Health inspection·June 26, 2025

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few In an observation and interview on 6-24-2025 at 11:50 AM, dried food regurgitation was seen on both sides of Resident #52's bed. Resident #52 was observed to be the sole resident in his room. Resident #52 was not able to communicate how long the regurgitated food was on the floor but said it made him feel nasty because it had been there a while. In an observation on 6-24-2025 at 2:40 PM, it was witnessed that the dried regurgitated food, next to Resident #52's bed, had not been cleaned up since 11:50 AM. In an interview with CNA E, on 6-24-2025 at 2:40 PM, it was learned that CNA E had worked the hallway where Resident #52 resided and had worked at the facility for 3 weeks. CNA E said she was unaware that throw-up was on the floor in Resident #52's room. CNA E said the facility had a housekeeping department that cleaned the resident's rooms every day. CNA E said the CNAs were responsible to ensure resident's rooms were kept clean and free from food or liquids on their floors. CNA E said the potential harm to residents if their floors were not kept free of regurgitated food was a slippery floor and it could cause them to feel neglected. In an interview with LVN F, on 6-26-2025 at 1:35 PM, it was learned that LVN F was working the hallway where Resident #52 resided and had worked at the facility for 1 year. LVN F said the CNAs make rounds from time-to-time to make sure resident's rooms stay clean. LVN F said the nurses made rounds to ensure the cleanliness of resident's rooms as well. LVN F said the housekeeping department made rounds in the morning to clean resident's rooms then they were on PRN standby status to respond as needed by other staff to clean resident's rooms. LVN F said she expected the CNAs to make rounds to ensure spills and throw-up messes were cleaned in resident's rooms in a timely manner. LVN F said CNAs and housekeeping were responsible to ensure resident's rooms stay clean. LVN F said the nursing staff supervised the CNA staff. In an interview with the DON, on 6-26-2025 at 4:24 PM, it was learned the DON had worked at the facility for 6 months. The DON said the facility had a housekeeping department for cleaning, however, her expectations were for CNAs and nurses to make rounds and report debris on the floors to the housekeeping department for cleaning. The DON said her expectation was for staff to clean resident's rooms as soon as they see spills or food debris on the floors. The DON said the potential risk to residents not having throw-up cleaned off their floors, in a timely manner, was it could cause a fall or become an infection control issue. In an interview with the Administrator, on 6-26-2025 at 4:38 PM, it was stated the housekeeping depart was responsible to keep resident rooms clean. The Administrator said any staff who see food or liquid on the floor, in resident's rooms, should contact the housekeeping department for cleaning. The Administrator said floor staff and managers were supposed to make rounds to ensure floors were kept clean in a timely manner. The Administrator stated that he expected floors to not have debris on them for over an hour. The Administrator said the potential risk to residents having spills or regurgitation on their floors was not having a clean and comfortable environment. The Administrator said he was going to start in-services on timely cleaning of resident rooms. Record review of the facility's Grievance Log, for the past 90 days, revealed a complaint was made regarding the condition of a resident's room on 6-23-2025. Record review of the facility's non-dated policy entitled Resident Rights stated: The resident has a right to a dignified existence, self-determination, and communication with and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676098 If continuation sheet Page 2 of 21 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 676098 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Plaza at Richardson 1301 Richardson Dr Richardson, TX 75080 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 - Few access to persons and services inside and outside the facility, including those specified in this policy. A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident . Safe environment - The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. The facility must provide-- 1. A safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible . 2. Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676098 If continuation sheet Page 3 of 21 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 676098 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Plaza at Richardson 1301 Richardson Dr Richardson, TX 75080 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to must ensure that a resident who is continent of bladder and bowel on admission receives services and assistance to maintain continence unless his or her clinical condition is or becomes such that continence is not possible to maintain for one (the only medication room) of one medication rooms reviewed for pharmacy services. The facility failed to ensure expired gentle female intermittent catheters were removed from the facility's only medication room on [DATE]. These failures could place residents at risk for infection and possible adverse effects. Findings included: In an interview and observation on [DATE] at 09:10 a.m., expired supplies found stored in the medication room included: 75 count - Gentle Cath Female Intermittent Catheters, unopened, manufacturer expiration date of 06-01-24 LVN A was present and stated that the medication room should have been audited for expired supplies by an ADON each day and that all expired supplies should have been disposed of. She stated that the DON was responsible for monitoring to ensure that this took place. She stated that the risk to residents of expired medical supplies was infection. She then took and disposed of the expired supplies. In an interview on [DATE] at 10:20 a.m., the ADM reported that the medication