Health inspection·January 30, 2024

F 0755 Oxybutynin chloride 5 mg 1 tablet oral every 12 hours starting 1/16/23 Level of Harm - Minimal harm or potential for actual harm Gabapentin 300 mg 1 capsule oral hour of sleep starting 7/5/23. Iron (ferrous sulfate) 325 mg (65 mg iron) 1 tablet oral two times daily starting 7/27/23 Residents Affected - Few Methenamine Hippurate 1 gram 1 tablet oral two times daily for three hundred sixty five days starting 10/18/23. Record review of Resident #1's MAR dated January 2024 revealed the following entries: Clonazepam 0.5 mg 1 tablet two times daily starting 2/21/22 [diagnosis code] Anxiety Disorder. Schedule: 9:00 [9 AM] starting 10/10/23. 20:00 [8 PM] starting 10/10/23. The 8:00 PM entry for 1/14/24 reflected =. The MAR Legend reflected = meant Previously Scheduled. There was no indication on the MAR to indicate which staff member entered the symbol/code. Atorvastatin 10 mg 1 tab one time daily starting 6/29/22. [diagnosis code] hyperlipidemia. Schedule: 20:00 [8 PM] The 8:00 PM entry for 1/14/24 reflected =. The MAR Legend reflected = meant Previously Scheduled. There was no indication on the MAR to indicate which staff member entered the symbol/code. Calcium 600 + D(3) 600 mg-10 mcg (400 unit) 1 tablet two times daily starting 8/8/22. Schedule: 9:00 [9 AM] starting 10/10/23. 20:00 [8 PM] starting 10/10/23. The 8:00 PM entry for 1/14/24 reflected =. The MAR Legend reflected = meant Previously Scheduled. There was no indication on the MAR to indicate which staff member entered the symbol/code. Trazodone 50 mg tablet (1/2 tab=25 mg) hour of sleep starting 9/27/22. [diagnosis code] insomnia. Schedule: 20:00 [8 PM]. The 8:00 PM entry for 1/14/24 reflected =. The MAR Legend reflected = meant Previously Scheduled. There was no indication on the MAR to indicate which staff member entered the symbol/code. Oxybutynin chloride 5 mg 1 tablet every 12 hours starting 1/16/23. [diagnosis code] other muscle spasm. Schedule: 9:00 [9 AM] starting 10/10/23. 20:00 [8 PM] starting 10/10/23. The 8:00 PM entry for 1/14/24 reflected =. The MAR Legend reflected = meant Previously Scheduled. There was no indication on the MAR to indicate which staff member entered the symbol/code. Gabapentin 300 mg 1 capsule hour of sleep starting 7/5/23. [diagnosis code] pain (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676145 If continuation sheet Page 2 of 7 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 676145 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/30/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Prairie Estates 1350 Main St Frisco, TX 75034 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 Schedule: 20:00 [8 PM] Level of Harm - Minimal harm or potential for actual harm The 8:00 PM entry for 1/14/24 reflected =. The MAR Legend reflected = meant Previously Scheduled. There was no indication on the MAR to indicate which staff member entered the symbol/code. Residents Affected - Few Iron (ferrous sulfate) 325 mg (65 mg iron) 1 tablet two times daily starting 7/27/23. [diagnosis code] anemia in chronic kidney disease. Schedule: 9:00 [9 AM] starting 10/10/23. 20:00 [8 PM] starting 10/10/23. The 8:00 PM entry for 1/14/24 reflected =. The MAR Legend reflected = meant Previously Scheduled. There was no indication on the MAR to indicate which staff member entered the symbol/code. Methenamine Hippurate 1 gram 1 tablet two times daily for three hundred sixty five days starting 10/18/23. [diagnosis code] urinary tract infection. Schedule: 8:00 [8 AM] and 20:00 [8 PM]. The 8:00 PM entry for 1/14/24 reflected =. The MAR Legend reflected = meant Previously Scheduled. There was no indication on the MAR to indicate which staff member entered the symbol/code. Record review of Resident #1's progress notes dated 1/1/24 through 1/30/24 revealed there was no nursing entry made on 1/14/24 and no entry indicating the medications were refused or the physician was notified. An entry dated 1/17/24 at 10:39 PM by LVN H reflected: Resident stated she did not get her medication on Sunday night [1/14/24]. Resident agitated and wanting to take her night medication at [8:30 PM] every day. This nurse inform medication aide to give her medications at [8:30 PM] as requested. During an interview on 1/30/24 at 11:01 AM, MA B stated if a resident did not wish to take their medications at the time they were offered, she would circle back and try again. If they still did not wish to take them, she would attempt to find out the reason and then go and report it to the charge nurse. She stated the charge nurse handled the situation from that point on and it was the charge nurse's responsibility to document the missed doses. MA B stated she had the issue come up a couple of times on her hall but did not recall ever having an issue with Resident #1. She stated Resident #1 had taken her medications that morning and was participating in activities at the time of the interview. During an interview on 1/30/24 at 11:22 AM, LVN C stated if a resident did not want their medications and preferred