflected, may use oxygen @ 2 l/m (liter per minute) through nasal cannula. Observation and interview with Resident #67 on 12/12/2023 beginning at 10:33 AM revealed resident was on her with oxygen supplement via nasal cannula. The nasal cannula was connected to the oxygen concentrator. The oxygen concentrator did not have a humidifier. Resident #67 stated she had been on oxygen for the longest time. She said she had respiratory problem that was why she had oxygen. Resident #67 said sometimes the nurse would put a container with water inside on the oxygen concentrator but maybe the nurse forgot to put one. Interview with LVN H on 12/12/2023 at 11:19, LVN H acknowledged Resident #67's oxygen concentrator did not have a humidifier. LVN H said the humidifier keeps the nasal tract moistened to prevent dryness and irritations. LVN H said she would go ahead and get a humidifier. Observation on 12/12/2023 at 2:58 PM revealed Resident #67's oxygen concentrator had a humidifier. Interview with DON on 12/13/2023 at 3:13 PM, the DON stated an oxygen concentrator should have a humidifier to reduce the risks of potential sources of respiratory infections. The humidifier moistened up the nasal passage and prevent irritation to the throat and the nose. The DON concluded the staff must ensure the tubing of the nasal cannula and the mask were dated. She said she would continually remind and the educate the staff of the importance of a competent respiratory care. Interview with LVN K on 12/13/2023 at 3:28 PM, LVN K stated there should be a humidifier in an oxygen concentrator. LVN K continued the purpose of the humidifier was to provide moisture in the nasal passageway. She said the moisture would prevent irritation on the nose and the throat. If there was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675113 If continuation sheet Page 16 of 23 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 675113 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Park IN Plano 3208 Thunderbird LN 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 an irritation, it would be uncomfortable for the residents. Level of Harm - Minimal harm or potential for actual harm Interview with the Administrator on 12/14/2023 at 7:37 AM, the Administrator stated she was not familiar with the procedure about respiratory care and will let the DON answer the questions. The Administrator said the expectation was the staff would follow the procedure and policy for respiratory care to ensure the residents using oxygen supplement would get a good quality air. Residents Affected - Few Record review of facility's policy Oxygen Administration, Nursing Policy & Procedure manual 2003 rev. February 13, 2007, revealed Oxygen therapy includes the administration of oxygen (O2) in liters/minute (l/min) by cannula or face mask . Common oxygen sources for long-term administration include . or concentrator. All sources require humidification to prevent drying of mucous membranes and thickening of respiratory secretions if used routinely. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675113 If continuation sheet Page 17 of 23 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 675113 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Park IN Plano 3208 Thunderbird LN 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 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based interviews and record reviews, the facility failed to maintain the services of a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week, for 21 days of the 4-month review period, reviewed for RN coverage. The facility failed to ensure the facility maintained the services of a registered nurse for at least 8 consecutive hours a day on Saturdays and Sundays for 21 days of the four months (July 20023 - December 2023) reviewed. This failure placed residents at risk of receiving higher levels of patient care. Findings included: Review of the facility provided time sheets for Registered Nurses (RN) for the review period from July 2023 to December 2023, the facility failed to have the required RN coverage of at least 8 consecutive hours a day, for the following dates: 07/16/23 - (6.2 hours recorded) 07/22/23 - (2 hours recorded) 09/09/23 - (2 hours recorded) 09/30/23 - (2 hours recorded) 11/19/23 - (6.3 hours recorded) 11/25/23 - (2 hours recorded) 11/26/23 - (2 hours recorded) 12/03/23 - (0 hours recorded) 12/10/23 - (0 hours recorded) Interview on 12/14/23 at 01:00 PM with the DON, she stated she had been the DON at the facility for a year and two months. She stated they had an RN that covered the weekends, but the person had quit. She stated they were seeking to hire an RN for weekend coverage and currently they were receiving assistance from the corporate nurse. She stated the risk of not having an RN available could result in missed skills being needed for care. Interview on 12/14/23 at 01:15 PM with the Administrator, she stated she was aware that there were concerns with RN coverage on the weekends and had their corporate nurse assisting them in coverage by covering for the facility whenever and RN had called out or was on vacation. She stated that they had an RN that covered weekends, but the person quit unexpectedly. She stated they were seeking to hire an RN supervisor to help with coverage. She stated it was needed for oversight of clinical care. She stated the facility had not policy referencing RN coverage. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675113 If continuation sheet Page 18 of 23 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 675113 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Park IN Plano 3208 Thunderbird LN 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 0727 Level of Harm - Minimal harm or potential for actual harm Review of the facility's policy on Quality of Care, undated, revealed Residents and their Families or representatives have the right to expect and receive the high-quality care that meets their individual needs and preferences. Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675113 If continuation sheet Page 19 of 23 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 675113 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Park IN Plano 3208 Thunderbird LN 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record reviews the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety for the facility's only kitchen reviewed for kitchen sanitation. The facility failed to ensure foods in the facility's dry storage area, refrigerators, and freezer were labeled and dated according to guidelines and in a sanitary manner in the facility's only kitchen. The facility failed to ensure the kitchen was clean and sanitized. These failures could place residents at risk for cross contamination and other air-borne illnesses. Findings included: Observations on 12/12/23 from 09:10 AM to 09:20 AM in the facility's only kitchen revealed: The Ice Machine had dark black dirt stains along the inside door of the machine and along the inside walls of the machine. The lid of the ice machine hinges had rust and brownish dirt [NAME] in the springs of the door hinges. Just about the ice was a white panel that had black dirt grit sprinkled along the edge. The outside of the Ice Machine had white water stains going down the machine. One gallon container of poppyseed dressing, located in a stand-alone refrigerator, was undated. No expiration date observed. One frozen bag of tortellini was unlabeled and undated. No expiration date observed. Two large bags if frozen onion ring, located in the freezer was undated. No expiration date observed. Two frozen bags of English muffins (6 servings in each bag) were unlabeled and undated. No expiration date observed. One medium sized container of dark red jelly substance, located in a stand-alone refrigerator, was unlabeled and undated. Five large frozen pot roasts were undated. No expiration date observed. Two tubes of guacamole, located in the walk-in refrigerator, was unlabeled and undated. No expiration date observed. The kitchen floors under the cooking and storage equipment had thick built-up black dirt particles under them. Two large bags of corn tortilla chips were undated and no visible expiration date. