Inspection·June 27, 2024

F 0558 unsteadiness of feet. Level of Harm - Minimal harm or potential for actual harm Review of Resident #21's Quarterly MDS Assessment, dated 03/27/2024, reflected Resident #21 had a severe cognitive impairment with a BIMS score of 06. Resident #21 required assistance for bed mobility, transfer, and toilet use. Residents Affected - Some Review of Resident #21's Comprehensive Care Plan, dated 05/06/2024, reflected Resident #21 was at risk for falls r/t unsteady gait and balance and one of the interventions was to be sure her call light is within reach. Observation and interview with Resident #21 on 06/14/2024 at 9:14 AM revealed resident was lying in bed. Resident #21's call light was noted on the floor, between the wall and the head of the bed. The resident said she used the call light to call the staff. The resident searched for the call light but was not able to find it. She said the call light should be clipped to her pillow so it will not fall on the floor. Resident #51 Review of Resident #51's Face Sheet, dated 06/26/2024, reflected resident was a [AGE] year-old male admitted on [DATE]. Resident #51's diagnosis was anoxic brain damage (lack of oxygen to the brain). Review of Resident #51's Quarterly MDS Assessment, dated 05/15/2024, reflected Resident #51 was cognitively intact with a BIMS score of 14. Resident #51 required moderate assistance for shower, dressing, and personal hygiene. Review of Resident #51's Comprehensive Care Plan, dated 06/15/2024, reflected Resident #51 was at risk of falls r/t gait/balance problems and one of the interventions was to keep the call light within reach at all times. Observation and interview with Resident #51 on 06/25/2024 at 10:17 AM revealed resident was in his wheelchair inside his room. He said his call light was behind the head of the bed. He said he would put it always on the side but when the staff would make his bed, the staff would misplace it. He said it was challenging for him to get the call light because there was a chair in front of the bed's side table. He said it was hard for him to get the call light and clip it on his pillow because his hands were unstable. It was observed that the resident transferred to his bed but had a hard time pulling the call light. Resident #51 said he hope the staff would clip the call light to his bed before leaving the room. Resident #54 Review of Resident #54's Face Sheet, dated 06/25/2024, reflected resident was a [AGE] year-old female admitted on [DATE]. Relevant diagnoses included muscle wasting (loss of muscle mass due to the muscles weakening and shrinking) and unsteadiness of feet. Review of Resident #54's Quarterly MDS Assessment, dated 05/10/2024, reflected Resident #54 had a moderate impairment in cognition with a BIMS score of 11. Resident #54 required moderate assistance for toilet use, dressing, and personal hygiene. Review of Resident #54's Comprehensive Care Plan, dated 05/06/2024, reflected Resident #54 was at (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675453 If continuation sheet Page 2 of 16 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 675453 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Collinwood Nursing and Rehabilitation 3100 S Rigsbee Rd Plano, TX 75074 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 risk for falls related to immobility and one of the interventions was to keep the call light within reach at all times. Observation and interview with Resident #54 on 06/25/2024 at 10:40 AM revealed resident was lying in bed. Resident #54's call light was noted wrapped on the drawer's handle of the side table. The resident said she used the call light every time she needed assistance. She said the call light was so far that she cannot reach it. Observation and interview with CNA D on 06/25/2024 at 10:53 AM, CNA E stated he did incontinent care for Resident #21 but did not notice that the call light was on the floor. CNA D said he did not make sure the call light was with the resident when he left Resident #21's room. CNA D went to Resident #21's room, picked up the call light from the floor, cleaned it, and clipped it on the pillow. He said he would also check the call lights in Resident #2, #54, and #51's room. He said the call light must always be within the reach of the residents because they use the call lights to call the staff in case they need something or they were not feeling well. CNA D added that if the call lights were not with the residents, the residents might fall, or the staff would not know the residents were having an emergency. He said he was responsible for ensuring the call lights were within reach for his assigned residents. In an interview with LVN B on 06/26/2024 at 9:53 AM, LVN B stated the call light should be within the reach of the residents at all times. LVN B said for some residents, the call light was their sense of protection. She added the residents use the call lights when they needed something, were having an emergency, or were in pain. LVN B said the residents might fall trying to get up to get the call light or may be frustrated because they cannot call anybody to