Health inspection·June 12, 2025

F 0583 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of Resident #53's Physician Order, dated [DATE], reflected Monitor for side effects every shift: ANTIANXIETY LORAZEPAM. SIDE EFFECTS: 0. NONE 1. Hypotension 2. Sedation 3. Dizziness 4. Dry Mouth 5. Blurred Vision 6.Urinary Retention 7. Drowsiness, Fatigue 8. Slurred Speech 9. Confusion 10. Nightmares 11. Appetite Changes. Record review of Resident #53's Physician Order, dated [DATE], reflected Monitor for side effects every shift: ANTIDEPRESSANTS TRAZODONE, SIDE EFFECTS: 0. NONE 1. Dry Mouth 2. Blurred Vision 3. Constipation 4. Urinary Retention 5.Hypotension 6. Appetite Changes 7. Headache 8. Insomnia 9. Dyspepsia 10. Weight Changes 11.Suicidal ideations; Wishes of death; Attempts to harm self. In an interview and observation on [DATE] at 8:40 AM, LVN B was about to do Resident #53's bolus feeding and at the same time administer his medications. She said she would wash her hands first before she prepares the resident's medications. She parked her nurse's cart beside the resident's door and went inside the resident's bathroom to wash her hands. It was observed that there was a laptop on top of the cart. The laptop was open, facing the hallway, and displayed the resident's name, directive, was on hospice, primary physician, emergency contact, allergies, and that the resident was on NPO and tube feeding. Physician orders to monitor the resident for pain and the side effects of antianxiety and antidepressant were also visible. LVN B went back to her cart after washing her hands and saw that her laptop was open. She closed the laptop and said she forgot to close it before washing her hands. She said she should have locked, minimized, or closed the monitor of her laptop every time she left the cart. She said the purpose was to protect the health or personal information of the residents. She said she should be mindful to close her computer every time she left it. In an interview on [DATE] at 6:29 AM, the ADON stated the staff should make sure that no information about any resident be left on top of the cart before leaving the cart unattended because it was HIPAA violation. He said the resident's information were confidential and should not be seen by unauthorized individuals. He said the expectation was for the staff not to leave any personal or medical information about a resident. He said he would coordinate with the DON to do an in-service about privacy and confidentiality. In an interview on [DATE] at 7:00 AM, the DON stated personal and medical information about a resident should be protected and not be visible for everybody to see because those were confidential information. She said the health information of a resident could not be shared without the permission of the resident or the resident's responsible party. She said the staff should have closed the monitor, minimized the monitor, or parked the cart not facing the hallway before going inside the resident's room. She said if the confidential information were exposed, non-nursing staff, other resident, and visitors will be able to see it. She said all staff were expected to provide full privacy and confidentiality of all the residents' personal and medical information. The DON stated she would start an in-service about privacy and confidentiality of the residents' information. In an interview on [DATE] at 7:29 AM, the Administrator stated the staff must make sure the residents' information was not exposed because it was a violation of the resident's privacy and confidentiality of the care/treatment they were receiving. He said it was a HIPAA violation when unauthorized individuals saw the medical information. He said the expectation was for all the staff to make sure the personal and medical information of a resident were secured and their laptop were closed to prevent exposure of the said information. He said she would collaborate with the DON and the ADON to do an in-service about privacy and confidentiality. Record review of the facility's policy, INFORMATION SECURITY Leadership Policies and Procedures (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676248 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 676248 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/12/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Founders Plaza Nursing & Rehab 721 S Hwy 78 Wylie, TX 75098 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 0583 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete revised [DATE] revealed POLICY . 3. Users who logon to a computer system . log off of the system and network or, at minimum, lock the computer or laptop prior to leaving the workstation . Procedures . 2. Proper Treatment . E. Shared workstations . 1) Users log-off when leaving the workstation unattended . F. Dedicated workstations . 1) Users lock the workstation when unattended. Event ID: Facility ID: 676248 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 676248 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/12/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Founders Plaza Nursing & Rehab 721 S Hwy 78 Wylie, TX 75098 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 - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure residents had the right to a safe, clean, comfortable, and homelike environment including but not limited to receiving treatment and supports for daily living safely for 10 of 15 resident rooms on the 100 hall (Resident rooms #1, #2, #3, #4, #5, #6, #7, #8, #9 and #10), and residents eating in the dining room, reviewed for environment. 