Health inspection·December 7, 2023

F 0657 resident care plan meetings. Level of Harm - Minimal harm or potential for actual harm Interview on 12/07/23 at 1:15 PM with ADON B revealed she participated in short term care plan meetings with the Social Worker and Director of Rehab. She stated in the meetings she reviewed medication, ADL needs of the resident and any medically relevant information. She stated the Social Worker coordinated the resident care plan meetings and sent an email usually the day of the care plan meeting invitations to include which resident care plan meetings would be held. She stated she could not recall Resident #54's care plan meeting on 11/29/23 and did not think she attended. She stated the resident and/or resident representative would be invited by the Social Worker and attended the meeting if they wanted. She stated she was aware the CNA and Dietary Manger should attend the care plan meeting. She stated she was not aware the resident's attending physician and/or representative of the attending physician should be at resident care plan meetings. She stated the Dietary Manager and attending physician did not attend the resident care plan meetings for residents . Residents Affected - Few Interview on 12/07/23 at 1:24 PM with ADON A revealed she participated in the long-term care residents' care plan meetings and did not participate in Resident #54's care plan meeting. She stated in long term care resident meetings only facility staff in the meetings were the Social Worker and her along with the resident and/or resident representative if they wanted to attend. She stated the Social Worker was responsible for inviting the attendees which included facility staff, resident and resident representative to the care plan meetings. She stated she was not aware of the resident's attending physician being involved in meetings and the Dietary Manager. Follow up interview on 12/07/23 at 1:31 PM with ADON B revealed she did participate in Resident #54's initial care plan meeting on 11/29/23 and recalled discussing discharge planning for Resident #54 but could not recall anything else that was discussed. She stated the Social Worker was responsible for documenting about the care plan conference. She stated Dietary Services and the physician had not participated in the resident care plan meetings. Interview on 12/07/23 at 2:25 PM with the DON revealed the Social Worker was responsible for coordinating resident's care plan meeting and the ADON and Director of Rehab attended the care plan meetings for residents. She stated the resident's attending physician and CNA did not attend the care plan meetings. Record review of ADON B's Email, dated 11/29/23, reflected the Social Worker sent an email to the Rehab Director, the DON and the ADON on 11/29/23 about a care plan meeting which included Resident #54. Record review of the facility's policy Care Plan - Process, last revised 02/12/20 and reviewed 03/27/23, reflected 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 .3. The Interdisciplinary Team identifies members' responsibilities. Suggested team members included: .Medical Providers and Nursing (including Nurse Assistants). The care plan policy did not address the required members to participate in the care plan process. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676096 If continuation sheet Page 2 of 19 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 676096 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Baybrooke Village Care and Rehab Center 8300 Eldorado Parkway West McKinney, TX 75070 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 carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for two of eight residents (Residents #52 and Resident #14) reviewed for ADL care. Residents Affected - Some The facility failed to ensure staff provided consistent showers/baths and grooming for Resident #52 and Resident #14. This failure could place residents at risk of not receiving needed hygiene care which could cause skin breakdown, a loss of dignity and self-worth. Findings include: 1. Record review of Resident #52's Significant Change MDS assessment, dated 10/23/23, reflected an [AGE] year-old male who was admitted to the facility on [DATE]. He had a BIMS of 8, which indicated he was moderately cognitively impaired. He had not rejected care and he indicated his daily preferences for choosing between a shower and sponge bath were very important to him. He was totally dependent for bathing with 2-person assistance and required maximum assistance of one for personal hygiene. His active diagnoses included a hip fracture and Alzheimer's disease. Record review of Resident #52's care plan, reviewed on 10/30/23, reflected, .Self-care deficit .Related to limited joint mobility .Supervision or touching assistance with personal hygiene .Partial/moderate assistance with Shower/Bathe .Interventions .Provide assistance with self-care as needed Record review of hall 400 shower schedule, dated 11/28/23, reflected Resident #52 was scheduled for a shower on Tuesday's, Thursday's, and Saturdays on the 6 a.m. to 6 p.m. shift. Record review of Resident #52's ADL flow record history report for November 2023 through December 07, 2023, reflected no showers on scheduled days for 11/02/23, 11/11/23. 11/28/23, 12/01/23 and 12/07/23. Shaving was not a separate entry. In an observation and interview with Resident #52 on 12/05/23 at 10:05 a.m. revealed Resident #52 lying in bed. He had approximately a 1/4 inch of facial hair on his chin and upper lip. Resident #52 stated he had received his showers or been shaved. He stated he had not been showered or shaved in over three weeks and stated he wanted to be shaved and showered. Observation of Resident #52 on 12/07/23 at 8:35 a.m. revealed the resident was up in the dining room finishing his breakfast. The resident was still not shaved. In an interview with CNA E on 12/07/22 at 8:45 a.m. revealed she was assigned to Resident #52 on 12/05/23 and today. She stated she showered Resident #52 on 12/05/23 but had not shaved him, nor had she asked him if he wanted a shave. She stated she was not sure if he wanted to have a beard or if he had wanted a shave. She stated she had not asked him or the charge nurse about his grooming preference. In an observation and interview in conjunction with the DON on 12/07/23 at 8:50 a.m. revealed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676096 If continuation sheet Page 3 of 19 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 676096 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Baybrooke Village Care and Rehab Center 8300 Eldorado Parkway West McKinney, TX 75070 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 Level of Harm - Minimal harm or potential for actual harm Resident #52 in his room sitting