Health inspection·February 15, 2023

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few room. She stated Resident #38's dignity could be affected due to not having a privacy cover for his catheter bag. Interview with the DON on 02/15/23 at 12:45 PM revealed Resident #38 was supposed to have a privacy cover on his catheter bag while outside of his room. He stated his expectation was for all staff to ensure residents had a privacy cover on their catheter bags while outside of his room. He stated the facility was not out of privacy bags. He stated Resident #38's dignity was affected by not having a privacy cover on his catheter bag. Interview with the Administrator on 02/15/23 revealed the facility did not have a policy regarding privacy covers for catheter bags. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675196 If continuation sheet Page 2 of 11 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 675196 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Park Health and Rehabilitation Center 1720 N McDonald McKinney, TX 75069 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 2 of 2 residents (Resident #10 and #46) reviewed for transfers. The facility failed to ensure Resident #10 and #46 were transferred appropriately per the resident's plan of care. This failure could place residents at risk of not receiving adequate supervision and assistive devices to prevent injury. Findings included: Review of Resident #10's face sheet dated 2/15/23 reflected he was a [AGE] year-old male, and he was admitted to the facility on [DATE]. Admitting diagnoses included depressive disorder, pain, stiffness of unspecified knee, weakness, muscle weakness and atrophy, contracture of left knee, abnormal posture, and aged related osteoporosis without current pathological fracture. Review of the Quarterly MDS (Minimum Data Set) assessment, dated 12/23/22 reflected Resident #10 had severe cognitive impairment, he required extensive assistance with transfers and had functional limitation in range of motion to bilateral lower extremities. Review of the comprehensive care plan, revised 4/13/22, reflected Resident #10 had an activities of daily living self-care performance deficit related to cerebrovascular disease. Intervention was for the resident to be transferred by a mechanical lift with two staff assistance. Observation on 2/14/23 at 11:33 AM, revealed LVN A and the restorative aide transferring Resident #10 from the bed to the wheelchair. Both staff positioned the resident on the side of the bed and each staff placed their hands underneath the resident's shoulder and picked the resident from the bed to the chair. The restorative aide had a gait belt around her waist. In an interview on 2/14/23 at 1:30 PM, LVN A stated when transferring the resident alone the staff was supposed to use the gait belt but when transferring a resident with two staff, they did not need a gait belt. LVN A stated they could transfer the resident lifting the resident by the pants. LVN A changed his statement and stated they needed a gait belt to transfer the resident. LVN A stated they were supposed to use the gait belt to prevent harming the resident or causing a shoulder dislocation. LVN A also stated the staff were supposed to use the required transfer per the plan of care. In an interview on 2/15/23 on 1:50 PM, the restorative aide she stated she assisted in the therapy department and assisted with transfers in the facility. She also stated she trained the aides on the proper ways transfer with Hoyer lift, use of gait belt, and sit to stand transfers. The restorative aide stated the staff were to use the gait belt on the resident, but she had a large gait belt, and the small gait belt was in the gym area, and it was far, and the resident was ready to be transferred. The Restorative aide stated the staff were to use the required transfer per the plan of care. She stated the staff were to use the gait belt for every transfer to prevent resident harm or shoulder dislocation. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675196 If continuation sheet Page 3 of 11 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 675196 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Park Health and Rehabilitation Center 1720 N McDonald McKinney, TX 75069 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of Resident #46's face sheet dated 2/15/23 reflected the resident was admitted on [DATE]. Her admitting diagnoses included dementia, history of falling, major depression and anxiety disorder. Review of the quarterly MDS assessment dated [DATE] reflected Resident #46 was severely impaired with cognitive skills for daily decision making, needed extensive assistance with transfer, and during transitions and walking she was not steady, only able to stabilize with staff assistance. Review of Resident #46's care plan revised 8/23/21 reflected the resident had activities of daily living deficit related to dementia. Intervention on transfer reflected the resident required extensive assistance of one staff for transferring. Observation on 2/14/23 at 1:10 PM revealed CNA B and ADON C transferring Resident #46 from the wheelchair to bed. Both staff gloved and ADON C was behind the resident holding the wheelchair and CNA B was in front of Resident #46 and placed her hands underneath the resident ' s arms and picked the resident from the wheelchair to the bed. Then they both assisted the resident to reposition in bed. In an interview on 2/14/23 at 1:22 PM with CNA B said Resident #46 required one staff for transfer and that was why she transferred her by herself. When asked if she was supposed to use any assistive device to transfer the resident, she stated