help them. LVN B said everybody was responsible in making sure the call lights were with the residents, whether the resident was independent or not. LVN B said she should have checked the call lights during her initial round. In an interview with the ADON on 06/27/2024 at 07:24 AM, the ADON stated the call light was important for the residents. She said the residents use the call lights if they needed help or assistance. She said if the call light was not with the resident, they might try to get up or try to go to the bathroom by themselves. She said it could result in fall, injury, and compromised skin integrity. She added that if the call lights were far from the residents, their needs will not be addressed. She said she would do an in-service about call lights. She said the expectation was all staff that would enter the room would leave the call light with the resident before coming out of the resident's room. In an interview with the DON on 06/27/2024 at 07:37 AM, the DON stated the call lights were important for the residents because this would alert the staff that the resident needed something, was having pain, was experiencing shortness of breath, or if there was a change in condition. She added if resident was non-ambulatory, the resident might try to get out of the bed, wheelchair, or recliner and fall. She said call lights were the responsibility of everybody. She said expectation was for the staff to make an effort to make sure the call light was with the residents when they leave the room. She said she will do an in-service about call light being with the residents at all times. She concluded she would follow-up and would ask why the call light was not given to the resident before leaving the room. In an interview with the Administrator on 06/27/2024 at 08:06 AM, the Administrator stated the call light is the residents' voice to let the staff know that they needed something. She said the residents use the call lights if they were in danger or in pain. She said if the call lights were not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675453 If continuation sheet Page 3 of 16 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 675453 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Collinwood Nursing and Rehabilitation 3100 S Rigsbee Rd Plano, TX 75074 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 within the reach of the residents, it could result in injury, sickness, death, or the residents not being happy. She said the expectation was for the staff would make sure the call lights were within reach. She said any staff that would see that the call lights were on the floor or not within reach, they should pick it up and clip it somewhere the resident could access it. She said the call lights were everybody's responsibility, even housekeeping, management, or therapy. She concluded they would in-service all the staff in the facility and would monitor them if they were making sure the call lights were with the residents. Record review of facility's policy Answering the Call Light reviewed December 2023 revealed, Purpose: The purpose of this procedure is to respond to the resident's requests and needs . General Guidelines . 5. When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675453 If continuation sheet Page 4 of 16 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 675453 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Collinwood Nursing and Rehabilitation 3100 S Rigsbee Rd Plano, TX 75074 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on 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 6 rooms (room [ROOM NUMBER], #507, #509, #511, #510, and #610) of 10 rooms observed for environment. The facility failed to ensure that Resident room [ROOM NUMBER], #507, #509, #511, #510, and #610 were cleaned and sanitized. This deficient practice could place residents at risk of living in an unclean and unsanitary environment which could lead to a decreased quality of life. Findings included: An observation on 06/25/24 at 10:59 AM of Resident room [ROOM NUMBER] reflected the air conditioning located in the room had dirt particles and black dirt grime on the top and between the vents of the units. The air filters had a thin layer of dust on them. The base of the faucet handles had thick calcium build up. The handrails in the bathroom had black specks of dirt and reddish dots. An observation on 06/25/24 at 11:01 AM of Resident room [ROOM NUMBER] reflected the air conditioning located in the room had dirt particles and black dirt grime on the top and between the vents of the units. The air filters had a thin layer of dust on them. An observation on 06/25/24 at 11:04 AM of Resident room [ROOM NUMBER] reflected the air conditioning located in the room had dirt particles and black dirt grime on the top and between the vents of the units. The air filters had a thin layer of dust on them. The base of the faucet handles had calcium building up and was cracked. An observation on 06/25/24 at 11:08 AM of Resident room [ROOM NUMBER] reflected the base of the faucet handles had calcium building up. The handrails in the bathroom had black specks of