on his bedside. The DON asked the resident if he received his showers and if he wanted to be shaved. Resident #52 stated, he had not been showered or shaved in the last three weeks and stated yes he wanted to be shaved. The DON asked the resident if he was certain he had not gotten a shower on 12/05/23 prior to his doctor's appointment and he stated no he had not received a shower. The DON told the resident he would be getting a shower and shaved today (12/07/23) for certain. Residents Affected - Some In a follow up interview with the DON on 12/07/23 at 8:55 a.m., she stated the CNAs were supposed to inform the charge nurse anytime a resident refused a shower. She stated grooming, such as shaving, nail care and hair care was to be done on the shower days, and if the resident refused, they were to notify the charge nurse as well and they were to document it in the electronic record. She stated Resident #52 was forgetful, but he was restating the same thing two days in a row about not receiving care and he had obviously not been shaved in several days. She stated when the staff did not report or document refusal then they could not follow up on the next shift or next day to see if the resident might be willing to take their shower at another time. She stated lack of personnel hygiene could lead to skin problems and overall dignity. In an interview with CNA F on 12/07/23 at 9:10 a.m., she stated she worked last Thursday (11/30/23) and she showered Resident #52, but stated he refused to let her shave him. She stated she did not document in the record, because there was not a place to document it. She stated all the personnel care items were all lumped into one category, so if they did one form of personnel care they checked it as being completed. She stated she reported to LVN C about Resident #52's refusal of shaving. In an interview with LVN C on 12/07/23 at 9:25 a.m., she stated they were responsible for ensuring the resident's showers and ADL care were performed. She stated the CNAs were supposed to let them know if a resident refused ADL care or if they were unable to give the scheduled shower or bath. She stated she had not been notified by any of the CNAs that Resident #52 refused to be shaved or any of his showers had been missed. 2. Record review of Resident #14's MDS assessment, dated 10/26/2023, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. He had a BIMS of 13, which indicated he was cognitively intact. His active diagnoses included Hemiplegia or hemiparesis (unilateral paresis, is weakness of one entire side of the body), hypertension (high blood pressure), chronic obstructive pulmonary disease (a type of progressive lung disease characterized by long term respiratory symptom and airflow limitation), and rheumatoid arthritis (an inflammatory form of arthritis that cause joint pain, swelling and damage). He was totally dependent of all ADLs with the assistance of two except for eating which only required set up assistance. Record review of Resident #14's care plan, dated 11/06/2023, reflected . History of stroke. History of Hemiplegia Resident Prefers Bath in AM .limited joints mobility interferes with dressing Limited joints mobility interferes with Hygiene Goal .Resident will assistance with bathing and hygiene daily. Interventions: Provide assistance with self-care as needed Record review of the Hall 500 shower schedule, dated 11/28/2023, reflected Resident #14 was scheduled for a shower on Monday's, Wednesday's, and Fridays on the 6 a.m. to 2 p.m. shift. Record review of Resident #14's ADLs Coding report, for December 2023, reflected no showers on scheduled days for 12/01/23, 12/06/2023, and for November 2023 reflected no showers on scheduled days for 11/29/23, no record for the November 1st to November 6th, 2023, and for October 23 reflected no (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676096 If continuation sheet Page 4 of 19 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 676096 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Baybrooke Village Care and Rehab Center 8300 Eldorado Parkway West McKinney, TX 75070 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 showers on scheduled days for 10/13/2023 and 10/20/2023. Level of Harm - Minimal harm or potential for actual harm In an observation and interview with Resident #14 on 12/06/2023 at 12:00 PM revealed Resident #14 was up in his motorized wheelchair in his room. Resident #14 stated he did not get a shower today (12/06/2023) in the morning as scheduled, and last week he got one shower on Monday (11/27/2023). Resident #14 stated he was scheduled for a shower on Mondays, Wednesdays, and Fridays in the morning before breakfast. Resident #14 stated he had been getting his showers on Monday's, and missed his showers sometimes on Wednesday and Friday he hardly ever got a shower. Residents Affected - Some In an interview with CNA I on 12/06/2023 at 12:15 pm. revealed she had worked at the facility for about three months. She stated her regular shift time was 6:00 AM to 2:00 PM, Monday through Thursday. She stated she had a shower schedule that indicated who required showers on her shift 6:00 AM to 2:00 PM. She stated Resident #14 was on the schedule to be showered today (12/06/2023), but she started her shift at 9:00 AM, and she did not know he missed his shower this morning (12/06/2023). She stated Resident #14 reported to her a couple of times on Monday's that he missed his shower on Friday's, and she had not notified anyone. She stated Resident #14 never refused to take a shower with her. She stated if a resident refused to take a shower she would report it to the charge nurse, and document it. In an interview with the charge nurse, LVN D, on 12/06/23 at 12:32 PM revealed she had worked at the facility for two years as a charge nurse for Hall 500 Monday through Friday 6:00 AM to 2:00 PM shift. She stated she was aware of the resident's shower schedule and the CNAs were to notify her if a resident refused a shower. She stated she was not made aware he had not received his shower on 10/13/23, 10/20/23, 11/29/23, 12/01/23, and 12/06/23. She stated she would ensure he received his shower today. In an interview with ADON A on 12/07/23 at 10:17 AM, she stated Resident #14 may prefer, the person working on Monday and Wednesday, to give him his shower. She stated the nurse would document the refusal and asked the resident if he/she would like to take a shower 3 times and offer him/her another time. ADON A stated it was the responsibility of the charge nurses to make sure the residents got their shower. Charge nurse, ADON, and DON were unable to give documents indicating resident refused to take shower. In an interview with the DON on 12/07/23 at 1:25 PM, the DON stated Resident #14 was supposed to get showers according