room was to be audited for expired supplies and medications twice weekly by Central Supply Personnel B. He reported that on the other days the supply room was audited by the ADONs. He reported that any expired medication should have been removed and discarded immediately. The ADM reported that the facility DON monitored to ensure the auditing was completed. He reported that while he did not fully understand the risks to residents regarding expired supplies, he understands that over time materials can degrade. In an interview on [DATE] at 10:50 a.m., the DON stated medication room supplies were audited for expiration dates by Central Supply Personnel B. She stated on other days the ADONs audited the medication room for expired supplies, and that she herself as the DON monitored the overall auditing. She stated the presence of expired supplies was maybe an oversight and that she had not been aware of their presence. She stated the risk to the resident of expired supplies was, possibly side effects and stated, the manufacturer writes that date there for a reason. In an interview on [DATE] at 11:05 a.m., Central Supply Personnel B stated he was responsible for monitoring the medication room for expired supplies. He reported he did a clean sweep once a month in which he removed all expired supplies. He stated that he also monitored expired supplies twice weekly as he was ordering supplies. He stated he had not been aware of the presence of the expired supplies. He stated he threw away any expired supplies immediately. He stated, the nurses also monitor for expired supplies and nurses are in there every day. He reported that, we don't want to use compromised materials with the resident. There was a reason for the manufacturer's expiration date. We want the full effect of what we are using it for. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676098 If continuation sheet Page 4 of 21 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 676098 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Plaza at Richardson 1301 Richardson Dr Richardson, TX 75080 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 In an interview on [DATE] at 1:13 pm, RN C reported that the facility did not have a policy that specifically covered expired medical supplies. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676098 If continuation sheet Page 5 of 21 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 676098 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Plaza at Richardson 1301 Richardson Dr Richardson, TX 75080 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 0694 Provide for the safe, appropriate administration of IV fluids for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure parenteral fluids must be administered consistent with professional standards of practice and in accordance with physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences for one (the only medication room) of one medication rooms reviewed for pharmacy services. Residents Affected - Few The facility failed to ensure expired IV/PICC supplies were removed from the facility's only medication room on [DATE]. These failures could place residents at risk for infection and possible adverse effects. Findings included: In an interview and observation on [DATE] at 09:10 a.m., expired supplies found stored in the medication room included: 1 count - Insyte Autoguard IV Catheter 24 Gauge, unopened, manufacturer expiration date of 08-2018 8 count - Insyte Autoguard IV Catheter 24 Gauge, unopened, manufacturer expiration date 12-01-21 17 count - Insyte Autoguard IV Catheter 20 Gauge, unopened, manufacturer expiration date of 03-01-22 3 count - Insyte Autoguard IV Catheter 20 Gauge, unopened, manufacturer expiration date of 02-01-24 1 count - Invision Plus Needleless IV Connector, unopened, manufacturer expiration date of 07-01-23 1 count - Invision Plus Needleless IV Connector, unopened, manufacturer expiration date of 02-01-24. 1 count - Stat Lock PICC Plus Stabilization Device, unopened, manufacturer expiration date of 04-28-24 1 count - Stat Lock PICC Plus Stabilization Device, unopened, manufacturer expiration 10-28-23 LVN A was present and stated that the medication room should have been audited for expired supplies by an ADON each day and that all expired supplies should have been disposed of. She stated that the DON was responsible for monitoring to ensure that this took place. She stated that the risk to residents of expired medical supplies was infection. She then took and disposed of the expired supplies. In an interview on [DATE] at 10:20 a.m., the ADM reported that the medication room was to be audited for expired supplies and medications twice weekly by Central Supply Personnel B. He reported that on the other days the supply room was audited by the ADONs. He reported that any expired medication should have been removed and discarded immediately. The ADM reported that the facility DON monitored to ensure the auditing was completed. He reported that while he did not fully understand the risks to residents regarding expired supplies, he understands that over time materials can degrade. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676098 If continuation sheet Page 6 of 21 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 676098 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Plaza at Richardson 1301 Richardson Dr Richardson, TX 75080 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 0694 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few In an interview on [DATE] at 10:50 a.m., the DON stated medication room supplies were audited for expiration dates by Central Supply Personnel B. She stated on other days the ADONs audited the medication room for expired supplies, and that she herself as the DON monitored the overall auditing. She stated the presence of expired supplies was maybe an oversight and that she had not been aware of their presence. She stated the risk to the resident of expired supplies was, possibly side effects and stated, the manufacturer writes