she was supposed to use the gait belt to transfer the resident, but she did not have one with her, but she was able to access the gait belt. CNA B stated she was supposed to use a gait belt to prevent harming the resident or the resident falling. CNA B stated she had been in-serviced on transfers using the gait belt. In an interview on 2/14/23 at 1:34 PM, ADON C stated she asked CNA B to get the gait belt, but CNA B did not, surveyor was in the room and never heard ADON C telling CNA B to go get the gait belt. ADON C stated she could have stopped CNA B from transferring the resident until she had the gait belt for the transfer. ADON C stated transfer was to be completed with a gait belt to prevent resident injury from shoulder dislocation or fall. In an interview on 2/15/23 at 10:47 AM with the DON he stated the facility had completed in-service on transfer upon hire, yearly and when the facility had incident of fall. The DON stated the facility completed transfer Inservice in January and on 2/14/23 after it was reported on the improper transfers. The DON stated the residents were supposed to be transferred per each resident's plan of care. The DON stated the staff were not supposed to pick the residents underneath their arms because it could cause injury like shoulder dislocation. The DON stated he was responsible to make sure the transfers were, completed properly and most of the time he would randomly observe the staff transferring the residents. Provided the transfer in-services completed on 2/14/22 and they were reviewed. Review of the facility policy dated 2003 and titled Moving a Resident, bed to chair/chair to bed reflected, .The purpose is to allow the resident to be out of his or her bed as much as possible and to provide for safe transferring of the resident 9. If moving a resident from bed to chair; .h. Position a gait belt around the resident ' s waist and clasp it. Make sure it is tight enough that only a slight hand movement will guide the resident, but not so tight that you cannot firmly grasp the belt without making the patient comfortable.10. If moving a resident from chair to bed. e. Position a gait belt around the resident ' s waist and clasp it. Make sure it is tight enough that only a slight hand movement will guide the resident, but not so tight that you cannot firmly grasp the belt without making the patient comfortable. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675196 If continuation sheet Page 4 of 11 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 675196 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Park Health and Rehabilitation Center 1720 N McDonald McKinney, TX 75069 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident received appropriate treatment and services to prevent urinary tract infections for one (Resident #66) of four residents observed for indwelling urinary catheters. The facility failed ensure Resident #66's drainage urine bag was below his bladder to prevent urine from flowing back into the bladder. These failures could place residents with urinary catheters at risk for urethral tears, dislodging of the catheter, and urinary tract infections. Findings included: Review of Resident #66's Quarterly MDS assessment dated [DATE] revealed he was a [AGE] year-old male who was admitted to the facility 11/22/22. His diagnoses included: hypertension, neurogenic bladder, obstructive uropathy, diabetes mellitus, hyperlipidemia, cerebrovascular accident, Non-Alzheimer's Dementia, seizure disorder, malnutrition, depression, and dysphagia. He was usually understood, usually understood others, and had unclear speech. His BIMS score (6) revealed he was severely cognitively impaired. There was no evidence of delirium or psychotic behaviors. He had an indwelling catheter. Review of Resident #66's Care Plan, undated, revealed he had an indwelling catheter due to neurogenic bladder. His goals were to show no signs and symptoms of urinary infection through review date. He was to also be/remain free from catheter related trauma through review date. His interventions were to have a 16fr and 10cc foley catheter. His catheter bag and tubing were to be positioned below the bladder level. In an observation and interview with Resident #66 on 02/14/23 at 3:14 PM, revealed his catheter bag was lying beside him in bed. His catheter bag contained an output of 350 ml of urine. His catheter tubing appeared to be cloudy. His urine appeared to be amber colored. Resident #66 did not respond to questions regarding his catheter bag. Interview with LVN D on 02/14/23 at 3:20 PM, revealed she did not know why Resident #66 had his catheter bag laying beside him in bed. She stated his catheter bag was supposed to be clipped to the bed and hung below his bladder. She stated the catheter bag was supposed to be hung below the bladder to prevent urine from flowing back to the bladder. She stated Resident #66 could be at risk of an infection due to the catheter bag not being hung below his bladder. Interview with CNA E on 02/15/23 at 1:40 PM revealed Resident #66's catheter bag was not supposed to be laying beside him in bed. She stated his catheter bag was supposed to be hung on the side of his bed and below his bladder. She stated she provided care to Resident #66 and forgot to replace his catheter bag. She stated he was at risk for bladder issues due to his catheter bag not being hung below the bladder for easy flow of urine. Interview with the DON on 02/15/23 at 12:57 PM revealed all resident catheter bags were to be kept below their bladder. He stated nursing staff were responsible for ensuring Resident #66's catheter (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675196 If