to his scheduled update and posted monthly, and it was the responsibility of the CNAs and the charge nurse to make sure residents got their showers, and if the resident refused to take a shower it should be documented. The DON stated the risk to Resident #14 not getting his shower for four days in row was he may become stinky, sweaty, and just not feeling good. Record review of the facility's policy titled, Hair Care-Combing and Shaving, dated January 2023 reflected, Hair care, combing and shaving will be proved for residents in accordance with standard practice guidelines .Record the procedure in the record Record review of the facility's policy titled, Bathing (Not Partial or Completed Bed Bath), dated January 2023, reflected, .Staff will provide bathing services for resident withing standard practice guidelines .In the event of refusal or behaviors associated with bathing, refer to the Pathways Memory Care Manual and Behavior Management for methods to assist with behaviors .Ask for assistance from other staff as needed .If the resident refuses to independently or allow staff to assist with bathing, document the refusal in the record. Multiple refusals of bathing needs shall be discussed with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676096 If continuation sheet Page 5 of 19 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 676096 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Baybrooke Village Care and Rehab Center 8300 Eldorado Parkway West McKinney, TX 75070 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 the resident and responsible party during car plan meeting with the interdisciplinary team in order to identify and implement proper hygiene habits and promote resident rights and dignity Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676096 If continuation sheet Page 6 of 19 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 676096 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Baybrooke Village Care and Rehab Center 8300 Eldorado Parkway West McKinney, TX 75070 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review the facility failed to ensure, based on the comprehensive assessment of a resident, the residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan and the residents' choices for one of eight residents (Resident #35) reviewed for quality of care. Residents Affected - Few The facility failed to ensure facility staff reported a wound on Resident #35's right upper arm which was first observed on 12/05/23 which in a delay of treatment until 12/06/23. This failure could place residents at risk of not receiving the care and treatment needed to their needs. Findings include: Record review of Resident #35's admission MDS assessment, dated 11/14/23, reflected a BIMS of 10, which indicated the resident was mildly cognitively impaired. Resident #35 required moderate assistance with toileting and upper body hygiene and was dependent on putting on/taking off footwear. Resident #35 was occasionally incontinent of bowel and bladder. Resident #35 had active diagnoses which included Diabetes Mellitus (inappropriately elevated blood glucose levels ), Non-Alzheimer's Dementia (repetitive movements, compulsive ritualistic behaviors, and repetitive use of verbal phrases), Anxiety (a feeling of fear, dread, and uneasiness), Depression (a common and serious medical illness that negatively affects how you feel, the way you think and how you act.), was at risk of developing pressure ulcers/injuries. Resident #35 had no unhealed pressure ulcers or wounds at the time of the assessment. Record review of Resident #35's care plan, initiated on 11/07/23, reflected the need to have 2 staff assistance for bathing, intervention plan to inspect skin daily with care and bathing. Skin Breakdown: At risk for /actual . inspect skin complete body head to toe every week and document results. Record review of Resident #35's Resident Consolidate Order report, printed on 12/07/23, reflected .Cleanse wound every AM shift, Cleanse abrasion to right upper arm W/NS, apply Xeroform, cover with border gauze. Change daily . with a start date 12/06/23. Record review of Resident #35's skin assessment, dated 11/06/23, reflected a wound (pressure, diabetic or stasis), skin tear located on the sacrum. There was no documentation of any skin issues on her right upper arm. Record review of Resident #35's skin assessment, dated 11/13/23, reflected no wound (pressure, diabetic or stasis), skin tear or abrasions. Staff documented a bruise to right upper arm. Record review of Resident #35's skin assessment, dated 11/27/23, reflected no wound (pressure, diabetic or stasis), skin tear or abrasions. Staff documented a scar to the right upper arm. Record review of Resident #35's last skin assessment, dated 12/04/23, reflected no wound (pressure, diabetic or stasis), skin tear or abrasions. Record review of Resident #35's Medication Administration Record for December 2023, reflected .Cleanse wound every AM shift, Cleanse abrasion to right upper arm W/NS, apply Xeroform, cover with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676096 If continuation sheet Page 7 of 19 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 676096 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Baybrooke Village Care and Rehab Center 8300 Eldorado Parkway West McKinney, TX 75070 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 0684 border gauze. Change daily . with a start date 12/06/23. Level of Harm - Minimal harm or potential for actual harm Observation and interview on 12/05/23 at 10:12 AM revealed Resident #35 lying on her bed. Resident #35 had two open areas approximately the size of a quarter on the right upper arm that was bright red and bleeding. The resident stated she was picking at the wound and she was treating it with Vaseline. Resident #35 stated she was not getting any treatment from the facility for this wound. Residents Affected - Few Interview with LVN C on 12/06/23 at 02:10 PM revealed the resident did not have any open wounds on her currently. LVN C along with the State Surveyor went to the resident's room. The State Surveyor showed the wound on the resident's right upper arm, between the elbow and shoulder. LVN C stated the resident had this wound when she was admitted and it healed. She stated the resident scratched and picked on the healed wound. LVN C stated she was not aware of this current wound, nobody including the CNA who gave showers to the resident had not reported this wound to her. LVN C stated the doctor should have been notified if someone had observed/reported this wound to her. LVN C stated the resident was diagnosed with diabetes, was obese and was not getting any treatment for this open wound at this time. LVN C stated the resident could develop an infection if the wound