that date there for a reason. In an interview on [DATE] at 11:05 a.m., Central Supply Personnel B stated he was responsible for monitoring the medication room for expired supplies. He reported he did a clean sweep once a month in which he removed all expired supplies. He stated that he also monitored expired supplies twice weekly as he was ordering supplies. He stated he had not been aware of the presence of the expired supplies. He stated he threw away any expired supplies immediately. He stated, the nurses also monitor for expired supplies and nurses are in there every day. He reported that, we don't want to use compromised materials with the resident. There was a reason for the manufacturer's expiration date. We want the full effect of what we are using it for. In an interview on [DATE] at 1:13 pm, RN C reported that the facility did not have a policy that specifically covered expired medical supplies. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676098 If continuation sheet Page 7 of 21 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 676098 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Plaza at Richardson 1301 Richardson Dr Richardson, TX 75080 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to store all drugs and biologicals in locked compartments and to permit only authorized personnel to have access to one medication cart of four medication carts observed for medication security, and for one medication in one of two common areas observed for medication security. 1. The facility failed to keep a dialysis medication cart locked in Resident #40's room. On 6/24/25 at 4:00 pm an unlocked dialysis medication cart containing intravenous medications was observed in Resident #40's room and unlocked dialysis fluids were observed in the room. 2. The facility failed to keep one medication (Advair Diskus) secured in a common area near the nurse's station . On 6/24/25 at 9:06 am an unlocked and unattended Advair Diskus was observed in the common area This failure could affect residents by placing them at risk of injury or harm of adverse medication reactions or side effects and placing the facility at risk for possible drug diversion. Findings included: In a record review of Resident #40's Quarterly MDS dated [DATE], Resident #40 was noted with a diagnosis of End-Stage Renal Disease (kidney failure) with dependence on renal dialysis. His BIMs score was 1, indicating severe cognitive impairment. In an observation and interview on 6/24/25 at 04:00 pm, Resident #40 was observed with an unlocked medication cart in his bedroom which contained: Heparin 30,000 units per ml, 30 ml vial, 12 unopened vials and 2 opened vials Zemplar 2 mg/ml, 1 ml vial, 41 unopened vials Observed sitting on Resident #40's bedroom floor: RenalPure Liquid Acid 1 Gallon plastic jugs, 2 opened jugs and 5 unopened jugs Resident #40 reported that an outside agency had used the medication cart and dialysis fluids to provide him with in-room dialysis. He stated he had not been aware that the medications and fluids were unlocked. He stated only the dialysis nurse accessed these medications and dialysis fluids. In an interview on 6/24/25 at 04:15 pm, RN C stated he had not been aware of the unsecured medications and dialysis fluids in Resident #40's room. He reported that Resident #40 received dialysis from a contracted agency, and that the dialysis nurses as well as the facility nurses were both (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676098 If continuation sheet Page 8 of 21 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 676098 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Plaza at Richardson 1301 Richardson Dr Richardson, TX 75080 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some responsible for ensuring that the medications remained securely locked. He reported that the medications being left unlocked were a risk to residents and could hurt them but was unsure what the exact chemicals and medications might cause. In an interview on 6/24/25 at 04:20 pm, the DON stated the contract dialysis nurse, and the facility nursing staff were responsible for having kept the medications in Resident #40's room locked. She stated that she herself and the ADONs made environmental rounds in the mornings and would monitor for unsecured medications, and she believed this was an oversight. She stated any unsecured medications that were found would have been immediately secured, and in-service staff training would have been done had any unsecured medications been found. She stated that if a resident had accessed these medications, they could have been injured or had a reaction. She stated that staff had received training quarterly and as needed on the need to securely lock medications. In an interview on 6/25/25 at 09:20 a.m., LVN D reported she was the dialysis nurse for Resident #40 today (6/25/25). She reported that she had always locked Resident #40's medications and dialysis fluids, and she stated, the medications should remain locked so that another resident doesn't wander in and could get hurt. She reported that the nurses are responsible for keeping medications locked, and she had received training on this. In an observation on 6/24/25 at 09:06 a.m., an unattended, unlocked/unsecured, opened, box of Fluticasone propionate/salmeterol diskus inhalation (Advair Diskus) was observed sitting in the basket of the vital sign machine against the wall near the nurse's station. The Diskus showed 57 doses remaining. Resident label was not observed. No staff or residents were observed in the immediate area. LVN A entered the area at approximately 9:08 am. In an interview on 6/24/25 at 09:08 a.m., when LVN A was shown the unlocked and unattended Advair Diskus she stated, That should not be there and it should be locked on a cart. She reported that nurses and medication aides were responsible for keeping medications secure. She stated the risk of unsecured medications to residents is, a resident could get it. She took the medication out of the basket to place it in a medication