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675113 If continuation sheet Page 20 of 23 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 675113 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Park IN Plano 3208 Thunderbird LN 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 Interview on 12/13/23 at 01:15 PM with the Dietary Manager, she was advised of all the concerns regarding the foods observed that were not labeled and dated and the cleanliness of the kitchen. Shé stated she did not have any dedicated person responsible for storing food when new inventory came in but based on all the concerns observed, she would in-service the kitchen staff on proper food storage, including dating and labeling food. She stated they deep clean the kitchen at least once a month but could not provide the exact date of the last kitchen deep clean. She stated the concerns addressed could result in food contamination and residents getting sick. Interview on 12/14/23 at 01:15 PM with the Administrator, she stated she had met with the Dietary Manager and was advised of some of the concerns observed in the kitchen. She stated she was confident that they would resolve the concerns observed in the kitchen. She stated the Dietary Manager works very closely with her team and will address the concerns observed. She stated the risk of not addressing the concerns could result in food contamination and residents getting sick. Record Review of the Facility's policy on Food Storage and Supplies dated 2012, revealed All facility storage areas will be maintained in an orderly manner that preserves the condition of food and supplies. Air-tight containers or bags are used for all opened packages of food. All containers are accurately labeled with the item and date opened. Review of the U.S. Food and Drug Administration (FDA) Code (2022) revealed, PACKAGED FOOD shall be labeled as specified in LAW, including 21 CFR 101 FOOD Labeling, 9 CFR 317 Labeling, Marking Devices, and Containers, and 9 CFR 381 Subpart N Labeling and Containers, and as specified under § 3-202.18. FOOD shall be protected from contamination that may result from a factor or source not specified under Subparts 3-301 - 3-306. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675113 If continuation sheet Page 21 of 23 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 675113 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Park IN Plano 3208 Thunderbird LN 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based observation, interview, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 (Resident #43 and Resident #55 [NAME] Banks) of 8 residents reviewed for infection control. Residents Affected - Some 1. The facility failed to ensure the ADON performed hand hygiene while providing incontinence care to Resident #43. 2. The facility failed to ensure the WCN performed hand hygiene while providing wound care to Resident #55. This failure could place residents at risk of cross-contamination resulting in infections. Findings included: 1. Record review of Resident #43's MDS assessment, dated 08/25/23, reflected she was an [AGE] year-old female who admitted to the facility on [DATE]. Her cognitive status was moderately impaired. Her diagnoses included stroke and seizure disorder. Resident #43 required extensive assistance of two staff for toileting. An observation and interview on 12/12/23 at 11:26 AM revealed Resident #43 was lying in bed. The ADON said the resident needed incontinence care and CNA C assisted her. The ADON and CNA C performed hand hygiene and put on gloves. CNA C turned the resident to her left side. The resident's outer right thigh had dried bowel movement on it. The resident's brief was full of urine and leaking onto the mattress. The resident was rolled to her back. The brief was unfastened. The ADON provided peri-care to front area. The resident was rolled to her left side. The ADON cleansed urine from the resident's buttocks, the ADON did not perform hand hygiene or change her gloves. The ADON placed a new brief under the resident, rolled her to her back, and fastened the brief. The Surveyor stopped the ADON and asked if she was supposed to perform hand hygiene during incontinence care. The ADON removed her gloves, washed her hands, and put on new gloves. An interview on 12/12/23 at 11:30 AM with the ADON revealed she forgot to perform hand hygiene while providing incontinence care to Resident #43. She said hand hygiene was important to prevent infection. 2. Record review of Resident #55's MDS assessment, dated 08/10/23, reflected she was a [AGE] year-old female who admitted to the facility on [DATE]. Her cognitive status was severely impaired. Her diagnoses included end stage renal disease requiring dialysis, stroke, and diabetes. The resident had one pressure ulcer. An observation and interview on 12/14/23 at 8:32 AM of wound care for Resident #55 revealed the WCN prepared her supplies. The WCN washed her hands and put on gloves. The resident had a wound on the area just below her right knee. The WCN removed the dressing, and the wound had a shallow opening, was approximately the size of quarter, and had no drainage. The WCN cleansed the wound and did not remove her gloves and perform hand hygiene. The WCN applied the treatment and a dressing to the wound. The WCN said she did not know that she needed to perform hand hygiene after removing the dressing (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675113 If continuation sheet Page 22 of 23 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 675113 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Park IN Plano 3208 Thunderbird LN 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 0880 and cleaning the wound. The WCN said she did not have hand sanitizer. Level of Harm - Minimal harm or potential for actual harm An interview on 12/14/23 at 9:25 AM with the DON revealed hand hygiene was important to prevent infection and she expected staff to perform hand hygiene before, during, and after care. Residents Affected - Some Review of the facility policy, Infection Control Plan: Overview, dated 2019, reflected: The facility will require staff to wash their hands after each direct resident contact for which hand washing is indicated by accepted professional practice . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675113 If continuation sheet Page 23 of 23