was not treated. Interview with CNA G on 12/06/23 at 02:34 PM revealed she worked at the facility for 5 months, currently on shift 2-10 PM. CNA G stated she provided care to Resident #35 the previous week, and she had not observed an open wound on the resident at that time. CNA G stated she would notify the Charge Nurse if she saw a new wound on a resident. Interview with CNA H on 12/06/23 at 02:38 PM revealed he worked shift 2-10 PM and provided services to residents currently. CNA H stated he did not notice a wound on Resident #35's upper right arm. Interview with the DON on 12/06/23 at 03:10 PM revealed she was not aware of Resident #35's wound until today. The DON stated the CNA and the charge nurse who provided services to Resident #35 did not report the wound. The DON stated the charge nurse did weekly skin assessments and if it was not treated, the wound could get infected. The DON stated she had the nurse do an assessment on Resident #35 today as soon as she came to know about the wound and they would immediately notify the doctor and start the treatment. Interview with CNA E on 12/07/2023 at 11:04 AM revealed she worked at the facility for 8 years. CNA E stated she gave a bath to Resident #35 on Wednesday 12/06/23 . CNA E stated she did not notice any open wounds on resident. CNA E along with CNA F gave a bed bath to the resident on 12/05/23 and she did not notice any open wound on resident's upper arm. CNA E stated she would report to the Charge Nurse if she saw a wound and Resident #35 could have an infection if the wound was not treated. Interview with CNA F on 12/07/23 at 11:09 AM revealed she worked at the facility for 5-6 months. CNA F stated she gave a bed bath to Resident #35 on 11/30/23 and noticed a scar on the resident's upper arm and she reported that to Charge nurse, LVN C. CNA F stated the resident did not have a wound on her upper arm on 11/30/23. CNA F stated she along with CNA E gave a bed bath to Resident #35 on 12/06/23, she did not notice a wound on the resident's upper arm. Interview with the Wound Care Nurse on 12/07/23 at 01:35 PM revealed CNAs were supposed to observe and notify the nurse if they saw any skin issues. She stated when the staff failed to notify her of skin problems, it caused a delay in treatment which could lead to further skin breakdown and infections. The Wound Care Nurse stated nobody reported the wound on Resident #35 to her. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676096 If continuation sheet Page 8 of 19 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 676096 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Baybrooke Village Care and Rehab Center 8300 Eldorado Parkway West McKinney, TX 75070 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 0684 Level of Harm - Minimal harm or potential for actual harm Record review of the facility's Policy and procedure titled Skin Data Collection: Licenses nurses, revised July 2018, reflected, . a licensed nurse will collect data during weekly skin evaluations The licensed nurse should pay attention to redness (check for blanching and document blanchable, or non-blanchable redness), rashes, discolorations, open areas, blisters, dry/flaking skin, edema .Any significant abnormal findings are reported to the patient's /resident's physician and resident or responsible party Residents Affected - Few Record review of the facility's policy titled Change of conditions, revised February 13, 2023, reflected, . The primary goal of identifying acute changes of condition is to enable staff to evaluate and manage a patient at the community and avoid transfer to a hospital or emergency room. To achieve this goal, the community's staff and practitioners must recognize an ACOC and identify its nature .new or worsening symptoms that does not meet the criteria .As part of the interdisciplinary team, Certified Nursing Assistants and Certified Medication Technician are expected to report findings that might represent an Acute Change Of Conditions. This should be communicated in the form of the stop and watch tool . Definitions: An acute change of condition ACOC is a sudden, clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional domains. Clinically important means a deviation that, without intervention, may result in complications. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676096 If continuation sheet Page 9 of 19 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 676096 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Baybrooke Village Care and Rehab Center 8300 Eldorado Parkway West McKinney, TX 75070 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 - Few 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 two of eight residents (Resident #10, Resident #12) reviewed for accident hazards and supervision. The facility failed to properly maintain wheelchairs for Residents #10 and #12. This failure could place residents at risk for discomfort, pain, and injuries. Findings include: 1.Record review of Resident #10's quarterly MDS assessment, dated 12/01/23, reflected an [AGE] year-old female with an admission date of 10/26/21. Resident #10 had a BIMS score of 9, which indicated she was mildly cognitively impaired. Resident #10 required moderate one-person assistance with transfers, and she had limited range of motion to both lower and upper extremities on one side. The resident was occasionally incontinent of urine and bowel. The resident's active diagnoses included cerebrovascular accident (stroke) Diabetes Mellitus. Record review of Resident #10's care plan, initiated on 10/26/21, reflected . [Resident #10] at risk for skin breakdown. Interventions will be taken to prevent skin breakdown .keep skin clean, dry and free of irritants. An Observation and interview with Resident #10 on 12/05/2023 at 10:49 AM revealed Resident #10 was sitting in her wheelchair in her room, the left arm rest of the wheelchair was wrapped in white cloth and the black leather had come off. No scratch marks were observed on resident's arm. An interview with Resident #10 revealed the wheelchair arm rest was bothering her and it was scratching on her arm. Resident #10 stated she has not told any staff about the wheelchair hand rest scratching her arm. 2. Record review of Resident #12's quarterly MDS assessment, dated 10/26/23, reflected a [AGE] year-old female with an admission date of 01/11/2020. Resident #12 had a BIMS score of 06, which indicated the resident was moderately cognitively impaired. Resident #12 was dependent on caregivers for shower and personal hygiene, required substantial 1 person assistance with transfers. The resident was frequently incontinent of urine and bowel (uncontrolled bowl and bladder movements). The resident's active diagnosis included non-Alzheimer's dementia (repetitive movements, compulsive ritualistic behaviors, and repetitive use of verbal phrases), Peripheral Vascular Disease (Reduced Blood flow to the limbs). Record review of Resident #12's care plan, initiated on 01/11/2020, reflected . [Resident #12] was at risk of skin breakdown . interventions will be taken to prevent skin breakdown . keep skin clean, dry, and free of irritants. Record review of the Maintenance log flected no maintenance request related to Residents #10 and #12 were requested related to wheelchair, from 08/04/23 to 12/06/23. Observation and interview on 12/05/23 at 10:17 AM revealed Resident #12 in the Television hall. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676096 If continuation sheet Page 10 of 19 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 676096 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Baybrooke Village Care and Rehab Center 8300 Eldorado Parkway West McKinney, TX 75070 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 - Few Resident #12 was sitting in her wheelchair and the resident's wheelchair left arm rest's black leather cover had come off and the resident had her blanket kept in between her arm and armrest to prevent scratches. Resident #12 stated she was not comfortable using the wheelchair due to the damage to the wheelchair arm rest. Interview with the Maintenance Director on 12/06/23 at 11:16 AM revealed he was responsible for maintaining the wheelchairs when a concern was reported to him or recorded in the maintenance log available in each nurse's station. He stated staff would often tell him about a problem, but not place in the log. He stated he was unaware of any concerns with Residents #10 and #12's wheelchairs. Interview with CNA E on 12/06/23 at 03:04 PM revealed she was not aware of the wheelchair arm rest damage to Residents #10 and #12 wheelchairs. The CNA stated the damaged arm rest could cause discomfort, pain and injury to the resident. Interview with LVN C on 12/07/23 at 09:20 AM revealed she was not aware of Residents #10 and #12 wheelchair arm rest damage. The LVN stated the CNA working on the hallway were supposed to notify the charge nurse about the damage, but it did not happen. LVN C stated the damaged arm rest could cause discomfort, pain and injury to the resident. Interview with CNA F on 12/07/23 at 11:10 AM revealed she had observed Resident #12's wheelchair damage to the arm rest and she notified the charge nurse and the maintenance director. LVN C, a week ago. CNA F stated she did not see the damage to Resident #10. CNA F stated the damaged arm rest could cause discomfort, pain and injury to the resident. Interview with the DON on 12/07/23 at 11:14 AM revealed she was not aware of the damage to Residents #10 and #12 wheelchair. The DON stated when a wheelchair or any type of resident equipment needed repair, staff were to write it in the maintenance request work log located at the nurse's station so the Maintenance Director could address the concern and resolve it. The DON stated the damaged arm rest could cause discomfort, pain and injury to the resident. Record review of the facility's, undated, policy titled, Equipment Maintenance, reflected, .Facility equipment was maintained according to manufacturer recommendations to ensure that the building and equipment were maintained in a safe and operable manner. The procedure stated, the maintenance director was responsible for . equipment are maintained in a safe and operable manner FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676096 If continuation sheet Page 11 of 19 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 676096 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Baybrooke Village Care and Rehab Center 8300 Eldorado Parkway West McKinney, TX 75070 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide pharmaceutical services, including procedures that assured the accurate acquiring, receiving, dispensing and administering of all drugs and biologicals, to meet the needs of each resident for three of six residents (Residents #63, # 35 and #33) reviewed for pharmacy services. 1. LVN C failed to follow the manufacturer's instructions to [NAME] the Novolin R Insulin (Hormone) Pen prior to dialing in the required amount of Insulin to be administered to Resident #63. 2. LVN C failed to follow the manufacturer's instructions to [NAME] the Admelog Insulin (Hormone) Pen prior to dialing in the required amount of Insulin to be administered to Resident #35. 3. LVN D failed to follow the manufacturer's instructions to [NAME] the Humalog Insulin (Hormone) Pen prior to dialing in the required amount of Insulin to be administered to Resident #33. These failures could place residents at risk of not receiving the full dosage of medication. Findings include: 1. Record review of Resident #63's Quarterly MDS, dated [DATE], reflected an [AGE] year-old female who was admitted to the facility on [DATE]. The resident had a BIMs of 9, which indicated she was moderately cognitively impaired. Resident #63's active diagnoses included diabetes mellitus . Record review of Resident #63's Physicians consolidated Orders Report, dated 12/06/23, reflected .Novolin R Flexpen 100 unit/mL (3 mL) subcutaneous insulin pen . Units Per Sliding Scale Subcutaneous . with a start date of 12/05/23. An observation on 12/05/23 at 11:00 a.m. of the medication pass revealed LVN C checked Resident #63's FSBS and obtained a reading of 437. LVN C returned to the medication cart, looked at the MAR and determined the resident would need insulin according to a sliding scale and would need to notify the doctor to determine if additional insulin would be required. LVN C left a message with Resident #63's physician. LVN C stated she was going to proceed with the ordered sliding scale and opened the medication cart and retrieved Resident #63's Novolin R Flex Pen. LVN C placed a needle on the insulin pen and dialed 10 units without priming the pen first. LVN C then administered the Insulin to Resident #63. 