Health inspection·March 22, 2024

F 0609 the wound the same day. Level of Harm - Minimal harm or potential for actual harm Interview on 03/21/24 at 03:36 PM LVN Q revealed most of Resident #34's falls are due to trying to toilet herself. LVN Q revealed the following to help prevent falls: keep door to room open, encourage Resident #34 to call for help-(LVN Q revealed Resident #34 forgets), do every15 minute checks on Resident #34. LVN Q revealed he did not witness the most recent fall for Resident #34. LVN Q revealed as he came on shift, he was given report about Resident #34's fall from the outgoing nurse. Residents Affected - Few Interview on 03/22/24 at 11:25 AM Receptionist revealed while walking down the 300 hall she saw Resident #34 on the floor in her room. The Receptionist revealed from just outside the resident's doorway she saw Resident #34 laying on her right side with the right side of her face with blood on the floor. The Receptionist revealed Resident #34 was not yelling or anything. The Receptionist said she flagged down the nurse and aide to come to the room. Interview on 3/22/24 at 12:00 noon Aide P revealed just prior to the fall Resident #34 was at the nurse's station. Aide P revealed she did not witness Resident #34's fall. Aide P said the Receptionist walked past Resident #34's room and found the resident on the floor. Aide P revealed her, and the nurse went to Resident #34's room where they assisted Resident #34 get into bed. Aide P reported I think there was blood on ground and a little in resident #34's hair. Aide P reported she did not remember if Resident #34 showed or expressed pain. Aide P reported she does not remember what time this occurred. Interview on 3/22/24 at 3:28pm the Administrator reported for falls they do assessments, monitor for pain, injury, notify Attending for orders of x-ray and/or send out to the hospital. The Administrator revealed they would find out what caused the fall. The Administrator revealed if the resident hit their head, they usually would send out depending on the outcome of the neuro checks, and if residents can tell what happened. The Administrator revealed the facility did not report the injury saying it did not meet the criteria for reporting. The Administrator is the Abuse Coordinator. Interview on 3/22/24 at 5pm the Treatment nurse- revealed he called the family members of Resident #34, who separately told him the same thing about the fall. The Treatment nurse revealed Resident #34 said the same as the that the reason for the fall was Resident #34 was bending over to try and pull up her pants and fell. The Treatment nurse stated he believes he documented but a record review reflected no documentation from the treatment nurse. Record Review of the facility's Reportable Incident Protocol Policy reflects the following, 1) Ensure all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source . 4) Report the results of all investigations to the Executive Director or his or her designee and to other officials in accordance with State law, including the State Survey Agency within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. The agency policy goes on to define injuries of unknown source as Any injury should be classified as an injury of unknown source when both of the following conditions are met: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676237 If continuation sheet Page 2 of 14 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 676237 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Belmont at Twin Creeks 999 Raintree Circle Allen, TX 75013 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 0609 - Level of Harm - Minimal harm or potential for actual harm The source of injury was not observed by any person, or the source of the injury could not be explained by the patient. Residents Affected - Few AND The injury is suspicious because of the extent of the injury or the location of the injury (e.g., the injury is located in an area not generally vulnerable to trauma) or the number of injuries observed at one particular point in time or the incident of injuries over time. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676237 If continuation sheet Page 3 of 14 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 676237 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Belmont at Twin Creeks 999 Raintree Circle Allen, TX 75013 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 0645 PASARR screening for Mental disorders or Intellectual Disabilities 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 ensure individuals with mental disorders were evaluated and received care and services in the most integrated setting appropriate to their needs for 1 of 3 residents (Resident #95) reviewed for PASRR Level I screenings. Residents Affected - Few The facility did not correctly identify Resident #95 as having a mental illness and did not complete a new PASRR Level I Screening. This failure placed residents at risk of not receiving adequate services or care related to mental illnesses. Findings included: Review of Resident #95's Face Sheet, dated 03/22/24, reflected she was a [AGE] year-old female who admitted to the facility on [DATE], with diagnoses including bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), and anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities). Review of Resident #95's MDS Assessment, dated 02/21/24, also reflected she had diagnoses including depression (other than bipolar) and