Health inspection·July 28, 2022

F 0812 Level of Harm - Minimal harm or potential for actual harm Observation on 07/26/22 at 9:05 AM in the freezer area revealed 50 bags of frozen peas, mixed vegetables, carrots, string beans, and corn in its original bags were undated with the stored date. Observation on 07/26/22 at 9:15 AM in the refrigerator area revealed one large clear container of whole green bell peppers and one large clear container of whole red bell peppers, did not have a stored date. Residents Affected - Some Interview on 07/28/22 at 11:10 AM the Dietary Manager. stated that he did not have any reasons why the observed food items were undated. He stated the food that was observed to be expired, were not. He stated he used the wrong labels on the container of pancake syrup packets, sugar free breakfast syrup packets, strawberry jam packets, grape jelly packets, and sugar free grape jelly packets which was supposed to be a stored date as opposed to use by date and he would have this corrected. The DM advised that he had no excuse for why the cans were not labeled, and because he is unsure of when the cans were first stored at the facility, he would destroy the cans. The DM stated that the frozen vegetable did originally arrive to the facility in a box, but he had removed the items from the original boxes for easier storage and he did not think to date the frozen vegetables with the stored date. The Dietary Manager stated he would address the concerns observed. The DM advised that he had no reason as why the containers of green and red bell peppers were not dated with the stored date. He stated the risk to not properly labeling and dating of food products could result in residents eating expired food and getting sick. Interview on 07/28/22 at 1:30 AM the Administrator stated she was not aware they had to be concerned with the kitchen area complying, since it is being managed by the Assisted Living side, who had a different owner, and they had to pay for their services. She stated that now that she knew this, she would ensure they had a representative that could assist in ensuring that the kitchen area complied with guidelines. She was asked the risk of the residents eating expired food and she stated that there was a risk for food poisoning. Review of the facility's policy and procedures on Food Storage, dated May 2019, revealed Food not stored in the product container or package in which it was obtained will be stored in a container identifying the food by name and the date of which it was stored in the container. Review of the facility's policy and procedures on Freezer Storage, dated February 2020, revealed Label products with delivery date indicating month, day, and year product was received. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676168 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 676168 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rambling Oaks Courtyard Extensive Care Community 112 Barnett Blvd Highland Village, TX 75077 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to establish and maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 1 of 4 residents (Resident #91) reviewed for infection control and urinary management devices. Residents Affected - Few The facility failed ensure LVN A performed proper hand hygiene during a urinary management device (foley catheter) change procedure on 07/27/2022 between 9:47a.m. and 10:05a.m. This deficient practice could result in the development of disease and infection. Findings included: Record Review on 07/27/2022 at 3:00pm of Resident #91's Face Sheet revealed he was an [AGE] year-old male admitted to the facility on [DATE] with primary diagnoses that included acute kidney failure, history of urinary tract infections, pneumonia, systemic infection , and bilateral open-angle glaucoma. Record Review on 07/27/2022 at 3:10pm of Resident #91's MDS revealed he was cognitively intact with a BIMS score of 15. Resident #91 used a wheelchair for mobility; and required the use of one staff member for bed mobility, transferring, dressing, and toileting . Observation on 07/27/2022 at 9:47 a.m. with LVN A and CNA B revealed Resident #91 in his bed with LVN A preparing to replace his urinary management device (foley catheter.) LVN A then left the resident's room and returned at 9:54 a.m. LVN A entered the room and immediately donned gloves. LVN A then walked over to the Resident #91's right side and with her gloves on, removed her watch and glasses, and placed them in her pocket LVN A then touched the resident's genital and groin area with her left hand and removed Resident #91's foley catheter tubing from his urethra with her right hand. LVN A then disposed of the tubing in the trash can along with her gloves. LVN A failed to perform hand hygiene before donning gloves, making resident contact, and providing care. At 9:57a.m., LVN A then applied sterile gloves. LVN A cleaned the resident's genitals with both hands, then obtained a new foley catheter tip with her right hand and inserted the device into Resident #91's urethra. LVN A failed to perform hand hygiene after removing the previous gloves, prior to the application of sterile gloves, making resident contact, and performing intervention. In an interview with LVN A on 07/27/2022 at 12:47 a.m., she stated she did not perform hand hygiene prior to entering Resident #91's room and applying gloves. She stated she did not perform hand hygiene between glove changes. She stated she should have performed hand hygiene at those times but stated she was nervous and forgot. She stated it was important to perform hand hygiene properly for infection control purposes, as cross contamination could occur and cause infections. LVN A stated she had been working full time at the facility as a nurse for 3 months, and prior to that worked as an agency nurse dating back to January 2022. She stated she did not complete a skills checkoff on foley catheters, but stated she was trained in school on how to complete the intervention. In an interview with ADON C on 07/27/2022 at 12:56 a.m., she stated her expectations were for all staff to have performed hand hygiene prior to resident care, prior to donning gloves, and between glove changes. She further stated proper hand hygiene should have been performed when the staff went (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676168 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 676168 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rambling Oaks Courtyard Extensive Care Community 112 Barnett Blvd Highland Village, TX 75077 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 from a dirty to clean procedure as in the foley catheters replacement procedure. She stated if proper hand hygiene was not performed, staff can introduce the body to foreign contaminants, and cause infection in the body. In an interview with ADON C on 07/27/2022 at 1:08 p.m., she stated that LVN A was not checked off on foley catheter care skills . In interview with Administrator on 07/28/2022 12:57 p.m., she stated she expected the staff to have followed company policy on hand hygiene. The Administrator stated if hand hygiene is not performed, something can be transferred one resident to the next, and referred to Resident #91, and stated improper hand hygiene could potentially cause a urinary tract infection. Record review on 07/28/2022 at 12:24 p.m. of LVN A's skills checkoff documentation titled, Catherization Insertion and Removal of an Indwelling Catheter, dated 05/20/22, revealed it was not performed/completed. Record Review on 07/28/2022 at 12:19 p.m. of facility policy titled, Fundamentals of Infection Control Precautions, dated 2010, stated 1. Hand Hygiene: Hand hygiene continues to be the primary means of preventing the transmission of infection. The following is a list of some situations that require hand hygiene: . Before and after performing an invasive procedure . Before and after inserting indwelling catheters . After removing gloves Record Review of the facility policy titled, Catheter Care, rev. 02/13/2007, reflected Procedure . 11. Wash your hands thoroughly with soap and water or alcohol 12. Apply gloves . 19. Remove gloves . 21. Wash hands FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676168 If continuation sheet Page 4 of 4