Health inspection·April 23, 2025

F 0695 Observation on 04/23/2025 at 9:39 AM revealed Resident #1's breathing mask was inside a plastic bag. Level of Harm - Minimal harm or potential for actual harm In an interview on 04/23/2025 at 11:19 AM, ADON A stated the breathing mask was supposed to be in a bag when the resident was not using it to prevent cross contamination and worsening of any respiratory issues. She said the expectation was for the staff to be mindful and make sure the breathing was bagged after administering the breathing treatment. She said it did not matter if the order was daily or as needed, the breathing mask must be in a plastic bag to keep it clean. She said he would conduct an in-service about respiratory care specifically about bagging; not just the breathing mask but also the nasal cannula, yankauer, and CPAP masks. Residents Affected - Few In an interview on 04/23/2025 at 12:35 PM, the Administrator stated everything the residents were using should be kept clean to prevent infection. He said he would coordinate with the ADON to educate and re-educate the nursing staff to bag the breathing mask if not in use. In an interview on 04/23/2025 at 12:18 PM, LVN C stated she was the one providing Resident #1's breathing treatment. She said she had not given the resident's breathing treatment for the day because the resident was done with her breakfast. She said she saw the breathing mask during her round, but it did not occur to her to bag it or change it. She said, most probably, she forgot to bag the breathing mask when she took it off the day prior. She said the breathing mask should be in a bag when the resident was not using it to prevent infection. She said she changed the breathing mask before administering the resident's breathing treatment and placed it in a bag after the treatment was done. Record review of the facility's policy, Oxygen Therapy - Discontinuation clinical operations revised January 12, 2020 revealed Procedures: 6. Remove cannula prong or mask from humidifier or regulator. (Discard if oxygen is not to be given again; or place in plastic bag if oxygen is to be administered on a PRN basis. Label and date.). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676096 If continuation sheet Page 2 of 4 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 04/23/2025 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 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 one (Resident #2) of 2 residents reviewed for Infection Control. Residents Affected - Few The facility failed to ensure CNA B performed hand hygiene and changed her gloves while providing incontinent care to Resident #2 on 04/23/2025. This failure could place residents at risk of cross-contamination and development of infections. Findings included: Record review of Resident #2's Face Sheet, dated 04/23/2025, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. The resident was diagnosed with urinary tract infection. Record review of Resident #2 Quarterly MDS Assessment, dated 01/23/2025, reflected the resident was cognitively intact with a BIMS score of 14. The Quarterly MDS Assessment indicated the resident was dependent on staff for toilet hygiene. Record review of Resident #2's Comprehensive Care Plan, dated 02/05/2025, reflected the resident was at risk for problems with elimination and one of the goals was to assist the resident with incontinence. Observation on 04/24/2025 at 10:31 AM revealed CNA B was about to transfer Resident #2 to his wheelchair. She said she would do incontinent care first before the transfer. CNA B washed her hands, put on a pair of gloves and a gown. She unfastened the resident's brief and pushed it between the resident's legs. CNA B then went at the foot of the bed and took the trash can and placed it beside her. She proceeded to clean the resident's perineal area (area between the legs). After cleaning the perineal area, she went to the resident's closet and took a brief. After taking the brief from the closet, she opened it and put it beside the resident. She did not change her gloves after touching the trash can, before cleaning the resident's perineal area, and before touching the new brief. She rolled the resident and cleaned the resident's bottom. After cleaning the resident's bottom, she pulled the soiled brief, and threw it on the trash can. She then took the new brief from the resident's side, put it under the resident, and fixed it. She did not change her gloves and sanitized her hands after cleaning the bottom and before touching the new brief. After fixing the brief, she took off her gloves, and washed her hands. In an interview on 04/23/2025 at 11:01 AM, CNA B stated she should have changed her gloves after touching the trash can because the trash can was obviously dirty. She said she also should have changed her gloves after cleaning the perineal area and before opening the new brief. She also said she also should have changed her gloves after cleaning the resident's bottom and before touching the new brief again. She said she did not do any hand hygiene all throughout incontinent care. She said she would be mindful to change her gloves after touching something dirty and do hand hygiene. In an interview on 04/23/2025 at 11:19 AM, ADON A stated CNA B told her she did not change her gloves during Resident #2's incontinent care. She said she reminded CNA B to change her gloves after (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676096 If continuation sheet Page 3 of 4 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 04/23/2025 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 - Few touching something dirty or presumed dirty to prevent cross contamination and urinary tract infection. She said she also reminded CNA B to do hand hygiene during incontinent care. She said the expectation was for the staff to change their gloves form dirty to clean and to do hand hygiene as appropriate. She said she would do a one-on-one in-service with CNA B and then would also do an in-service for all the staff. In an interview on 04/23/2025 at 12:35 PM, the Administrator stated not changing the gloves when going from soiled to clean, could contribute to cross contamination and infection. He said the expectation was for the staff to follow the policy and procedures pertaining to infection control. He said the ADON already did a one-on-one in-service for CNA B and would also in-service all the staff about infection control. Record review of the facility's policy, Hand Hygiene for Staff and Residents Infection Control revised February 2025 revealed Purpose: To reduce the spread of infection with proper hand hygiene . Policy: Proper hand hygiene technique is completed whenever hand hygiene is indicated . Procedure: . After . A. contact with soiled or contaminated articles, such as articles that are contaminated with body fluids . C. contact with a contaminated object or source where there is a concentration of microorganisms . H. removal of medical/surgical or utility gloves. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676096 If continuation sheet Page 4 of 4