dirt and reddish dots. An observation on 06/25/24 at 11:14 AM of Resident room [ROOM NUMBER] reflected the air conditioning located in the room had dirt particles and black dirt grime on the top and between the vents of the units. The air filters had a thin layer of dust on them. An observation on 06/25/24 at 11:26 AM of Resident room [ROOM NUMBER] reflected the air conditioning located in the room had dirt particles and black dirt grime on the top and between the vents of the units. The air filters had a thin layer of dust on them. An interview on 06/27/24 at 09:31 AM with the Director of Environmental Services, she stated she had been at the facility for 35 years. She stated she pairs the new housekeeping aides with the seasoned housekeepers, and they are showed how to clean the entire room, including the floor, bathrooms, and air conditioning. She stated maintenance cleans the air filters. She stated her staff understands English but when they get nervous, they need an interpreter. She stated the maintenance director was out on leave, but she would make sure that the air conditioning units in all the rooms were checked and cleaned. She was shown pictures of the concerns observed in Rooms #505, #507, #509, #511, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675453 If continuation sheet Page 5 of 16 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 675453 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Collinwood Nursing and Rehabilitation 3100 S Rigsbee Rd Plano, TX 75074 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 #510, and #604 and she stated she would have her team address the issues. She stated the risk of the areas mentioned not being clean could result in respiratory problems for the resident. An interview on 06/27/24 at 10:31 AM with the Administrator, she was made aware of the findings in Rooms #505, #507, #509, #511, #510, and #610. She stated that she was surprised to hear that there were concerns observed with the cleanliness of the facility. She stated that they took pride on how clean they keep the facility and she stated she would meet with the maintenance director upon his return to address the air conditioning filters being cleaned more regularly and she would also meet with the Director of Environment to ensure that in the future these items are being thoroughly cleaned. She stated the risk of not having these areas clean could result in respiratory problems for the residents. Review of the facility's policy on Safe/Comfortable/Homelike Environment (Revised 2022) reflected Housekeeping and Maintenance services include the cleaning, sanitization, and care for rooms and common areas of the facility to ensure that the facility is safe for all who reside, work, and visit. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675453 If continuation sheet Page 6 of 16 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 675453 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Collinwood Nursing and Rehabilitation 3100 S Rigsbee Rd Plano, TX 75074 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 0641 Ensure each resident receives an accurate assessment. 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 each resident received an accurate assessment, reflective of the resident's status for three (Resident #35, Resident #40, and Resident #46) of six residents reviewed for accuracy of assessments. Residents Affected - Some The facility failed to ensure Resident #35's Quarterly MDS Assessment, dated 06/14/2024, accurately reflected that Resident #35 had impairments to both upper extremities. The facility failed to ensure Resident #40's Quarterly MDS Assessment, dated 04/26/2024, accurately reflected that Resident #40 had impairments to both upper extremities. The facility failed to ensure Resident #46's Quarterly MDS Assessment, dated 04/04/2024, accurately reflected that Resident #46 had impairment to right upper extremity. These failures could place residents at risk for not receiving care and services to meet their needs, diminished function of health, and regressions in their overall health. Findings included: Resident #35 Review of Resident #35's Face Sheet, dated 06/25/2024, revealed that resident was a [AGE] year-old male admitted on [DATE]. Relevant diagnoses included contracture (tightening of the muscles, tendons, skin, and surrounding tissues that causes the joints to shorten and stiffen) of right hand's muscle and contracture of left hand's muscle. Review of Resident #35's Quarterly MDS Assessment, dated 06/14/2024, revealed the resident had a severe impairment in cognition with a BIMS score of 02. Resident #35's Minimum Data Set, Section GG Functional Abilities and Goals, GG0115 Functional Limitation in Range of Motion specified Resident #35 had no impairment to upper extremity. Review of Resident #35's Comprehensive Care Plan, dated 06/06/2024, reflected the resident did not want to wear bilateral hand splints. Review of resident #35's Physician Order, dated 04/26/2024, reflected Pt to wear [NAME] guards/hand splints at bedtime only every night. At bedtime for Hand and finger contractures BUE's Observation and interview on 06/25/2024 at 10:50 AM revealed Resident #35 was in his bed resting. It was noted that the resident's both hands were contracted. According to Resident #35, he had been in that condition since he was in an accident. He said he needed assistance with everything because he cannot fully use his hands. Observation and interview with LVN C on 06/26/2024 at 10:25 AM, LVN C stated Resident #35's had some sort of impairment on both upper extremities but said she was not sure to what extent. LVN C logged on to her computer and searched the resident's profile. She said Resident #35 had a diagnosis of contractures to both right and left hands. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675453 If continuation sheet Page 7 of 16 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 675453 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Collinwood Nursing and Rehabilitation 3100 S Rigsbee Rd Plano, TX 75074 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 0641 Resident #40 Level of Harm - Minimal harm or potential for actual harm Review of Resident #40's Face Sheet, dated 06/25/2024, revealed that resident was a [AGE] year-old female admitted on [DATE]. Relevant diagnoses included unspecified injury of head and sprain of ligament of cervical (pertaining to the neck) spine. Residents Affected - Some Review of Resident #40's Quarterly MDS Assessment, dated 04/26/2024, revealed the resident had a severe impairment in cognition with a BIMS score of 00. Resident #40's Minimum Data Set, Section GG Functional Abilities and Goals, GG0115 Functional Limitation in Range of Motion specified Resident #40 had no impairment to upper extremity. Review of Resident #40's Comprehensive Care Plan, dated 05/10/2024, reflected the resident had an alteration in musculoskeletal (pertaining to both musculature and skeleton) status related to contracture and wore an elbow extensor splint on left elbow and hand carrot splint (cone-shaped orthosis [device used for badly formed part of the body] used for contracted hands) in left hand. Review of Resident #40's Physician Order, dated 04/26/2024, reflected Pt to wear elbow extensor splint on left elbow to extend hand away from shoulder for 4 hours daily or as tolerated. Every day shift for elbow flexion contracture 4 hours only daily. Review of Resident #40's Physician Order, dated 04/26/2024, reflected Pt to wear hand carrot and or rolled washrag in left hand daily at all times, every shift for hand contracture. Observation on 06/25/2024 at 10:26 AM revealed Resident #40 was on her bed, sleeping. It was noted that resident's left hand was contracted. Resident #40 was not able answer the questions asked due to a cognitive communication deficit. In an interview with RN A on 06/25/2024 at 11:00 AM, RN A stated Resident #40 had a contracture on her left hand. She said the order for the resident's contracture was to put an elbow extensor and a splint with a shape of a carrot. Shae said the resident was dependent on all ADLs because of her impairment. Resident # 46 Review of Resident #46's Face Sheet, dated 06/27/2024, revealed that resident was a [AGE] year-old male admitted on [DATE]. Relevant diagnoses included hemiplegia (paralysis of one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (insufficient oxygen in the brain causing stroke) affecting right dominant side. Review of Resident #46's Quarterly MDS Assessment, dated 04/04/2024, revealed the resident was cognitively intact with a BIMS score of 15. Resident #46's Minimum Data Set, Section GG - Functional Abilities and Goals, GG0115 Functional Limitation in Range of Motion specified Resident #46 had no impairment to upper extremity. Review of Resident #46's Comprehensive Care Plan, dated 05/10/2024, reflected the resident had an ADL Self Care Performance Deficit r/t impaired mobility. Observation and interview on 06/25/2024 at 10:35 AM revealed Resident #46 was on his bed, resting. It was noted that resident's right arm was limp. Resident #46 stated he could not raise his right (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675453 If continuation sheet Page 8 of 16 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 675453 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Collinwood Nursing and Rehabilitation 3100 S Rigsbee Rd Plano, TX 75074 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 0641 hand. It was noted that the resident tried to move his right arm but was not able to do so. Level of Harm - Minimal harm or potential for actual harm In an interview with CNA D on 06/25/2024 at 10:53 AM, CNA D stated Resident #46 was unable to move his right arm. He said the resident was dependent on the staff for transfer, bed mobility, and personal hygiene because of his inability to move his hand. Residents Affected - Some In an interview and observation with MDS Coordinator on 06/26/2024 at 9:45 AM, the MDS Coordinator stated if a resident had an impairment, it should be reflected on the MDS assessment or on the resident's profile. She said the medical diagnosis, physician order, MDS, and the care plan should be all in-line and should match to provide a clear overview