2. Record review of Resident #35's admission MDS, dated [DATE], reflected a [AGE] year-old female who was admitted to the facility on [DATE]. The resident had a BIMs of 10, which indicated she was moderately cognitively impaired. Resident #35's active diagnoses included diabetes mellitus . Record review of Resident #35's Physicians consolidated Orders Report, dated 12/06/23, reflected .Admelog SoloStar U-100 Insulin lispro 100 unit/mL subcutaneous pen (INSULIN LISPRO) Units Per Sliding Scale Subcutaneous .with a start date of 11/07/23. An observation on 12/05/23 at 11:05 a.m. of the medication pass revealed LVN C checked Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676096 If continuation sheet Page 12 of 19 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 676096 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Baybrooke Village Care and Rehab Center 8300 Eldorado Parkway West McKinney, TX 75070 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some #35's FSBS and obtained a reading of 267. LVN C returned to the medication cart, looked at the MAR and determined the resident would need insulin according to sliding scale and opened the medication cart and retrieved Resident #35's Admelog insulin pen. LVN C placed a needle on the insulin pen and dialed 6 units without priming the pen first. LVN C then administered the Insulin to Resident #35. In an interview with LVN C on 12/05/23 at 11:10 a.m., she stated she was unaware the Insulin Pen had to be primed before administering the required dose . Record review of LVN C's Competency Evaluation, dated 05/04/22, reflected she was competent in Insulin administration. 3. Record review of Resident #33's admission MDS, dated [DATE], reflected an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #33 had a BIMs of 9, which indicated he was moderately cognitively impaired. Resident #33's active diagnoses included diabetes. Record review of Resident #33's Physicians consolidated Orders Report, dated 12/06/23, reflected .insulin lispro (Humalog) (U -100) 100 unit/mL subcutaneous pen (INSULIN LISPRO) Units Per Sliding Scale Subcutaneous .with a start date of 08/29/23. An observation on 12/05/23 at 11:05 a.m. of the medication pass revealed LVN D checked Resident #33's FSBS and obtained a reading of 199. LVN D returned to the medication cart, looked at the MAR and determined the resident would need insulin according to a sliding scale and opened the medication cart and retrieved Resident #33's Humalog (lispro) insulin pen. LVN D placed a needle on the insulin pen and dialed 2 units without priming the pen first. LVN D then administered the Insulin to Resident #33. In an interview with LVN D on 12/05/23 at 11:30 a.m., she stated was unaware the Insulin Pen had to be primed each time before administering the required dose. She stated the reason for priming the pen was to make sure all the air was expelled and to ensure the proper dose of insulin was administered. She stated it made sense to do it each time . In an interview with the DON on 12/06/23 at 10:45 a.m., she stated staff were to prime the Insulin pens first to ensure they removed the air and ensure the resident received the required amount of Insulin. She stated failing to follow procedures could result in residents not receiving the full amount of medication ordered. Record review of LVN Ds Competency Evaluation, dated 05/04/22, reflected she was competent in Insulin administration. Record review of the facility's procedure titled, Medication Administration Subcutaneous Insulin) dated 2007, reflected, .always perform the safety test before each injection. Performing the safety test ensures that you get an accurate dose by ensuring that pen and needle work properly. Removing air bubbles .Select the dose (2) of units by turning the dosage selector .Hold the pen with needle pointing upwards .Tap the Insulin reservoir so that any air bubbles rise up towards the needle .Press the injection button all the way in. Check if insulin comes out of the needle tip .You may have to perform the safety test several times before insulin is seen FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676096 If continuation sheet Page 13 of 19 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 676096 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Baybrooke Village Care and Rehab Center 8300 Eldorado Parkway West McKinney, TX 75070 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 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in the facility's only kitchen. Residents Affected - Many 1. The facility failed to ensure trash cans were covered and wiped down. 2. The facility failed to ensure 2 of 2 ovens were cleaned. 3. The facility failed to ensure the fryer was clean on the front and sides. 4. The facility failed to ensure the thickener container was sealed and the sugar plastic container wiped down, in the dry storage area. These failures place residents at risk for food-borne illness and food contamination. Findings include: 1. Observation on 12/05/23 at 9:48 AM revealed 3 of 4 kitchen trash cans, which had food debris, did not have full covered lids. There were food debris and particles on the trash can lid which had a 3-inch round hole in middle. One of four trash cans did not have a lid which had boxes and food debris in it between the food preparation area and dish area. One kitchen trash can lid had a crack on it from the hole to the side of the lid. Observation on 12/06/23 at 10:45 AM revealed three kitchen trash can lids had a 3-inch round hole in the center and had food debris on the lids of 2 of 2 kitchen trash cans. Interview on 12/05/23 at 10:12 AM, Dietary [NAME] K stated the trash can lids had a hole in the center since he was at facility. He was not aware the trash cans needed to be fully covered. He stated the facility had not discussed with him about trash cans needing to be covered in kitchen . Interview on 12/05/23 at 10:14 AM, Dietary Aide M stated he was not aware of trash can needing to be completely covered. He stated he had been at the facility for the last 3 months and worked at the facility before. He stated the kitchen had only trash can lids having a hole in them. He stated the trash can without a lid was down on the shelf. He stated the Dietary Manager recently quit. Interview on 12/06/23 at 10:56 AM with Dietitian revealed she was not aware kitchen trash cans had to fully covered and thought the trash can lid with a hole in center was acceptable. She stated she did expect the kitchen trash can lids to be cleaned when visibly dirty and would ensure they were cleaned. Interview on 12/06/23 at 11:25 AM with Maintenance Director revealed trash cans in the kitchen should be covered and can help keep pests out of the kitchen. Record review of the facility's policy Waste disposal, dated 08/01/2018, reflected Each container is thoroughly cleaned weekly or more often as needed throughout the day. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676096 If continuation sheet Page 14 of 19 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 676096 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Baybrooke Village Care and Rehab Center 8300 Eldorado Parkway West McKinney, TX 75070 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 2. Observation on 12/05/23 at 9:53 AM and 12/06/23 at 10:46 AM revealed on top of 1 of 2 oven doors was a blackish colored grease buildup which covered the top of 1 of 2 oven doors. Two of two oven doors, on the inside, had a dark blackish buildup and grease. The 2nd oven had blackish and whitish buildup and stains on inside door and on the bottom of the oven. Observation on 12/05/23 at 9:56 AM revealed the AM cook cleaning schedule which was displayed on the kitchen wall revealed for ovens to wipe spills daily polish front and sides and clean with oven cleaner on Saturdays . Interview on 12/05/23 at 9:54 AM with Dietary [NAME] K revealed he was a new hire and had been at the facility about 2 weeks. He did not know how often the oven was cleaned or the last time it was cleaned. He stated the Dietary Manager recently quit. Interview on 12/06/23 at 10:50 AM with the Corp Dietary Manager revealed the ovens should be cleaned daily or as needed. She stated the facility had the kitchen cleaning list on kitchen wall . 