cart. In an interview on 6/24/25 at 10:20 a.m., the ADM stated, there is no excuse for the Advair Diskus to have been left unsecured and that nurses and medications aides were responsible for maintaining the security of each of their own carts. He stated that DONs and ADONs made rounds each morning to monitor the environment, including monitoring for the presence of unsecured medications. He stated the risk to the resident would, depend on the type of medication but that, any resident could grab it and have adverse reactions. In an interview on 6/24/25 at 10:50 a.m., the DON stated that nurses and medications aides were responsible for maintaining medications in a locked manner. She stated that she made environmental rounds each morning and monitored for any unsecured medications but that she had been running today (6/24/15). She stated that the risk of an unsecured medication was that it could have been lost, and that the wrong resident could have taken it and experienced an allergic reaction. She stated that all nurses and medication aides have received training on the need to keep medications securely locked and that this training was done quarterly and as needed. In a record review of the facility policy titled, PCU027-Medication Storage in the Facility dated 2025, the policy reflected, Medications and biologicals are stored safely, securely, and properly following manufacturer's recommendations or those of the supplier. The medication supply is accessible (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676098 If continuation sheet Page 9 of 21 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 676098 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Plaza at Richardson 1301 Richardson Dr Richardson, TX 75080 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 only to license nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. 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: 676098 If continuation sheet Page 10 of 21 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 676098 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Plaza at Richardson 1301 Richardson Dr Richardson, TX 75080 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 observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen. Residents Affected - Many 1. The facility failed on 06/24/2025 to ensure the stand-by refrigerator opened food items were dated. 2. The facility failed to ensure the walk-in refrigerator food items were dated, labeled and securely stored. 3. The facility failed to ensure the walk-in freezer food items were dated and labeled. 4. The facility failed to ensure the dry storage food items were dated and labeled. 5. The facility failed to ensure that canned good food items were free of dents. 6. The facility failed to ensure that dishwashing protocol was followed. 7. The facility failed to ensure that prepared foods were held correctly and maintained safe temperatures. These failures could place residents at risk for foodborne illnesses and foodborne intoxication. Findings included: Observation on 06/24/2025 at 8:55AM upon entry to the kitchen revealed the following: In the stand-by refrigerator, a carton of soy milk beverage with a broken seal and a manufacturer statement of after opening . use within 7-10 day and with no opened on and use by date. Observation on 06/24/2025 of the walk-in refrigerator at 9:00AM revealed the following: A plastic bin of russet potatoes with no label and use by date. A zip closure bag of carrots with one molding carrot, no label, and no use by date. A zip closure bag of bread with no label of the type of bread and no use by date. A saran wrapped package of cinnamons rolls with no label and no use by date. A saran wrapped bag of mozzarella cheese, dated 5-29-25 with no use by date. An unsealed zip close bag of sliced cheese with condensation moisture in the bag, dated 5/4/25 with no use by date. Observation on 06/24/2025 at 9:03AM of the walk-in freezer revealed the following: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676098 If continuation sheet Page 11 of 21 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 676098 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Plaza at Richardson 1301 Richardson Dr Richardson, TX 75080 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 A saran wrapped bag of frozen vegetable medley with no use by date. Level of Harm - Minimal harm or potential for actual harm A frozen bag of sliced sausage covered in ice crystals, with no label of the type of sausage and no use by date. Residents Affected - Many An unsealed bag inside a box labeled hot water cornbread and dated 5-22-25, with no use by date. Observation on 06/24/2025 at 9:07AM of the dry storage closet revealed the following: A dented can of yams dated 3-6-25. A saran wrapped bag of uncooked macaroni noodles with no use by date. A saran wrapped bag of dry cake mix dated 3-20-25 with no use by date. A saran wrapped bag of roast beef flavored gravy mix dated 4-10-25 with no use by date. An interview on 06/24/2025 at 9:10AM with the DM revealed that the saran wrapped bag of cake mix was cherry cake mix. He stated the date on the bag indicated delivery date and that he had not known when it was originally opened. The DM stated that the risk of a dented can was that the seal can become broken and the canned good can be contaminated and unsafe to eat (foodborne illness). Observation on 06/24/2025 at 11:36AM upon entry in the kitchen revealed the following: Banana pudding cups with wafer sitting on trays for lunch. Fried chicken uncovered on the steam tray line. Observation and interview on 06/24/2025 at 11:40AM of the 3-compartment sink revealed the following: The 1st compartment, for washing dishes, only contained an empty 4-quart plastic container and stainless-steel bowl sitting in it. The stainless-steel bowl had soapy water in it. The 2nd compartment, for rinsing dishes, had a 7.5-quart plastic container filled with water and a large metal serving spoon sitting in it; food particles were observed in the bottom