Health inspection·February 7, 2024

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few -Memantine tablet 5 mg, give 1 tablet by mouth two times a day for dementia with an order date of 08/17/2021. Review of the facility's Provider Investigation Report involving Resident #1 dated 02/04/24 reflected, .Incident date 02/02/24 at 6:50 PM revealed local PD reported that family member of roommate to Resident #1 had made an allegation of possible sexual abuse to resident #1 based on camera footage. Local PD came to the facility. Investigation initiated by PD and facility. Employee suspended. MD notified, Resident #1's family notified and came to the facility. DON assessed Resident #1 with RP present at the bedside. No destress or change in behavior noted upon assessment. Resident #1 was sent to the hospital for SANE exam, and she returned back to the facility with no new orders. Every shift observation put in place to monitor for any behavioral, cognitive changes. Resident #1 was seen by MD and Psychiatric with no new orders. Police initial request was to hold off on staff interviews until further directive. On 2/5/24 detectives arrived in the facility to continue investigation. At this time, permission was given to interview staff but advised we could not contact the accused. On 2/6/24, the PD disclosed to the Administrator that the Alleged Perpetrator had been arrested in connection with this allegation. Provider response included in-service on abuse/neglect completed, QAPI was held on 2/6/24, and resident safe survey was completed. The Investigation Summary revealed after reviewing the findings, it is summarized that the facility has confirmed that abuse occurred. Record review of a camera video footage, dated 02/02/2024 not timed, reflected CNA A removed Resident #1 brief. He moved Resident #1 to the edge of the middle of the bed. Resident #1 was lying on her back with legs extended in an upright position. CNA A was facing the resident in a standing position between the legs. CNA A was observed putting his hands on the shoulders of the resident to pull her closer to him. CNA A moved in a repetitive forward motion and the resident moving with the motion. The resident was heard making unintelligible sounds on the video. CNA A then placed the brief on the resident, repositioned her in the bed and left the room. Record review of Resident #1's nurses note dated 02/04/24 electronically signed at 08:52 AM revealed on 02/03/24 at 11:20 PM DON went to Resident #1 room with RP at the bed side. The DON did head to toe skin assessment with no open areas or concerns noted. Record review of Resident #1's pain risk assessment dated [DATE] reflected pain intensity of 0 Record review of Resident #1 medical record reflected Resident #1 was sent to the hospital on [DATE] at 11:45 PM Record review of Resident #1's emergency room Hospital Records, dated 02/04/24, reflected the following: [AGE] year-old female with past medical history of dementia presented to the emergency department for SANE exam. Visit Diagnosis: Abrasion of labia. Record review of Resident #1's hospital records dated 02/04/24 reflected the following: RN assisted SANE nursing in cleaning and changing Resident #1, rash visible around groin and genital area. Resident #1 seen scratching multiple times throughout process. Record review of Resident #1's hospital records dated 02/04/24 reflected Resident #1 was discharged from the hospital, on 02/04/24, back to the facility. In an interview on 02/05/24 at 10:15 AM, the Administrator stated the DON got the call from RN E on 02/03/24 at 9:50 PM, police officer in the facility. Around 9:30 to 10 PM he was in the building. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676096 If continuation sheet Page 2 of 5 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 02/07/2024 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few The officer told him on the phone he had evidence of sexual potential assault. By the time Administrator got to the facility CNA A had already left. The officer would not share the video with the facility. The facility requested the video from Resident #1's roommate's family member. The facility notified Resident #1's RP. They were in the facility 15 - 20 min later. The DON went with the RP to Resident#1's room. Assessment reflected redness could be from the brief. Resident#1 transferred to Baylor [NAME] & with Medical Center. The facility talked to the RP on Sunday 02/03/24, she said at the hospital they did the exam at 4:00 AM on Sunday. Resident came back the same morning. The facility received the video on 02/04/24 at 12:56 PM In an interview on 02/05/24 at 11:21 AM, Resident #1's roommate's family member stated Resident #2 called her on the phone on 02/03/24 and told her she heard, last evening, sexual comments between Resident #1 and a CNA. The family member stated she looked at the camera, she observed inappropriate act from the CNA. She stated she took the camera footage to the police station. The officer watched the camera footage with other officers, and they went to the facility. In an interview on 02/05/24 at 12:46 PM, Detective C assigned to the case requested to hold off on staff interviews until further directive. On 2/5/24 at 2:35 PM, Detective C arrived in the facility to continue investigation. At this time, permission was given to interview staff, but he advised not to contact CNA A. On 02/05/24 at 2:40 PM, attempted to interview Resident #1, she responded illogically to most questions asked of her or