manic depression (bipolar disease). Review of Resident #95's PASRR Level I Screening, dated 02/15/24, reflected there was no evidence that Resident #95 had indicators of a mental illness. Observation of Resident #95 on 03/19/24 at 10:35AM revealed she was clean, well-groomed, and appropriately dressed. She was free from any odors. There were no visible marks or bruises noted on her person. Resident #95 was alert and oriented; she was also visibly distressed and crying out. During an interview with Resident #95 on 03/19/24 at 10:35AM, she stated facility staff treated her exceptionally well and reported she felt as though she had the best nurses and aides in the world. She had no concerns regarding the facility or the care received; however, she described trauma she had recently sustained including almost dying due to illness (prior to her admission to the facility) and her immediate family member recently dying without a known cause. She appeared to be very upset and grief-stricken throughout the duration of the interview. During an interview with the MDS Coordinator on 03/21/24 at 3:03PM, she stated Resident #95's PASRR Level I was completed at the hospital prior to her admission and indicated she did not have a mental illness; therefore, she did not qualify for a PASRR Level II evaluation. The MDS Coordinator stated upon a resident's admission to the facility, she verified a PASRR Level I screening had been completed and reviewed the resident's diagnoses to ensure they were appropriately captured on the PASRR Level I screening. She stated when she checked Resident #95's PASRR Level I screening and medical history, her diagnoses including bipolar disorder, major depressive disorder, and anxiety disorder had not been uploaded in her medical history. She stated because of these diagnoses, Resident #95 should have received a PASRR Level II evaluation. The MDS Coordinator stated she was not aware of any risk (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676237 If continuation sheet Page 4 of 14 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 676237 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Belmont at Twin Creeks 999 Raintree Circle Allen, TX 75013 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 0645 factors present due to Resident #95 not yet receiving a PASRR Level II evaluation. 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: 676237 If continuation sheet Page 5 of 14 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 676237 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Belmont at Twin Creeks 999 Raintree Circle Allen, TX 75013 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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care for 1 (Resident #95) of 3 residents reviewed for baseline care plans, in that: The facility failed to ensure Resident #95's baseline care plan was completed and included information related to her care needs and status at the time of her admission. This failure could place newly admitted residents at risk of not receiving continuity of care and communication among nursing home staff to ensure their immediate care needs are met. Findings included: Review of Resident #95's Face Sheet, dated 03/22/24, reflected she was a [AGE] year-old female who admitted to the facility on [DATE], with diagnoses including bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), and anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities). Review of Resident #95's MDS Assessment, dated 02/21/24, also reflected she had diagnoses including depression (other than bipolar) and manic depression (bipolar disease). Resident #95 was identified as needing ADL assistance including bathing and dressing. Review of Resident #95's Baseline Care Plan, dated 02/14/24, reflected no areas of the document had been completed; there was no information regarding Resident #95's status or care needs. During an interview with the Administrator on 03/22/24 at 3:48PM, she stated the expectation was for baseline care plans to be completed upon a resident's admission to the facility, by the nursing staff completing the admission. She stated the risk of a resident's baseline care plan not being completed included staff not knowing how to best care for a resident. The facility's policy regarding baseline care plans was requested from the Administrator on 03/22/24 at 4:57PM but was not provided. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676237 If continuation sheet Page 6 of 14 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 676237 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Belmont at Twin Creeks 999 Raintree Circle Allen, TX 75013 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review the facility failed to develop and implement a comprehensive person care plan for each resident that included measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs for two of eight residents reviewed for care plans. (Residents #08 and #35). The facility failed to develop and implement person-centered care plans for Residents #08 and #35. This deficient practice placed residents at risk of not having their individualized needs met in a timely manner and communicated to providers and could result in injury and a decline in physical well-being. Findings Included: 1. Review of Resident #08's Face Sheet, dated 06/15/23, reflected he was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses including Dementia (a term used to describe a group of symptoms