3. Observation on 12/05/23 at 9:55 AM revealed the deep fryer had brownish particles and substances all over front and sides. Observation on 12/05/23 at 9:56 AM revealed the PM cook cleaning schedule which was displayed on the kitchen wall revealed deep fat fryer to wipe off after each use with degreaser. Observation on 12/06/23 at 10:49 AM revealed the deep fryer had a brownish substances on both sides of fryer. Interview on 12/05/23 at 9:57 AM with Dietary [NAME] K revealed he was about to use the fryer for lunch. He was not sure how often it was cleaned or the last time it was cleaned . Interview on 12/06/23 at 10:52 AM with the Corp Dietary Manager revealed the fryer should be cleaned on the outside of it at least weekly and/or as needed after use by dietary staff. 4. Observation on 12/05/23 at 10:05 AM of the dry storage area revealed a plastic container labeled thickener which was opened about 2 inches with white powder on floor in front of the container. Observations of the dry storage room on 12/05/23 at 10:06 AM and 12/06/23 at 10:54 AM revealed a plastic container with sugar which had a whitish powder and substances on the top of the lid. Observation on 12/05/23 at 9:56 AM revealed the AM cook cleaning schedule which was displayed on the kitchen wall revealed the spices and thickener bin to wipe shelving and bottles and wipe bin daily. Interview on 12/05/23 at 10:05 AM with Dietary Aide L revealed Dietary [NAME] K used the thickener this morning for breakfast when he made puree and must have left it open. She stated it should be closed . Interview on 12/05/23 at 10:07 AM with Dietary [NAME] K stated he used thickener this morning for puree and forgot to close it. He stated he was trained for 4 days when he started and had his food handlers license . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676096 If continuation sheet Page 15 of 19 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 676096 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Baybrooke Village Care and Rehab Center 8300 Eldorado Parkway West McKinney, TX 75070 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 Interview on 12/06/23 at 10:59 AM with the Corp Dietary Manager revealed she and the Dietitian both were covering until the facility had a Dietary Manager. She stated the containers in dry storage should be sealed to prevent food contamination . Interview on 12/06/23 at 11:02 AM with the Dietitian revealed the sugar containers should be wiped off when noticed and when the dietary staff refilled them. She stated she visited the facility at least twice weekly. She stated the facility did not have a current Dietary Manager for about 2 weeks. Record review of the facility's, undated, kitchen daily cleaning list reflected ovens were to be cleaned outside daily and clean inside spills daily, food bins cleaned daily. It did not specify about cleaning for the fryer. Record review of the facility's policy Food Storage, dated 08/01/2018, reflected Food is stored, prepared, and transported .and by methods designed to prevent contamination. Under procedure in storeroom it reflected, Air-tight containers or bags are used for all opened packages of food .Food is protected from splash .or other contamination. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676096 If continuation sheet Page 16 of 19 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 676096 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Baybrooke Village Care and Rehab Center 8300 Eldorado Parkway West McKinney, TX 75070 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 establish and 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 three of eight residents (Residents #63, #35 and #33) reviewed for infection control. Residents Affected - Some 1. LVN C failed to perform hand hygiene after performing FSBS on Resident # 63. 2. LVN C failed to perform hand hygiene after performing insulin injection on Resident #63. 3. LVN C failed to perform hand hygiene after cleaning the soiled glucometer and prior to administering Resident #35's pain medication. 4. LVN D failed to perform hand hygiene after cleaning the soiled glucometer and prior to drawing up Resident #33's insulin. Theses failure could place residents at risk for cross contamination and the development and transmission of communicable diseases and infections. Findings include: 1. Record review of Resident #63's Quarterly MDS, dated [DATE], reflected an [AGE] year-old female who was admitted to the facility on [DATE]. The resident had a BIMs of 9, which indicated she was moderately cognitively impaired. Resident #63's active diagnoses included diabetes mellitus . An observation on 12/05/23 at 11:00 a.m. of the medication pass revealed LVN C performed hand hygiene and entered Resident #63's room to perform a FSBS. Blood sugar reading was obtained and LVN C returned to the medication cart, placed the soiled glucometer on the cart next to a clean glucometer, disposed of the lancet and test strip and removed her gloves. Without performing hand hygiene, LVN C checked the computer determined the resident would need insulin according to a sliding scale and she would need to notify the doctor to determine if additional insulin would be required. LVN C left a message with Resident #63's physician and opened the medication cart to retrieve the resident's insulin. LVN C determined she would need to go to the medication room to retrieve an insulin pen for the resident. LVN C walked to the medication room, searched for the insulin, and then returned to the desk and retrieved the insulin pen. LVN C dialed 10 units of insulin on the insulin pen, performed hand hygiene and put on gloves and entered Resident #63's room and administered the insulin. LVN C returned to the cart, removed her gloves and without performing hand hygiene placed the insulin pen back into the medication cart and proceeded to the next resident's room. 2. Record review of Resident #35's admission MDS, dated [DATE], reflected a [AGE] year-old female who was admitted to the facility on [DATE]. The resident had a BIMs of 10, which indicated she was moderately