them at a given time, the MA or nurse should go back and attempt to give them at that time. She stated if the time requested was outside the dose range, the nurse should call the physician and obtain guidance. She stated some medications may conflict with others due at a later time so it was up to the physician to determine whether it was okay to administer them. LVN C stated any changes or medication refusals should be documented in the MAR and progress notes and it was the nurse's responsibility to ensure the documentation was completed. She stated the risk for missing medications depended on the medication as they were prescribed for a reason. She stated, if a resident missed a blood pressure medication, it could cause an increase in their blood pressure and that was why they needed to let the physician know. LVN C stated she cared for Resident #1 and, from what she had heard, Resident #1 had preferences for her medication times and would call and let them know when she wanted them. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676145 If continuation sheet Page 3 of 7 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 676145 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/30/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Prairie Estates 1350 Main St Frisco, TX 75034 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 - Few An observation and interview on 1/30/24 at 12:27 PM revealed Resident #1 was in her room, sitting in her wheelchair, clean and well-groomed. Resident #1 complained she had missed her evening medications on 1/14/24. She stated it was a Sunday night about 7:30 PM and a MA came in to deliver her medications. She stated she told the MA it was too early and she did not want them yet. She could not remember the name of the MA. Resident #1 stated she later got changed and was waiting for him to return; she was playing a game on her phone and fell asleep. She stated she did not wake up until the next morning and remembered she did not get her medications the evening before. She stated she called for the morning nurse [LVN C] and complained to her that she had not received her medications the evening prior. Resident #1 stated LVN C asked her if she had called the evening nurse and asked about the medications and she told the nurse, No, because I was sleeping and it's not my job. Resident #1 stated she became angry and asked to speak to a manager. Resident #1 stated Unit Manager A came to see her and she reported the situation to him. She stated Unit Manager A returned later and stated he had spoken with the MA who admitted he had forgotten to follow-up on the medications but he had checked on her three times and she had been sleeping. Resident #1 stated she did not believe that was true because staff usually woke her up to take her medications. She stated Unit Manager A told her he planned to write-up the staff involved and give additional training and asked her if she felt better about the situation. Resident #1 stated she told him it did not make her feel better and she was going to call the State and make sure it didn't happen again. Resident #1 stated the Administrator came to see her the next day to investigate and she told the Administrator she did not want this to happen to other residents. Resident #1 stated the staff had previously offered to change her dose times but she refused and wanted the dose times to remain as they were. In an interview on 1/30/24 at 1:30 PM, LVN D stated residents had a right to refuse their medications and the MA or nurse should try to determine the cause. She stated the MA could try again and administer the medication if it was still within the dose window, otherwise they should report the refusal to the charge nurse. She stated it was the nurse's responsibility to determine the reason for the refusal, notify the physician and RP, and document the refusal and physician contact in the MAR and progress notes, and follow the physicians' orders. During an interview on 1/30/24 at 1:35 PM, Unit Manager A stated he was aware of Resident #1's complaint about missing her evening medications on 1/14/24. He stated they had in-serviced the staff and had 1 on 1 counseling with the MA involved, [MA E]. He stated he had done a full assessment of Resident #1 and she did not appear to have any adverse effects . He stated the pharmacy consultant had also come and provided 1 on 1 training to the medication aides related to medication rights and medication errors. Unit manager A stated staff should always follow the rights of medication administration. Medications could be administered 1 hour before to 1 hour after the scheduled dose time. He stated, if a resident did not take their medication, the MA should notify the charge nurse and could try again if it was still within the dosage window. He stated medications should never be signed as administered unless the medication was taken by the resident. He stated the medications were not signed out in the instance with Resident #1 and the MA was waiting for her to call and let him know