affecting memory, thinking and social abilities), psychotic disturbance(a group of serious illnesses that affect the mind) and anxiety disorder (anxiety disorder includes persistent and excessive anxiety and worry about activities or events ) and schizophrenia. Review of Resident #08's Care Plan, with a section dated 06/15/23 reflected, Resident #08 problems included: Parkinson's Disease and is at risk for injury from increased tremors and involuntary muscle movement. Record review of Resident #08 care plan reflected, was took Sinemet . Record review of Resident#08 care plan reflected, goals .no occurrence of injuries . Record review of Resident#08 care plan reflected, interventions included: Give medication as order and monitor labs No documentation of Resident #08 schizophrenia Review of Resident #08 patient medication profile (undated) reflected, Resident# 08 was proscribed Seroquel 25mg tablet for three times a day. Record review of Resident #08 Patient Medication profile reflected; Seroquel medication is used to treat certain mental/mood disorders (such as schizophrenia .) Review of Resident #08 quarterly MDS, dated [DATE], reflected Resident #08 had a BIMS of 03, severe cognitive impaired. Record review of quarterly MDS reflected active diagnosis of psychiatric/mood disorder included Schizophrenia. Interview at 03/22/24 at 2:00 PM with MDS coordinator revealed she overlooked the diagnosis and did not add it to his care plan. The MDS coordinator stated by not adding the Schizophrenia diagnosis could prevent the resident from getting the care he needed. The.MDS coordinator stated her, and the DON are responsible for adding information to care plan. Interview at 03/22/24 at 2:15 PM with DON revealed that residents' family member wanted resident to be back on Seroquel because the last hospital visits the doctors put him on that medication. The DON revealed she found pervious documentation that resident was on Seroquel when he was in [state]. Family member signed the consent on 02/29/24 and resident began medication treatment. The DON stated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676237 If continuation sheet Page 7 of 14 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 676237 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Belmont at Twin Creeks 999 Raintree Circle Allen, TX 75013 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 0656 care could be missed by not adding needed information to care plan. Level of Harm - Minimal harm or potential for actual harm 2. Record review of Resident #35's face sheet, dated 03/22/24, reflected a [AGE] year-old female, was admitted to the facility on [DATE] with the following diagnoses which included, acute kidney failure (occurs when your kidneys suddenly become unable to filter waste products from your blood), hypertensive (commonly known as high blood pressure), type 2 diabetes mellitus (condition characterized by high blood sugar levels, insulin resistance, and relative lack of insulin), and vitamin deficiency and pain. Residents Affected - Few Record review of Resident #35's admission MDS, undated, reflected Resident #35 had a BIMS score of 15 reflecting no cognition impaired. Required minimum to maximum assistance with activities of daily living. Resident #35 was taking anticoagulants, hypnotics, opioids, and hypoglycemia (including insulin). Record review of Resident #35's Comprehensive Care Plan revealed the resident did not have a care plan. Observation and interview on 03/19/24 at 12:15 PM, revealed Resident #35 was in the room. Resident #35 was in the room, she was awake and alert. The resident stated she was having a cough and it was getting better. In an interview on 03/21/24 at 11:53 AM with LVN H (ADON), she reviewed the clinical records and then LVN H stated Resident #35 was missing the care plan. LVN H stated she did not complete the Resident #35's care plan because she missed to complete the care plan. LVN H stated she completed the comprehensive care plan of the residents upon admission and at times the MDS personnel will complete the care plan. LVN H stated Resident #35 care plan was to be completed to indicate the resident's care needs. LVN H stated Resident #35 not having a care plan could lead to the staff not meeting the resident's care. LVN H stated she was the only one responsible to make sure the care plans were completed timely. In an interview on 03/22/24 at 10:13 AM with the DON she stated she was responsible to check and make sure the care plan was completed timely. The DON stated she completed random checks to make sure the nurses were completing the care plan correctly, and she had not checked if Resident #35 care plan had been completed. The DON stated the care plan was to be completed to show the resident needs and goals and interventions met. Record review of the facility policy, revised March 2022 titled, Care Plan, Comprehensive Person-Centered reflected, A comprehensive person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, physiological and functional needs is developed and implemented for each resident.A comprehensive person-centered care plan is developed within seven (7) days of the completion of the required MDS assessment (Admission, Annual, or Significant Change in Status), and not more than 21 days after admission. Tge policy also reflected, .12. The interdisciplinary team reviews and updates the care plan: 07. B) Describes the services that are to be furnished to attain or maintain the resident's highest practicable . e) reflects currently recognized standards of practice for problem area and conditions . 