of the resident's current condition. She said, by doing so, accurate goals and interventions would be provided. The MDS Coordinator logged on to her computer, searched for Resident #35, #40, and #46's profile, and put the appropriate code for the residents' functional limitation in range of motion. She said the nurses were doing the assessment but said she should have double-checked to see if the assessment was accurate. She said if the resident had impairments, it should be communicated to the MDS Coordinator. She said an accurate MDS assessment was important because it would be the basis of the care needed by the resident. If the assessment was not accurate, the current status of the resident would not be correct resulting in a possible confusion on the residents' care. She said inaccurate assessment could also result in the resident not getting the appropriate care needed. She said she would do an in-service about accurate assessment and for the staff to document if the resident has contracture or other form of impairments. In an interview with PT E on 06/26/2024 at 11:48 AM, PT E stated the objective of an assessment was to know the current status or identify the level of function of the resident. She said a detailed assessment is necessary to be able to facilitate a comprehensive problem list so the goals and interventions could be properly constructed. She said it was also important to know the resident's functional deficits, weakness, or strengths that could help in planning. She said if there was no accurate assessment, the condition of the resident could worsen. She also said that any assessment should be reflected on the resident's profile so all the staff would know the appropriate care. In an interview with the ADON on 06/27/2024 at 07:24 AM, the ADON stated she was not familiar with the MDS but said if a resident had an impairment, it should be reflected on the system to make sure all the needed care was given to the residents. She said accuracy in assessment would help the staff make a correct care plan for the resident. The ADON said if there was no accurate assessment, there could be a misunderstanding about the care needed by the resident and the resident might not be able to get the treatment needed. In an interview with the DON on 06/27/2024 at 07:37 AM, the DON stated if a resident had impairments, it should be indicated on the resident's profile. She said it should be reflected on the medical diagnosis, physician orders, MDS, and care plan. She said the resident should be accurately assessed to provide the needed interventions. If the residents were not properly assessed, the proper care and needs would not be met. The DON said the expectation was the residents were properly assessed not only during admission but every day to see if there was a change in condition, any refusal of care, or resident acting different than usual. She said she would collaborate with the MDS Coordinator and the ADON to audit MDS assessments and make appropriate changes. In an interview with the Administrator on 06/27/2024 at 08:06 AM, the Administrator stated that if a resident had an impairment, it should be on the MDS to reflect the current condition of the resident. She said, by doing so, the needs of the residents would be addressed. She said she would coordinate with the clinical managers to evaluate the situation, discuss it during quality assurance and do (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675453 If continuation sheet Page 9 of 16 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 675453 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Collinwood Nursing and Rehabilitation 3100 S Rigsbee Rd Plano, TX 75074 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 0641 in-services. Level of Harm - Minimal harm or potential for actual harm Record review of facility policy, Conducting an Accurate Assessment revised 12/2023 revealed, Policy: The purpose . assure that all residents receive an accurate assessments, reflective of the resident's status . Policy Explanation and Compliance Guidelines: . 2. Qualified staff . will conduct an accurate assessment addressing each resident's status, needs, strengths, and areas of decline . 3 . will correctly document the resident's medical, functional abilities and psychological status. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675453 If continuation sheet Page 10 of 16 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 675453 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Collinwood Nursing and Rehabilitation 3100 S Rigsbee Rd Plano, TX 75074 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 (Resident #50) of 6 residents reviewed for care plans. The facility failed to ensure Resident #50 was care planned for his diagnosis of Parkinson's disease (nerve disorder). This failure could place the resident at risk of needs not being met. Findings included: Record review of Resident #50's face sheet dated 06/27/24 revealed an [AGE] year-old male who was admitted to the facility on [DATE]. Relevant diagnoses included Parkinson's disease. Record review of Resident #50's Quarterly MDS assessment