continuation sheet Page 5 of 11 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 675196 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Park Health and Rehabilitation Center 1720 N McDonald McKinney, TX 75069 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete bag was hung below his bladder. He stated Resident #66's catheter bag was not supposed to be lying next to him in bed. He stated he was at risk of an infection due to urine going back up the tube. Review of the facility policy titled, Catheter Care, dated 02/13/07, revealed The bag must be held lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder. Event ID: Facility ID: 675196 If continuation sheet Page 6 of 11 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 675196 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Park Health and Rehabilitation Center 1720 N McDonald McKinney, TX 75069 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview, and record review, the facility failed to, in accordance with State and Federal laws, ensure all drugs were stored in locked compartments under proper temperature controls, and permit only authorized personnel to have access to these drugs, to meet the needs of each resident, for one (Resident #9) of six residents reviewed for medication storage. The facility failed to ensure Resident #9 did not have prescription pills and unsecured medication in his room on 02/13/23. This failure could place residents at risk of not being monitored for their medications, adverse reactions, and drug diversion. Findings included: Review of Resident #9's MDS assessment dated [DATE] revealed he was a [AGE] year-old male who was admitted to the facility 07/06/22. His diagnosis included: hypotension, diabetes mellitus, hyperlipidemia, cerebrovascular accident, Dementia, hemiplegia, seizure disorder, and depression. He was understood, understood others, and had clear speech. His BIMS score (8) revealed he had moderate cognitive impairment. There was no evidence of delirium or psychotic behaviors. Review of Resident #9's physician orders dated 02/15/23 reflected the following medications: - Allopurinol tablet 300 mg give 1 tablet by mouth in the morning for inflammation. - Apixaban tablet 2.5 mg give 1 tablet by mouth two times a day for anticoagulant related to unspecified atrial fibrillation - Calcium 600+D tablet 600-400 mg unit give 1 tablet by mouth in the morning for supplements - FerrouSul tablet 325 mg give 1 tablet by mouth in the morning for supplement. - Levetiracetam tablet 500 mg give 1 tablet by mouth two times a day related to unspecified convulsions - Metformin HCl tablet 500 mg give 1 tablet by mouth two times a day related to type 2 diabetes mellitus without complications There were no physician orders for Ascorbic acid tablet 500 mg or Zinc tablet 50 mg. Review of Resident #9's MAR dated 01/01/23 to 01/31/23 reflected the resident was given the following medication by LVN F: - Allopurinol tablet 300 mg scheduled for 7:00 AM - Ascorbic acid tablet 500 mg scheduled for 8:00 AM (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675196 If continuation sheet Page 7 of 11 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 675196 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Park Health and Rehabilitation Center 1720 N McDonald McKinney, TX 75069 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 0761 - Calcium 600+D tablet 600-400 mg scheduled for 7:00 AM Level of Harm - Minimal harm or potential for actual harm - FerrouSul tablet 325 mg scheduled for 7:00 AM - Zinc tablet 50 mg scheduled for 8:00 AM Residents Affected - Few - Apixaban tablet 2.5 mg scheduled for 7:00 AM - Levetiracetam tablet 500 mg scheduled for 7:00 AM - Metformin HCl tablet 500 mg scheduled for 7:00 AM In an observation on 02/13/23 between 10:58 AM and 11:15 AM revealed there were 6 different pills in a plastic medication cup on Resident #9's beside table. Resident #9 was observed sleeping in his bed. In an interview with Resident #9 on 02/13/23 at 11:32 AM revealed he had taken his medication that was left on his bedside table. He stated he did not want to answer any more questions and wanted to be left alone. Interview with LVN F on 02/13/23 at 12:19 PM revealed she left Resident #9's morning medications on his bedside table and left the room to take other residents' vitals. She stated she later returned to his room and supervised him taking his medications. She stated she was never supposed to leave his medications unsupervised on his bedside table. She stated Resident #9 was not supposed to self-administer his own medication. She stated she did not know what medications she administered to him but could check his MAR. She stated Resident #9 was at risk of not taking his medications or some else could have come in his room and taken his medication. Interview with the DON on 02/15/23 at 1:00 PM, revealed Resident #9's medications were not to be left on his bedside table. He stated LVN F was supposed to administer medications and supervise Resident #9. He stated Resident #9 was at risk of not taking medication or another resident could have gone into his room and taken the medications. Interview with Administrator on 02/15/23 revealed the facility did not provide a policy regarding medication storage. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675196 If continuation sheet Page 8 of 11 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 675196 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Park Health and Rehabilitation Center 1720 N McDonald McKinney, TX 75069 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation. The facility failed to ensure food was properly stored in the facility's kitchen. This failure could place residents at risk for food-borne illness. Findings Included: Observation of the facility's freezer on 02/13/23 at 9:50 AM revealed: - 1 cup of orange sherbet open and exposed to air; - 1 box of double chocolate cookie dough open and exposed to air; and - 1 box of frozen pie dough sheets. Observation of the facility's dry storage on 02/13/23 at 9:54 AM revealed: -1 bag of long grain parboiled rice open and exposed to air; and - 1 bag of large lima beans open and exposed to air. Observation of the facility's freezer located in the dining room on 02/13/23 at 9:58 AM revealed: - 1 box of swai fillets open and exposed to air. In an interview with the Dietary Manager on 02/15/23 at 3:15 PM, revealed he checked the freezers and dry storage Monday through Friday. He stated the weekend dietary staff were responsible for checking the freezers and dry storage on the weekends. He stated he did not know why items in the freezers and dry storage were unsealed. He stated improper food storage could cause residents to get sick. Review of the facility policy titled 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. Review of U.S Department of Health and Human Services Food Code, dated 2017, revealed, 3-202.15 Package Integrity reflected: Food packages shall be in good condition and protect the integrity of the contents so that the food is not exposed to adulteration or potential contaminants. Review of the Food and Drug Administration Food Code, dated 2017, reflected, .3-302.12 Food Storage Containers, Identified with Common Name of Food. Except for containers holding food that can be readily and unmistakably recognized such as dry pasta, working containers holding food or food ingredients that are removed from their original packages for use in the food establishment, such as cooking oils, flour, herbs, potato flakes, salt, spices, and sugar shall be identified with the common name (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675196 If continuation sheet Page 9 of 11 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 675196 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Park Health and Rehabilitation Center 1720 N McDonald McKinney, TX 75069 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 FORM CMS-2567 (02/99) Previous Versions Obsolete of the food 3-305.11 Food Storage. (A) .food shall be protected from contamination by storing the food: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination .(B) .refrigerated, ready-to eat time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety Event ID: Facility ID: 675196 If continuation sheet Page 10 of 11 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 675196 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Park Health and Rehabilitation Center 1720 N McDonald McKinney, TX 75069 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 on 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 one (Resident #2) of six residents observed for infection control in that: Residents Affected - Few 1. CNA B failed to perform hand hygiene during incontinent care for Resident #2. Findings included: 1. Review of Resident #2's Face Sheet 2/15/23 reflected a [AGE] year-old male with an admission date of 3/14/14. Primary diagnoses included anxiety, lack of coordination, bipolar and muscle wasting and atrophy. Review of Resident #2's Care Plan revised 11/11/19 reflected, . [Resident #2] has an ADL self-care performance deficit r/t Bipolar Disorder .Interventions .Toilet use .requires up to limited assist x 1 staff for toileting. Observation on 2/14/23 at 12: 45 PM revealed CNA B providing incontinent care to Resident #2. CNA B gloved, Resident #2 was resting in bed and CNA B informed the resident she was going to provide him with incontinent care. CNA B gloved and took off the resident's dirty brief, the resident was moderately soiled with urine. CNA B cleaned the resident with wipes, after cleaning the resident she proceeded to applying the resident's clean brief without any form of hand hygiene. With the same dirty gloves CNA B assisted the resident to put on his pants. When CNA B was done assisting the resident, she got the trash and left the room without any form of hand hygiene. In an interview on 02/14/23 at 1:22 PM with CNA B she said she realized she did not change the gloves between care. CNA B stated she was supposed to change gloves after taking the resident's dirty brief off. Asked about completing hand hygiene she stated she was supposed to wash hands after cleaning the resident to prevent the spread of infections. She stated she had been in-serviced on infection control a few weeks ago In an interview on 02/15/23 at 10:54 AM with the DON he said when providing incontinent care the staff was supposed to complete hand hygiene before, in between care after the staff was done cleaning the resident and before applying the clean brief and after completing the resident care. The DON stated the staff was supposed to complete hand hygiene during incontinent care to prevent the spread of infection. The DON stated the facility completed in-service on infection control in January. Review of the facility policy, not dated and titled Fundamentals of Infection Control Precautions, reflected, .Hand Hygiene. Hand hygiene continues to be the primary means of preventing the transmission of infection. The following is a list of some situations that require hand hygiene: .When hands are visibly soiled (hand washing with soap and water); Before and after the resident direct contact (for which hand hygiene is indicated by acceptable professional practice) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675196 If continuation sheet Page 11 of 11