of the 2nd compartment. The 3rd compartment was empty. At this time, the assistant dietary manager picked up the serving spoon from the bottom of the 2nd compartment and began to walk to the steam tray line. This surveyor intervened and asked what the serving spoon was going to be used for. The assistant dietary manager stated it was for stirring green beans. This surveyor asked if the serving spoon had been cleaned, and the assistant dietary manager stated that she had washed it. This surveyor further asked if she had sanitized the spoon, and she stated, not yet. This surveyor pointed out the food particles at the bottom of the sink. The assistant dietary manager proceeded to turn on the sanitizing solution dispenser and use the sanitizer solution dispenser tube to cover the serving spoon in sanitizer. This surveyor asked how the 3-compartment sink was used; the assistant dietary manager stated she washes dishes in the 1st compartment, rinses dishes in the 2nd compartment, and sanitizes dishes in the 3rd compartment. When asked if using the tube to disperse sanitizing solution on the dishes was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676098 If continuation sheet Page 12 of 21 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 676098 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Plaza at Richardson 1301 Richardson Dr Richardson, TX 75080 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 the correct way to sanitize dishes. She explained that sanitizing solution was diluted with water and that the dip test paper strip to check sanitizing solution concentration was supposed to be yellow-green colored. At this time, the assistant dietary manager and DM placed a drain stopper in the sink and filled the sink with the sanitizing solution. A dip test strip to test the concentration; the test strip revealed a green blue color. The DM stated that he checks the sanitizing solution concentration daily. When the DM was asked what the solution concentration should be, he stated 200 ppm but the diagram says 150 ppm. The DM further stated it was expected that after rinsing, dishes should be immersed in sanitizing solution for 10 seconds. He pointed out the instructional diagrams on the wall behind the 3-compartment sink that were provided by the chemical supply company and discussed they should be utilized. Record review on 06/24/2025 at 11:57 PM of the instructional diagrams provided by the dishwashing chemical supply company posted on the wall behind the sink reflected: The Three-Compartment Sink Procedure instructed the 2nd compartment to be filled with hot water and rinse all items in clean hot water. The 3rd compartment instructed to be filled with proper sanitizer solution; completely immerse (dishes) in the sanitizer solution for at least one minute. The Sanitize Test Procedure instructed to dip test paper in sanitizing solution for 10 seconds and compare strip to color chart on test paper dispenser (color chart on dispenser to compare to quaternary ammonia sanitizing solution concentration). Further instructions reflected the test paper must read 150-400 ppm (0 ppm - red, 150 ppm - yellow-orange, 200 ppm - dark yellow, 400 ppm - yellow-green, 500 ppm green-blue). Observation and interview on 06/24/2025 at 12:05PM with the DM revealed that he filled the 3rd compartment of the sink with the sanitizing solution and was able to show a dark yellow colored test strip result. He explained that he added water the sanitizing solution to achieve the right concentration. He further stated it's important to have the right concentration. He explained that if not enough sanitizer is used, dishes can carry pathogens; if too much sanitizer was used on dishes, it can make residents sick (foodborne intoxication). Observation and interview on 06/24/2025 at 12:13PM with the assistant dietary manager revealed the following: The assistant dietary manager had prepared to plate food from the stream tray table. This surveyor intervened and asked was going to check the holding temperatures of food items on the steam tray table before plating. She stated she had already checked food temperatures after food were cooked, but not the temperature the foods were held at. She proceeded to check the holding temperatures of the food items on the steam tray table. The temperature of the pureed pinto beans was 100°F. The temperature of the banana pudding cups with wafers was 59.7°F The assistant dietary manager stated that the holding temperature for hot foods should be 145°F. Interview on 06/24/2025 at 12:20PM with the DM revealed that holding temperatures for cold foods should be 41°F or lower. He did not know how long the banana pudding cups had sat out, and that (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676098 If continuation sheet Page 13 of 21 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 676098 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Plaza at Richardson 1301 Richardson Dr Richardson, TX 75080 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 oatmeal cream pies would be used as a substitute for the banana pudding cups. He stated the importance of foods meeting temperatures as required was for palatability, taste, and to make sure foods are properly cooked for safety. Interview on 06/26/2025 at 10:30AM with the registered dietitian revealed she had done in-service training regarding the food temperatures checks. She stated temperatures checks were expected to be done prior to serving food from the steam tray line. Hot held foods should be 135°F or hotter, and cold foods should be 41°F or less. She further explained if hot foods are not 135°F or hotter, they must be reheated to at least 165°F, and cold foods should be kept on ice. She stated the importance of meeting these temperatures was for food palatability, taste, and safety; if foods are not kept at the appropriate temperatures, they can grow bacteria, leading to foodborne illness. Interview on 06/26/2025 at 12:20PM with the DM revealed the expectation for temperature checks for foods on the steam tray table and cold foods was to be done prior to plating foods. He stated the expectation for using the 3-compartment sink was for it to be used as directed on the instructional diagrams and for dishes to be submerged in the sanitizing solution. When asked if the assistant dietary manager should have attempted to use the serving spoon, the DM stated she should not have and he expected it to sanitized prior to use. He explained these expectations are important to follow because of the bacteria risk to residents. He stated that since 06/24/2025, he in-serviced the assistant dietary manager on how to use the 3-compartment sink and temperature checks. Record review of the facility's Equipment Sanitation Policy dated 2012 reflected: We will provide clean and sanitized equipment for food preparation. The facility will clean all food service equipment in a sanitary manner. Procedure: . 