dated [DATE] revealed the resident had a BIMS score of 15 (cognitively intact). The assessment also indicated the resident had an active diagnosis for Parkinson's disease. Record review of Resident #50's Comprehensive care plan dated 06/18/24 revealed no care planning for the Resident's diagnosis of Parkinson's disease. An interview on 06/26/24 at 12:30 PM with the DON, ADON, and MDS Nurse, they verified that Resident #50 had Parkinson's disease and stated that it should be care planned. The MDS Nurse verified that Resident #50 did not have the diagnosis care planned. They all stated that if the resident's care plan does not have his Parkinson's disease, he may not receive all the required care he needs. Record review of facility's policy, Comprehensive Person-Centered Care Planning, Policy & Procedure, Policy: It is the policy of this facility that the interdisciplinary team (IDT) shall develop a comprehensive person-centered care plan for each resident . Procedure: . 3. The facility team will provide a written summary . initial goals . any services and treatments to be administered. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675453 If continuation sheet Page 11 of 16 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 675453 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Collinwood Nursing and Rehabilitation 3100 S Rigsbee Rd Plano, TX 75074 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 - Many 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 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 food storage, labeling, dating, and kitchen sanitation. The facility failed to ensure food in the facility's refrigerator, was labeled and dated according to guidelines. The facility failed to ensure food in the facility's freezer, was labeled and dated according to guidelines. The facility failed to discard expired foods according to guidelines. The facility failed to discard dented cans according to guideline. The facility failed to ensure all damaged eggs were removed from the other eggs stored in its original container. These failures could place residents at risk for cross contamination and other air-borne illnesses. Findings included: Observations on 06/25/24 from 09:05 AM to 09:15 AM in the facility's only kitchen reflected: Two-pound container of Strawberry Yogurt had a prep date of 05/14/24 and the container had a best used by date of 06/24/24, expired, was observed in the refrigerator. Five-pound container of coleslaw dressing dated 10-03-23 and had an opened date of 6-12-24. There was no visible expiration date. Five-pound container of cottage cheese with a prep date of 6/4/24 and the container had a best used by date of 06/23/24, expired, was observed in the refrigerator. One broken egg in a tray with other eggs located in the walk refrigerator. A zipped lock bag containing sliced meat was dated 6-13-24 (expired) was stored in the refrigerator. One 6.5 pound can of diced pears, located in the pantry area, was dented. One 6.5 pound can of peas located in the pantry area, was dented. Two raw pork chops in a zipped lock bag was unlabeled and undated. One 10-pound bag of frozen meat was unlabeled and undated. There was no visible expiration date. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675453 If continuation sheet Page 12 of 16 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 675453 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Collinwood Nursing and Rehabilitation 3100 S Rigsbee Rd Plano, TX 75074 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 An interview on 06/26/24 at 01:05 PM with the Dietary Manager and Dietician, they were shown the concerns observed in the kitchen. The DM stated she had all kitchen staff assigned to storing the food and removing any expired foods. The DM and Dietician stated they would in-service the team on the food storage requirements and will remove the concerns observed. They both stated the risk of the concerns not being addressed could result in food contamination. Residents Affected - Many An interview on 06/27/24 at 10:31 AM with the Administrator, she was made aware of the findings in the kitchen. She stated that she expects the kitchen to meet all required expectations. She stated the kitchen area had made some improvements since she had been at the facility. She stated she would follow up with the DM. She stated the risk of the concerns not being addressed could result in food contamination. Record Review of the Facility's policy on Food Storage dated 12/2023, revealed Foods shall be received and stored in a manner that complies with safe food handling practices. All foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date). 