cognitively impaired. Resident #35's active diagnoses included diabetes mellitus. An observation on 12/05/23 at 11:05 a.m. of the medication pass revealed LVN C entered Resident #35's room and performed hand hygiene and then returned to the medication cart. LVN C put on gloves and retrieved a germicidal wipe and cleaned the soiled glucometer and removed her gloves. LVN C re-gloved without performing hand hygiene and entered Resident #35's room and obtained a FSBS. LVN C (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676096 If continuation sheet Page 17 of 19 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 676096 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Baybrooke Village Care and Rehab Center 8300 Eldorado Parkway West McKinney, TX 75070 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 - Some returned to the medication cart, disposed of the lancet and test strip, and removed her gloves and did not perform hand hygiene before checking the computer to determine the amount of Insulin required. LVN C determined the resident would need insulin according to a sliding scale. LVN C then performed hand hygiene and opened the medication cart and retrieved Resident #35's insulin pen. LVN C placed a needle on the insulin pen and dialed 6 units of Insulin and entered Resident #35's room and administered the Insulin. Resident #35 asked for some Tylenol. LVN C returned to the medication cart, removed her gloves and without performing hand hygiene, logged into the computer. LVN C then picked up the soiled glucometer to obtain the blood sugar reading and logged it into the computer. LVN C then opened the medication drawer and pulled out a bottle of Tylenol 325 mg ( analgesic) and poured 2 tablets into a medication cup. LVN C then re-entered Resident #35's room and administered the Tylenol. LVN C then returned to the medication cart and performed hand hygiene. In an interview with LVN C on 12/05/23 at 11:10 a.m., she stated was supposed to perform hand hygiene before and after each procedure. She stated she thought she had, but then realized she had missed some steps and stated she should have performed hand hygiene as soon as she had removed her gloves each time. She stated failure to do hand hygiene could risk spread of germs and cross contamination. Record review of LVN C's Competency Evaluation, dated 05/04/22, reflected she was competent in Insulin administration, which included when to perform hand hygiene. 3. Record review of Resident #33's admission MDS, dated [DATE], reflected an [AGE] year-old male who was admitted to the facility on [DATE]. The resident had a BIMs of 9, which indicated he was moderately cognitively impaired. Resident #33's active diagnoses included diabetes mellitus. An observation on 12/05/23 at 11:05 a.m. of the medication pass revealed LVN D placed a glucometer, test strips and lancet on a piece of wax paper on top of the medication cart. LVN performed hand hygiene and entered Resident #33's room and obtained a FSBS. LVN D returned to the medication cart, placed the soiled glucometer on the wax paper, disposed of the lancet and test strip and removed her gloves. LVN D re-gloved without performing hand hygiene and pulled out a germicidal wipe and cleaned the soiled glucometer. LVN D then removed her gloves and without performing hand hygiene looked at the MAR and determined the resident would need insulin according to a sliding scale and opened the medication cart and retrieved Resident #33's Humalog (lispro) insulin pen. LVN D placed a needle on the insulin pen and dialed 2 units. LVN D then performed hand hygiene and put on clean gloves and administered the Insulin to Resident #33. LVN D then removed her gloves and performed hand hygiene. In an interview with LVN D on 12/05/23 at 11:30 a.m., she stated she was supposed to perform hand hygiene before and after the FSBS and before and after the insulin administration. She stated she missed the step of performing hand hygiene after cleaning the glucometer. She stated failing to perform hand hygiene could risk exposing residents to infections and cause cross-contamination. In an interview with the DON on 12/06/23 at 10:45 a.m., she stated staff were always supposed to perform hand hygiene before and after each procedure, the FSBS, cleaning the glucometer and administering insulin. She stated they were instructed to sanitize their hands as soon as they removed their gloves. She stated failure to follow the correct procedures could lead to infections and cross contamination. Record review of LVN D's Competency Evaluation, dated 05/04/22, reflected she was competent in insulin administration which included when to perform hand hygiene. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676096 If continuation sheet Page 18 of 19 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 676096 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Baybrooke Village Care and Rehab Center 8300 Eldorado Parkway West McKinney, TX 75070 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 - Some Record review of the CDC guidelines obtained on 01/27/23 from https://www.cdc.gov/cliac/docs/addenda/cliac0313/07B_CLIAC_2013March_Glucose_Monitoring.pdf, reflected, .The Centers for Disease Control and Prevention (CDC) has become increasingly concerned about the risks for transmitting hepatitis B virus (HBV ) and other infectious diseases during assisted blood glucose ( blood sugar) monitoring and insulin administration .Unsafe practices during assisted monitoring of blood glucose and insulin administration that have contributed to transmission of HBV or have put person at risk for infection include .Failing to change gloves and perform hand hygiene between fingerstick procedures .A simple rule for safe care .Blood glucose Meters .disinfected after every use .General .unused supplies and medications should be maintained in clean areas separate from used supplies and equipment .Do not carry supplies and medications in pockets .Hand hygiene .Perform hand hygiene immediately after removal of gloves and before touching other medical supplies intended for use on other person's Record review of the facility's policy titled, Hand hygiene for Staff and Residents, revised in August 2018, reflected, Purpose To reduce the spread of infection with proper hand hygiene .Proper hand hygiene technique is completed whenever hand hygiene is indicated . Hand hygiene is done before .resident contact .taking part in a medical .procedure .After contact with soiled or contaminated articles, such as articles that are contaminated with body fluids .resident contact .removal of medical/surgical gloves .Contact with environment surfaces in the immediate vicinity of resident FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676096 If continuation sheet Page 19 of 19