did not respond at all. When attempted to discuss the recent sexual abuse allegation Resident #1 responded with unmeaningful words. On 02/05/24 at 2:45 PM, RN E stated he worked on 02/03/24 from 2 PM to 10 PM. RN E stated around 9:50 PM a police officer approached him and asked him about the manager. RN E called the DON. RN E did not know why the police where in the facility, he stated couple minutes later the DON, and the Administrator came to the facility. RN E stated he was not assigned to Resident #1. In an interview on 02/07/24 at 9:00 AM, Administrator stated, on an interview on 02/06/24, Detective C told him CNA A admitted he attempted to sexually assault Resident #1. He told him CNA A was arrested on 02/05/24. On 02/07/24 at 11:06 AM attempted to call Detective C; left message. Observation on 02/07/24 at 11:25 AM with CNA F who performed incontinent care for Resident #1 revealed redness to the left inner thigh at brief lining area. In an interview on 02/07/24 at 1:12 PM, Resident #1' RP stated the police department called her and informed her CNA A was arrested on 02/05/24 because he confessed to the sexual act. Review of CNA A's timesheets reflected he worked on 02/02/24 from 1:54 PM to 10:09 PM. Record review of Resident #1 psychiatric services note dated 02/06/24 revealed Resident #1 was seen for trauma/stressor related disorders, issues with trauma. The report stated Resident #1 was the recent victim of possible sexual assault. The report indicated Resident #1 was very confused with severe cognitive impairment. The document was signed by PA B (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676096 If continuation sheet Page 3 of 5 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 02/07/2024 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 0600 Review CNA A's personal file reflected no barrier for employment: Level of Harm - Immediate jeopardy to resident health or safety - Residents Affected - Few - Criminal history conviction name search on 12/19/22 - No search results found. Nurse aide: NA certification status: Active. Certification number: NA0008319536. Issue date: 4/27/2005. Expiration: 6/12/2025 Texas HHS Employability status check search results date 12/19/2022: Unemployable? NO. NAR status: Active. NAR active unemployable: NO. MAR status: Active. Incident on the EMR: NO No result found for CNA A. Annual checklist: Office of inspector general: 11/22/23 DADS Employability status: 11/22/23 DPS CCH Verification: 11/22/23 Performance Evaluation: 11/20/23 Compliance Code of Conduct Certification: 11/20/23 In-Services: Abuse - 10/13/23, Abuse - 12/20/22, Abuse - 12/1/23, Abuse - 1/26/24. In an interview on 02/07/24 at 1:17 PM, the Administrator revealed CNA A was suspended on 02/03/24 and terminated on 02/04/24. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676096 If continuation sheet Page 4 of 5 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 02/07/2024 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few In an Interview on 02/07/24 at 1:25 PM, the DON stated she never got any complaint about CNA A. She stated some family members requested him to assist there loved one. She stated she watched the video, and it was disturbing. She stated all staff had been in serviced on abuse neglect before they start their shift. Review grievance log for last 3 months reflected no grievance about CNA A. An impromptu Quality Assurance and Performance Improvement was completed on 02/06/24 with the MD, Psych, Psychology, Administrator, DON, and Social Worker. Review of facility's in-services to nursing staff dated 02/03/24 to 02/05/24 reflected eleven nurses and twelve CNAs were in-serviced on Abuse and neglect reporting and prevention. Individual interviews with LVNs, RNs, CNAs, and MA from different shifts (LVN G, LVNH, LVN I, RN J, RN E, RN K, CNA L, CNA F, CNA M, CNA N, CNA O, CNA P, CNA Q, CNA R, and MA S) on 02/05/24 and 02/07/24 revealed they had received in-service training on abuse and neglect. All staff were able to verbalize understanding of in-service training regarding abuse and sexual abuse. Review of the facility's policy titled Abuse, Neglect and Exploitation and Misappropriation of Resident Property, dated 06/23/2017 and reviewed 02/12/2020 reflected, .1. Each resident has the right to be free from abuse, neglect, exploitation, misappropriation of resident's property, corporal punishment, and involuntary seclusion. Residents must not be subjected to abuse, neglect, exploitation, misappropriation of resident's property by anyone, including, but not limited to, facility staff, other residents, consultants, volunteers, staff of other agencies serving the resident, family members Definition of abuse: The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish . Sexual abuse: Includes, but is not limited to, sexual harassment, sexual coercion, or sexual assault. On 02/07/24 at 4:40 PM the Administrator was informed an Immediate Jeopardy was determined to have existed from 02/02/24 to 02/04/24. The IJ was determined to have been removed on 02/04/22 due to the facility's implemented actions that corrected the non-compliance prior to the beginning of the investigation on 02/05/24. On 02/08/24 at 2:30 PM, Detective D stated she was calling from Detective C's office. She stated they arrested CNA A on 02/25/24, and he was in jail. She stated, he admitted it. The detective was very short on the information she provided. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676096 If continuation sheet Page 5 of 5