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 §section 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: 675453 If continuation sheet Page 13 of 16 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 675453 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Collinwood Nursing and Rehabilitation 3100 S Rigsbee Rd Plano, TX 75074 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 two (Resident #21 and Resident #46) of eight residents observed for infection control. Residents Affected - Few The facility failed to ensure that CNA D performed hand hygiene and changed his gloves while providing incontinence care to Resident #21. The facility failed to ensure that CNA D performed hand hygiene and changed his gloves while providing incontinence care to Resident #46. These failures could place the residents at risk of cross-contamination and development of infection. Findings included: Resident #21 Review of Resident #21's Face Sheet, dated 06/25/2024, reflected resident was an [AGE] year-old female admitted on [DATE]. Relevant diagnoses included hemiplegia (paralysis of one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (insufficient oxygen in the brain causing stroke) affecting left non- dominant side. Review of Resident #21's Quarterly MDS Assessment, dated 03/27/2024, reflected Resident #21 had a severe cognitive impairment with a BIMS score of 06. Resident #21 required assistance for bed mobility, transfer, and toilet use. Review of Resident #21's Comprehensive Care Plan, dated 05/06/2024, reflected Resident #21 had an ADL Self Care Performance Deficit r/t impaired mobility. Review of Resident #21's Bowel and Bladder Assessment, dated 05/17/2024, revealed resident had incontinence for bowel and bladder. Observation and interview on 06/25/2024 at 9:14 AM revealed CNA D was walking on the hallway holding a plastic bag with linens and a brief. CNA D said he was about to change Resident #21. CNA D went inside the room and told the resident that he would clean her up. The resident nodded her head. CNA D proceeded to put on a pair of gloves. He did not wash his hands before putting on the gloves. Before doing incontinent care, CNA D pulled the trash can and placed it beside him. CNA D then pulled the blanket to the foot part of the bed. He then took the new brief from inside the plastic bag, opened it, and placed it on the side of the resident's leg. He unfastened the brief and pushed the front part in between the resident's legs. He pulled some wipes and placed the wipes on top of the plastic container for the wipes. CNA D cleaned the front part of the resident from front to back, rolled the resident towards the wall, and cleaned the bottom of the resident. While CNA D was cleaning the resident's bottom, the resident had a bowel movement. CNA D continued to clean the resident's bottom. After he was done cleaning the resident's bottom, CNA D pulled the soiled brief, threw it in the trash can, pulled the new brief from the side of the resident, and put it on the resident's bottom. He (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675453 If continuation sheet Page 14 of 16 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 675453 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Collinwood Nursing and Rehabilitation 3100 S Rigsbee Rd Plano, TX 75074 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 Level of Harm - Minimal harm or potential for actual harm rolled back the resident, fixed the brief, took a thin blanket from the plastic bag, and put it on top of the resident. He took off his gloves and threw them in the trash can. CNA D said he was done cleaning Resident #21 and would go to another resident to do another incontinent care. He went out of the room. He did not change his gloves all throughout incontinent care nor wash his hands before leaving the room. Residents Affected - Few Resident #46 Review of Resident #46's Face Sheet, dated 06/27/2024, revealed that resident was a [AGE] year-old male admitted on [DATE]. Relevant diagnoses included hemiplegia (paralysis of one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (insufficient oxygen in the brain causing stroke) affecting right dominant side. Review of Resident #46's Quarterly MDS Assessment, dated 04/04/2024, revealed the resident was cognitively intact with a BIMS score of 15. The Quarterly MDS Assessment indicated Resident #46 was always incontinent for bowel and bladder. Review of Resident #46's Comprehensive Care Plan, dated 05/03/2024, reflected the resident had bowel and bladder incontinence r/t impaired mobility and one of the interventions was to change every two hours and PRN. Observation on 06/25/2024 at 10:35 AM revealed CNA D was about to provide incontinent care for Resident #46. CNA D prepared the things needed. CNA D washed his hands and put on a pair of gloves. CNA C then unfastened the tape on both sides of the brief, rolled the front half of the brief, and pushed it between the resident's thighs. CNA D cleaned the front part of Resident #46. CNA D instructed and assisted the resident to roll to the right. CNA D changed his gloves but did not sanitize his hands before putting on the new pair of gloves. CNA D then proceeded to clean the bottom of the resident. After wiping down the resident, CNA D rolled the rest of the brief, pulled it, and threw it in the trash can. CNA D took off the soiled gloves and proceeded to change his gloves. He did not do hand hygiene in between gloves changes. CNA D then proceeded to get the new brief, opened it, and placed it at the bottom of the resident. The resident