6. Pots and Pans: a. Manual dishwashing of pots, pans and equipment: Three compartment sinks should be used. b. Prior to washing, all utensils and equipment shall be pre-scraped or pre-flushed and, when necessary, pre-soaked to remove gross waste. c. Effective concentration of a suitable detergent shall be used. d. This detergent solution shall be kept reasonably clean. e. All equipment and utensils shall be thoroughly rinsed free of the detergent solution. f All equipment and utensils shall be sanitized by one of the following methods: g. Immersion for at least one-half minute in clean, hot water at a temperature of at least 180 degrees F. h. Immersion for a period of at least one minute in a sanitizing solution containing: . - Any other approved chemical-sanitizing agent containing at least 150-400 ppm of quaternary ammonia at a temperature of approximately 70 degrees F. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676098 If continuation sheet Page 14 of 21 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 676098 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Plaza at Richardson 1301 Richardson Dr Richardson, TX 75080 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 7. Facilities shall use an approved test kit to measure the parts per million (ppm) of the chemical solutions in pot sinks on a daily basis. Records of test results should be kept on the temperature/chemical log. Any abnormal test results shall be reported to the Dietary Service Manager, and the solution shall not be used until at the correct ppm . Residents Affected - Many Record review of the facility's Food Storage and Supplies policy dated 2012 reflected: All facility storage areas will be maintained in an orderly manner that preserves the condition of food and supplies. We will ensure storage areas are clean, organized, dry and protected from vermin, and insects. Procedure: . 4. Open packages of food are stored in closed containers with covers or in sealed bags, and dated as to when opened . 6. When items are received from the vendor, they should be first examined for expiration date, and if an expiration date is present, it is beneficial to mark it by circling it so it is readily visible and noticeable . If an item does not have a date designated by the manufacturer as an expiration date, then the item should be dated as to when it is received, and shelf-stable items will be stored in a first in, first out manner, to be used within one year . 7. According to the USDA fact sheet on Food Product dating . products without a dated shipping label should be dated when they are received by the facility so there is a method to keep track of the age of the product. These dates do not indicate that the product is no longer safe after one year, but give a method to track the age of a product so that it can be evaluated for quality before service. 8. On perishable foods, microorganisms such as molds, yeasts, and bacteria can multiply and cause food to spoil. Spoiled foods will develop an off odor, flavor or texture due to naturally occurring spoilage bacteria. If a food has developed such spoilage characteristics, it should not be eaten . 9. Perishable and non-perishable foods are classified based on their pH and water content . These non-perishable foods are still dated when received if they do not have an expiration date and once opened, but do not need to be discarded within 7 days after opening. Perishable items that are refrigerated are dated once opened and used within 7 days (if they do not have an expiration date or best by/use by date), but non-perishable items that are refrigerated once opened should be dated when opened but do not need to be discarded until their expiration date or until the quality has deteriorated. 10. Frozen items that should be thawed before preparation should be stored under refrigeration until thawed, and should be dated with the date removed from the freezer and used within 7 days . If a frozen food does not have an expiration date or a dated shipping label it will be dated when received or is removed from original packaging . Record review of the U.S. FDA Food Code 2022 reflected the following: 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding. (A) Except during preparation, cooking, or cooling, or when time is used as the public health control as specified under §3-501.19, and except as specified under (B) and in (C) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: (1) At 57°C (135°F) or above . (2) At 5°C (41°F) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676098 If continuation sheet Page 15 of 21 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 676098 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Plaza at Richardson 1301 Richardson Dr Richardson, TX 75080 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 or less . Level of Harm - Minimal harm or potential for actual harm 3-602.11 Food Labels. (A) FOOD PACKAGED in a FOOD ESTABLISHMENT, shall be labeled as specified in LAW, including 21 CFR 101 - Food labeling, and 9 CFR 317 Labeling, marking devices, and containers . Residents Affected - Many 3-302.12 Food Storage Containers, Identified with Common Name of Food: Except for containers holding FOOD that can be readily and unmistakably recognized such as dry pasta, working containers holding food or food ingredients that are removed from their original packages for use in the food establishment, such as cooking oils, flour, herbs, potato flakes, salt, spices, and sugar shall be identified with the common name of the food. Section 3-501.17 . Commercial processed food: Open and hold cold . B . 