she was ready. He stated the MAs did not document medication refusals. Unit Manager A stated the MA should report the occurrence to the charge nurse who then should assess the resident and document the refusal as they are responsible to follow-up with the resident and intervene when necessary. Contact information was requested for the MA and the LVN who worked with Resident #1 on 1/14/24. During a follow-up interview with LVN C on 1/30/24 at 2:30 PM, she stated she spoke with Resident #1 on the morning of 1/15/24 and she complained that she had missed her medications the evening before. She stated Resident #1 told her she had initially declined her medications because (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676145 If continuation sheet Page 4 of 7 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 676145 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/30/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Prairie Estates 1350 Main St Frisco, TX 75034 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 of an upset stomach. She stated Resident #1 told her the MA returned a second time and she told him she was not ready and asked him to leave the meds on her table and he refused. LVN C stated she had asked Resident #1 if she had called for her medications when she was ready for them, and she felt Resident #1 was annoyed with her for asking. She stated she reported the matter to Unit Manager A. LVN C stated she assessed Resident #1 and did not note any adverse reactions to missing her medications . Residents Affected - Few During an observation and interview on 1/30/24 at 3:22 PM, LVN F was observed performing a medication pass. After the medication pass, LVN F stated if a resident had refused to take their medications when offered, she would have tried to determine why they did not want their medications and when they would want to take them. If the time was outside the administration window, she would document the refusal, notify the physician and RP and document the event in the progress notes. During a telephone interview with MA E on 1/30/24 at 3:45 PM, he stated he was aware of Resident #1's complaint about missing her medications on 1/14/14. He stated he attempted to administer medications to Resident #1 that evening and she told him she was nauseated and wanted to wait and asked him to come back later. MA E stated he reported what she told him to RN G. MA E stated he returned to Resident #1's room to try again at around 8:30 PM and she told him she would call when she was ready for them. MA E stated he locked her medications in his cart and forgot about it afterward. He stated his shift ended at 10:00 PM and he did not recall notifying anyone else about medications and repeated that he had informed the charge nurse when she initially refused them. He stated he did not notify the oncoming shift about the missed doses and should have taken it up with the nurse. He stated he did not document the missed doses anywhere because he did not have access to do so. When asked about the risks to residents if there was a failure to administer their medications, MA E stated, I did not fail to administer the medications. I attempted to give them. Failing is when you don't go; I went. In an interview on 1/30/24 at 3:57 PM, Unit Manager A provided contact information for RN G. Attempts to call RN G two times were unsuccessful and no voicemail box was available to leave a message. In an interview with the DON on 1/30/24 at 5:01 PM, she stated all residents had a right to refuse medications. If a resident requested to take them later and they were still within the administration window they should be administered. If outside the administration window or the resident outright refused the medication, the charge nurse should call the physician and discuss the situation and follow their guidance. She stated the nurse should document the refusal. The DON stated she was aware of the incident involving Resident #1 and MA E and had investigated it. She stated MA E told her Resident #1 had initially refused the medications complaining of nausea and refused them again a second time. She stated MA E told her he had reported the situation to the nurse. The DON stated she questioned RN G and he told her he was not aware Resident #1 had refused her medications. She stated she did not investigate the night nurse because the matter was between MA E and RN G. She stated the night nurse would not have known the medications were not administered because the MAR would only reveal medications due to be administered on their shift. She denied receiving any reports of medications left on the medication cart and that MA E told her he had destroyed the medications after the resident refused them. The DON stated she wrote up both employees the next day and could not tell what was what. She stated the pharmacy consultant conducted in-service training with the MAs. The DON stated it was important for the nurses to notify the physician when medications were missed so that the physician could determine if