was instructed to roll back. CNA D took off his gloves, fixed the brief, and fastened the tape on both sides. He did not have any gloves on when he fixed and fastened the brief. CNA D then put on a pair of gloves and pulled the blanket up. CNA D did not sanitize his hands before putting on the gloves. CNA D took off his gloves, threw them in the trash can, and washed his hands. Interview with CNA D on 06/25/2024 at 10:53 AM, CNA D stated it is important to wash the hands before and after doing any care for the resident. He then acknowledged that he did not wash his hands when he did the first incontinent care. He said he also did not change his gloves after cleaning the residents' bottom and did not sanitize his hands in between changing of gloves. He said hand washing was important to prevent cross contamination and infection. He said it was also important to change gloves when touching clean items and to sanitize hands when changing the gloves to make sure the hands were clean when touching the residents. He also said he should have changed his gloves when he touched the trash can and put it on his side. He said he had in-services about infection control and hand hygiene. In an interview with LVN B on 06/26/2024 at 9:53 AM, LVN B stated the right procedure was to wash the hands before and after incontinent care. She said it was also important to change the gloves and to sanitize the hands during the duration of incontinent care especially if soiled items were (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675453 If continuation sheet Page 15 of 16 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 675453 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Collinwood Nursing and Rehabilitation 3100 S Rigsbee Rd Plano, TX 75074 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few touched. LVN B added that any soiled items should not touch the clean items to prevent cross contamination and possible infection. She said, for the same reason, the gloves should have been changed after touching the trash can. In an interview with the ADON on 06/27/2024 at 07:24 AM, the ADON stated hands should be washed before and after any care done for the residents. The ADON said gloves should be changed and hands should be sanitized after touching soiled items such as the soiled brief and the trash can. The ADON added that not washing the hands, not changing the gloves after touching a soiled brief, and not sanitizing the hands when changing the gloves could result in cross contamination. She continued that cross contamination could lead to infection such as urinary tract infection. The ADON said the expectation was for the staff to wash their hands and change their gloves during incontinent care. She said she would start an in-service to address the infection control issue. In an interview with the DON on 06/27/2024 at 07:37 AM, the DON stated she was made aware, by the CNA, about the issue during incontinent care. She said she already talked to the staff and did a one-on-one in-service with him. She said she would also do an in-service about infection control, hand hygiene, and incontinent care for all the staff responsible for the residents' direct care. She said not washing their hands before and after any care, not changing their gloves after touching soiled items, and not sanitizing the hands in between changing of gloves could eventually introduce microorganisms to the clean items. She said not doing proper hand hygiene could result in any kind of infection. She said the DON and the ADON were responsible in making sure the staff were adhering to the infection control practices. The DON said the expectation was for the staff to carry out care without the possibility of cross contamination and introduction of infection. She also would do a check off with CNA D about peri-care. She concluded that she would continually remind the staff to be attentive to the procedures for infection control. In an interview with the Administrator on 06/27/2024 at 08:06 AM, the Administrator stated not washing hands and not changing gloves could cause cross contamination and possible infection. She said clean and dirty items should not be touching each other to prevent infection. She said the expectation was for the staff to be mindful and do the right and proper way of care to protect the residents. The Administrator said she would collaborate with the clinicals to address the issue. Record review of facility's procedure, Hand-Washing/Hand Hygiene reviewed December 2023, revealed Policy Statement: This facility considers hand hygiene the primary means to prevent the spread of infections . Policy Interpretation and Implementation . 2. All personnel shall follow the hand-washing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors . 7. Use an alcohol-based hand rub; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations . b. Before and after direct contact with residents . After contact with a resident's intact skin . j. After contact with blood or bodily fluids . m. After removing gloves. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675453 If continuation sheet Page 16 of 16