1. The day the original container is opened in the food establishment shall be counted as Day 1. 2. The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety . C. 2. Marking the date or day of preparation, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (A) of this section. 3. Marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (B) of this section. Definitions 3 . Food Receiving and Storage - When food, food products or beverages are delivered to the nursing home, facility staff must inspect these items for safe transport and quality upon receipt and ensure their proper storage, keeping track of when to discard perishable foods and covering, labeling, and dating all PHF/TCS foods stored in the refrigerator or freezer as indicated . 4-501.114 Manual and Mechanical Warewashing Equipment, Chemical Sanitization - Temperature, pH, Concentration, and Hardness .A chemical SANITIZER used in a SANITIZING solution for a manual or mechanical operation at contact times specified under 4-703.11(C) shall meet the criteria specified under 7-204.11 Sanitizers, Criteria, shall be used in accordance with the EPA-registered label use instructions, P and shall be used as follows: . (C) A quaternary ammonium compound solution shall: (1) Have a minimum temperature of 24oC (75oF), P (2) Have a concentration as specified under § 7-204.11 and as indicated by the manufacturer's use directions included in the labeling . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676098 If continuation sheet Page 16 of 21 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 676098 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Plaza at Richardson 1301 Richardson Dr Richardson, TX 75080 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 observations, interviews, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for (Resident #65) one of one resident reviewed for infection control. Residents Affected - Few The facility failed to ensure CNA A performed hand hygiene while feeding lunch to Resident #65 on 06/24/25. This deficient practice could place residents at risk for infections. Findings included: Record review of Resident #65's face sheet, dated 06/25/25, reflected a [AGE] year-old male, with an admission date of 09/24/24. Resident #65 had diagnoses of Dementia (loss of memory, language, problem-solving and other thinking abilities), Muscle Wasting and Atrophy (loss of muscle mass and strength), Protein-Calorie Malnutrition (inadequate intake of food), Dysphagia (difficulty swallowing), Hypertensive Heart Disease (a condition where the heart is damaged to due to long-term high blood pressure), Cerebral Atherosclerosis (a buildup of fats, cholesterol, and other substances in the artery walls), Constipation (difficult -to-pass bowel movements), Pain (a signal in the nervous system that something may be wrong), Muscle Weakness (difficult for muscles to contract and move as they normally would), and Benign Prostatic Hyperplasia without Lower Urinary Tract (prostate gland enlarges). In an observation on 06/24/25 at 12:35 PM, CNA A was observed as she texted on her cellphone while she fed resident #65. CNA A did not apply any hand sanitizer while she fed resident #65. In an interview on 06/24/25 at 12:40 PM, CNA A stated she did not normally use her phone while she fed a resident, because staff were not supposed to have phones out when they fed residents. She stated she texted another staff member about the transportation van. CNA A stated she did not use hand sanitizer after she used her phone before she assisted resident #65. CNA A stated a risk of not using hand sanitizer was cross contamination. In an interview on 06/26/25 at 1:22 PM, the DON stated staff were expected to wash their hands or sanitize properly before feeding the residents. The DON stated staff are not allowed to use their phones while feeding the residents. The DON stated the risk of CNA A texting while feeding a resident would cause choking. Record review of the facility's undated policy titled, Hand Hygiene reflected the following: You may use alcohol-based hand cleaner or soap/water for the following .Before and after assisting a resident with meals . Record review of the facility's undated policy titled, Eating, Assistive/Complete reflected the following: (15. Constant supervision will be provided throughout the meal for complete feeders. Close supervision will be provided throughout the meal for complete feeders. Close supervision will be provided (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676098 If continuation sheet Page 17 of 21 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 676098 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Plaza at Richardson 1301 Richardson Dr Richardson, TX 75080 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 throughout the meal for assistive feeders). Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676098 If continuation sheet Page 18 of 21 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 676098 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Plaza at Richardson 1301 Richardson Dr Richardson, TX 75080 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 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an effective pest control program for two of the three hallways reviewed for pest control and the facility's only kitchen. Residents Affected - Many The facility failed to ensure Hall 200 and 400 were free of gnat flies. The facility failed to ensure the facility's only kitchen was free of gnat flies. This failure could lead infestation of pests and compromise resident health Findings included: Observation on 06/24/2025 at 8:55AM upon entry to kitchen revealed the following: 2 gnats flying around the hand washing sink. Interview on 06/24/2025 at 9:48AM with the DM revealed that there had been a gnat issue in the kitchen. He stated that pest control is coming and that staff had currently been trying to maintain pest control by pouring bleach down the drains in the kitchen. The DM stated he had put a pest control order in for maintenance. Observation on 06/24/2025 at 9:48AM in hall 200 revealed the following: 1 gnat flying around in room [ROOM NUMBER] 1 gnat flying around in the common area (activities and dining) 1 gnat flying around in the hallway Observation on 06/24/2025 at 11:36AM upon entry to the kitchen revealed the following: 3 gnats flying around the hand washing sink. When the DM moved a stainless-steel bowl with sauce in it, 3 gnats flew out of it. 1 gnat flying around near the deep fryer (12:13PM) 2 gnats flying around near the steam tray table (12:42PM) 1 gnat flying around near the steam tray table (12:47PM) 1 gnat flying around near the steam tray table (12:55PM) Observation on 06/26/2025 at 11:30AM with Resident #52 revealed 1 gnat flying around his head. This surveyor attempted to interview Resident #52; he was unable to coherently communicate. Observation and interview on 06/26/2025 at 2:26PM with Resident #40 revealed 2 gnats flying around (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676098 If continuation sheet Page 19 of 21 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 676098 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Plaza at Richardson 1301 Richardson Dr Richardson, TX 75080 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 0925 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many his room upon entry. Resident #40 resides in hall 400. The resident stated that the gnats have been a problem and have been in the facility for a long time. Resident #40 stated the gnats bother him and he had complained to staff but did not know who and does not know what else to do about the gnats. The resident appeared agitated by the gnats, based on reactions to asking about the gnats and tone of voice. Observation and interview on 06/26/2025 at 2:35PM with Resident #33 revealed the resident had many gnats in her room. Resident #33 resides in hall 100. She stated she had talked to someone in the facility but was unsure of who. She further stated she wanted her family to bring traps to control the gnats since they have continued to be an issue. When asked if the gnats bothered her, she said yes and that one gnat flew in her mouth while she was eating and that she almost threw up. Interview with the ADON on 06/26/2025 at 3:10PM revealed she had seen gnats around the facility and in hall 200. She stated there were no current swarms. Interview on 06/26/2025 at 3:36PM with the maintenance supervisor revealed that he was responsible for pest control. He stated that food in a resident's room caused the gnats to populate, and he was able to locate the source of the gnats. He explained that traps were set to control the gnat population, prior to pest control treatment on 06/10/2025. He stated pest control came again on 06/25/2025 and when pest control was not in the facility, he continues to maintain gnats with traps, sprays, and pouring bleach or vinegar down drains. He stated it is important to take time to continue to manage the gnats because the facility was the resident's home and there should not be pests. Interview with the ADM on 06/26/2025 at 4:28PM revealed that maintenance overlooks pest control in the facility. He stated that the gnat problem was due to food that was in a resident's room. He explained that pest control comes to the facility once a month and does follow ups and after treatment. The ADM further stated that pest control had currently done treatment more than once a month due to the gnat issue. This surveyor asked the ADM how the facility monitors the gnats to prevent further increase in gnat population, he stated during morning meetings with staff, everyone is assigned halls to check and assess all rooms for any issues, including pests. The ADM expect staff to log and let maintenance know of pest issues, and maintenance to inform pest control. He stated that maintenance uses sprays and traps to manage the gnats. Observation during an interview with ADM on 06/26/2025 at 4:28PM revealed 1 gnat flying in front of this surveyor's face. Record review of pest control log dated 06/10/205 reflected: (the head nurse) said (room [ROOM NUMBER]) was the source of the gnats . 200 HALLWAY AND DINING ROOM EXPERENCING HEAVY GNAT PRESSURES . treatment applied to the common area and resident's room . targeted pests: gnat . Record review of the facility's Insect and Rodent Control policy dated 2012 reflected: The facility will maintain an effective pest control program in order to provide an insect and vermin free food service department. Procedure: 1. Arrangements are made with a reputable company for regular spraying for insects which includes rodent control when required. 2. Facility will maintain appropriate screens, close fitting doors, properly sealed water/sewer (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676098 If continuation sheet Page 20 of 21 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 676098 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Plaza at Richardson 1301 Richardson Dr Richardson, TX 75080 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 0925 pipes, structurally maintained walls, baseboards, etc. to prevent entrance access of insects and rodents. Level of Harm - Minimal harm or potential for actual harm 3. Sanitation of facility will be maintained per other stated sanitation policies to prevent food sources, breeding places, etc. for insects or rodents. Residents Affected - Many 4. Deliveries of food and supplies will be monitored for prevention of insect and rodent access. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676098 If continuation sheet Page 21 of 21