they needed to order different medications or change the plan of care. She stated the general risk for missing medications depended on the medication and number of doses missed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676145 If continuation sheet Page 5 of 7 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 676145 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/30/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Prairie Estates 1350 Main St Frisco, TX 75034 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 - Few During a follow-up interview and record review with Unit Manager A and the DON on 1/30/24 at 5:40 PM, Unit Manager A stated he notified the physician the next day [1/15/24] and informed them of the missed doses. He stated the resident was fully assessed and had no adverse reactions. He stated he monitored MARs daily for missed doses or other concerns and discussed them in daily meetings. He stated, in Resident #1s instance, the complaint came to him first thing in the morning before he had pulled his reports. He stated Resident #1 had a thorough assessment and had no adverse effects. Unit Manager A reviewed the missed medications and stated he did not believe the missed medications contributed to her anxiety. He stated Resident #1 had a history of getting angry with staff and calmed down when they talked to her. He stated they had offered to change her medication times in the past and she never wanted the dose times changed. When deficient practice was discussed, the DON stated they did not feel they had deficient practice as the resident had refused her medications. She stated the refusal was documented on the MAR. When asked to identify the area on the MAR where the refusal was documented, the entries revealed =. The associated legend on the MAR reflected the symbol meant Previously Scheduled. There were no entries located on the MAR Legend which would indicate a resident refusal. Neither Unit Manager A or the DON were able to explain how a refusal was documented on the MAR and no documentation was provided to indicate anyone had documented Resident #1's refusal of her medications or that the physician had been notified on 1/14/24. In an interview with Physician I on 1/30/24 at 6:21 PM, he stated his Nurse Practitioner had been notified of Resident #1 missing her evening medications and had discussed the issue with him. He stated he was not certain when his Nurse Practitioner was notified. He reviewed the missed medications and did not believe there had been any risk posed to the resident when the medications were missed. Record review of an In-Service training Report dated 1/15/24 and conducted by Unit Manager A reflected, Topic: In-service/training completed on administering medications, rights of medication administration, Resident Rights, and abuse, neglect, exploitation and misappropriation. An attached undated document titled, Medication Administration In-Service reflected the following: 1. All Nurses must follow proper medication administration protocol. (6 Rights of Med Administration) . 5. All missed doses must be appropriately accounted for as follows: -Nurses must initial; then circle the omitted item. -Nurses must document on the back of the MAR why the dose was missed. Medication not available is not acceptable without a MD's order and documentation of the MD's intervention for the missed dose. This includes missed doses for new admissions. All other situations such as [patient's] refusal of a med or treatment must be explained with appropriate MD notification. Additional notes must be documented in the nurses notes. -The MD must be notified of a [patient's] initial refusal of a med or tx; if there are three consecutive refusals the MD must be notified again. MD's intervention MUST be documented!!! An attached attendance sheet reflected only MA E received the in-service training Record review of the facility's policy and procedure titled, Documentation of Medication Administration dated 2001, Revised November 2022 reflected the following: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676145 If continuation sheet Page 6 of 7 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 676145 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/30/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Prairie Estates 1350 Main St Frisco, TX 75034 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 Policy Heading: A medication administration record is used to document all medications administered. Level of Harm - Minimal harm or potential for actual harm Policy Interpretation and Implementation: Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete 1. A nurse or certified medication aide (where applicable) documents all medications administered to each resident on the resident's medication administration record (Mar) .3. Documentation of medication administration includes, as a minimum .f. reason(s) why a medication was withheld, not administered, or refused (as applicable) Event ID: Facility ID: 676145 If continuation sheet Page 7 of 7