12. C) when the resident has been readmitted to the facility from a hospital stay. D) At least (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676237 If continuation sheet Page 8 of 14 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 676237 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Belmont at Twin Creeks 999 Raintree Circle Allen, TX 75013 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 0656 quarterly, in conjunction with the required quarterly MDS assessment . 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: 676237 If continuation sheet Page 9 of 14 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 676237 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Belmont at Twin Creeks 999 Raintree Circle Allen, TX 75013 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents who are fed by enteral means receive the appropriate treatment and services to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, and metabolic abnormalities for one resident (Resident #51) of 2 residents reviewed for enteral nutrition. LVN E failed to check for residual volume prior to medication administration for Resident #51 These failures could affect all residents who receive enteral feeding and place them at risk for metabolic abnormalities, medical complications, or a decline in health due to not following appropriate procedures. Findings included: Review of Resident #51's face sheet, dated 03/22/24, reflected the resident was a [AGE] year-old female who originally admitted to the facility on [DATE]. Her diagnoses included Gastrostomy status (an opening in the stomach at the abdominal wall made surgically to introduce food), hypertension, type 2 diabetes, and chronic kidney disease. Review of Resident #51's annual MDS Assessment, undated, revealed Resident #51's BIMS score of 3 which indicated severe cognitive impaired. Resident # 51 required extensive assistance with activities of daily living with one to two persons assist. Further review revealed Resident #51 had a feeding tube, which she received 51% or more of the total calories. Record review of Resident #51's physician order review dated 02/23/22 reflected an order to, Check tube for proper placement by auscultation of injected air (place a stethoscope on the left side of the abdomen just above the waist) or visual inspection of aspirated stomach contents prior to instilling medication, and/or initiating a feeding. Check every shift . Order Date: 2/23/2022. Observation on 03/19/24 at 07:36 AM, revealed LVN F administering medication to Resident #51 through the feeding tube. LVN F got the following medications ready, levothyroxine 175 mg Aspirin chewable 81 mg, Acidophilus with citrus pectin, Vitamin D3 25 mcg (1000iu), Vitamin C 500 mg, Daily vitamins, Isosorbide 30 mg, Amlodipine Besylate 10 mg, Thiamin vitamin B-1 100 mg, Carvedilol 6.25 mg, Hydralazine HCL 100 mg, Protein supplement 30 cc. Crushed the medications separately in different medication cups and mixed with 10 cc of water. LVN F then checked for placement, staff did not check for residual. LVN F then administered medications and flushed in between medications and after medication administration. In an interview on 03/19/24 at 08:28 AM with LVN F she stated she was supposed to check for residual, but she forgot. She stated she was supposed to check for residual to check if the resident was not being overfed and digestion was okay. LVN F stated if Resident #51 had a lot of fluids in the stomach could lead to aspiration (happens when food, liquid, or other material enters a person's airway and eventually the lungs by accident). In an interview on 03/22/24 at 10:25 AM with the DON she stated LVN F was supposed to check for residual before medication administration, to make sure the feeding tube was at the right place and the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676237 If continuation sheet Page 10 of 14 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 676237 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Belmont at Twin Creeks 999 Raintree Circle Allen, TX 75013 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 0693 Level of Harm - Minimal harm or potential for actual harm amount in the stomach. The DON stated if the stomach was too full it could lead to aspiration. The DON stated she was responsible to check and make sure the medication administration was completed per the orders and correctly. The DON stated the facility had completed feeding tube medication administration check off in February, and LVN F was among the staff who had the check off. Reviewed the in-service and revealed LVN F completed the check off. Residents Affected - Few Record review of the facility policy revised 2018, titled Administering Medication through an Enteral Tube reflected, .6. Verify placement of the feeding tube: a. If you suspect and improper tube positioning, do not minister feeding or medication. Notify the charge nurse or Physician. The policy did not address checking for residual. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676237 If continuation sheet Page 11 of 14 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 676237 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Belmont at Twin Creeks 999 Raintree Circle Allen, TX 75013 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 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in the facility's only kitchen. The facility failed to ensure foods were properly stored, labeled, and expired foods were discarded. This failure could have affected 83 of the 87 residents at the facility by placing them at risk for food exposed to adulteration or contaminantes. Adulterated foods have had severe health effects. Diarrhea, nausea, allergic reactions, diabetes, and cardiovascular disease have been observed upon consumption of adulterated food. Findings included: Initial tour of the dry storage on 3/19/2024 beginning at 5:40am revealed the following: 3 bags of white corn 4 tortillas in a box labeled 6 flour tortillas with 6 flour tortillas. Observed a yellow/brown colored granular substance type item loosely wrapped in a heavy blue plastic, inside an acrylic container, unlabeled as to the contents with a date of 1-9-24. 1 of 4 dented 4 pounds 2.5-ounce cans were on the shelf with the other canned items, instead of in the area labeled as Dented Cans Only, do not use. 1 of 8 packages of tea bags were not labeled with a received or expiration date. An observation of a facility's refrigerator designated for resident use on 3/19/2024 at 5:40am revealed the following: 1 of 24 cups of cut fruit was not covered. 3 of 3 16 ounces of Margarine was not labeled with a received or expired date. 12 of 24 cups of dark liquid not labeled with contents, received date, or expiration date. An observation of a facility's freezer designated for resident use on 3/19/2024 at 5:40am revealed the following: 1 of 1 box of Tyson 8 piece cut chicken breast-98 individual pieces in an opened cardboard box sitting a shelf above boxes of bacon on a tray with blood leaking from below the box into the tray with the tray partially hanging off the shelf. 1 of 1 box of mixed food items altogether in one box with contents unlabeled, no received or expiration date. 1 of 1 package of [NAME] observed with frostbite. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676237 If continuation sheet Page 12 of 14 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 676237 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Belmont at Twin Creeks 999 Raintree Circle Allen, TX 75013 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 2 of 2 chickens were on a shelf above 2 other shelves with food on them. Level of Harm - Minimal harm or potential for actual harm Observation and Interview on 03/19/24 5:40am-Observed dirty dishes on a rack in the dining room from the day prior. Observed Head [NAME] in the kitchen preparing food for the day. Head [NAME] revealed Dietary Manager was the Kitchen Manager. Head [NAME] revealed breakfast is served at 7am, Lunch at 12noon, dinner at 5pm. Head [NAME] revealed residents in the dining room were served first then the trays were taken to the halls for the nursing staff to serve the residents that ate in their room. Residents Affected - Many 3/19/2024 at 11:23am Interview with Dietary Manager and Dietitian revealed dietitian came weekly. During this interview Observed Head [NAME] temp the lunch food and Dietary Manager documented the temps. All temps were within normal range. 3/19/24 at 11:23am Interview with Dietary Manager revealed he had reviewed the kitchen for the items discussed that were out of expiration, dented cans, foods with frost bite, improperly thawing and found not stored properly. Dietary Manager stated he was responsible for ensuring food was stored properly and for training staff on food storage procedures. During this interview The Head cook, Dietary Manager stated he took care of the issues the facility failed to properly store and lable along with discharding the frost bitten food. The Dietitian revealed she visits the facility kitchen usually on a weekly basis and checks with the Dietary Manager about the diets. The kitchen line staff acknowledged the importance of properly stored food. Review of the U.S. Public Health Service Food Code dated 2017 reflected: .3-302.11 Packaged and Unpackaged Food -Separation, Packaging, and Segregation. (7) Storing damaged, spoiled, or recalled food being held in the food establishment as specified under § 6-404.11; . Review of U.S Department of Health and Human Services Food Code, dated 2017, revealed, 3-202.15 Package Integrity reflected: Food packages shall be in good condition and protect the integrity of the contents so that the food is not exposed to adulteration or potential contaminants. Review of the Food and Drug Administration Food Code, dated 2017, reflected, .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 3-305.11 Food Storage. (A) .food shall be protected from contamination by storing the food: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination .(B) .refrigerated, ready-to eat time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (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 .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 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676237 If continuation sheet Page 13 of 14 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 676237 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Belmont at Twin Creeks 999 Raintree Circle Allen, TX 75013 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 identified with the common name of the food 3-305.11. Level of Harm - Minimal harm or potential for actual harm (B) .refrigerated, ready-to eat time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676237 If continuation sheet Page 14 of 14