1. The facility failed to ensure Resident rooms #1, #2, #3, #5, #6, #7,#8,#9 and #10, were thoroughly cleaned and sanitized. 2. The facility failed to ensure the trash can in the dining room had a lid on it while residents were dining. These failures deficient practices could place residents at risk of living in an unclean and unsanitary environment which could lead to a decreased quality of life. Findings include: An observation on 06/10/25 at 10:55 AM of resident room [ROOM NUMBER] reflected the air condition unit filters had thick dust in them. The air condition vents had white and [NAME] stains in them. An observation on 06/10/25 at 10:59 of resident room [ROOM NUMBER] reflected the air condition unit filters had thick dust in them. The air condition vents had white and [NAME] stains in them. An observation on 06/10/25 at 11:02 AM of resident room [ROOM NUMBER] reflected the air condition unit filters had thick dust in them. The air condition vents had white and [NAME] stains in them. The shower floor in the bathroom had white and brown stains on it. The corners and edges of the room floor had white dust build up. An observation on 06/10/25 at 11:06 AM of resident room [ROOM NUMBER] reflected the air condition unit filters had thick dust in them. The air condition vents had white and [NAME] stains in them. The bathroom floor had white and brown stains on along the corners of the floor and behind the toilet. The corners and edges of the room floor had white dust build up. An observation on 06/10/25 at 11:08 AM of resident room [ROOM NUMBER] reflected the air condition unit filters had thick dust in them. The air condition vents had white and [NAME] stains in them. The bathroom floor had white and brown stains on along the corners of the floor and behind the toilet. An observation on 06/10/25 at 11:15 AM of resident room [ROOM NUMBER] reflected the air condition unit filters had thick dust in them. The air condition vents had white and [NAME] stains in them. A black personal fan had thick dust on the fan blades and inside of the casing. The bathroom shower floor had large yellow and black stains all over it. the floor. The corners and edges of the room floor had white dust and black dirt build up. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676248 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 676248 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/12/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Founders Plaza Nursing & Rehab 721 S Hwy 78 Wylie, TX 75098 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 - Some An observation on 06/10/25 at 11:20 AM of resident room [ROOM NUMBER] reflected the air condition unit filter had thick dust in them. One of the filters was missing from the air condition unit. The air condition vents had white and [NAME] stains in them. The corners and edges of the room floor had black dirt build up. An observation on 06/10/25 at 11:24 AM of resident room [ROOM NUMBER] reflected the air condition unit filters had thick dust in them. The air condition vents had white and [NAME] stains in them. The bathroom shower floor had black stains along the edges of the floor. The bathroom floor had white and brown stains on along the corners of the floor and behind the toilet. The corners and edges of the room floor had black dirt build up. An observation on 06/10/25 at 11:30 AM of resident room [ROOM NUMBER] reflected the air condition unit filters had thick dust in them. The air condition vents had white and [NAME] stains in them. The bathroom shower floor had black stains along the edges of the floor. The bathroom floor had white and brown stains on along the corners of the floor and behind the toilet. An observation on 06/10/25 at 11:33 AM of resident room [ROOM NUMBER] reflected the air condition unit filters had thick dust in them. The air condition vents had white and [NAME] stains in them. The bathroom shower floor had yellow and black stains along the edges of the floor. The bathroom floor had white and brown stains on along the corners of the floor and behind the toilet. A white personal fan had thick dust on the fan blades and the inside of the casing. An observation on 06/10/25 at 12:33 PM in the facility's only dining room revealed a large trash can located in the dining area near a table where a resident was dining , with the lid removed from it. The trash can had trash in it and it had a vulgar smell coming from it. In an interview on 06/11/25 at 12:50 PM, the Dietary Manager was advised about a trash can being in the dining room without the top placed on it and it had an odor. She stated housekeeping and the nursing staff were responsible for ensuring the lid wasare placed back on the trashcans as food wasis being dumped into it. She stated the concerns of not covering it was that it could smell and not be pleasant for the residents. In an interview on 06/11/25 at 1:50 PM, Housekeeping R stated housekeeping ensured the trash cans had lids on them before the start of meals. He stated the kitchen aide was responsible for ensuring the lids remained on the trash cans during meals because it was a safety hazard if the trash cans did not have the lids on them. He stated housekeeping dumped the trays at the end of the meals and emptied the trash cans at the end of each meals, but sometimes the CNAs dump the trays and do not ensure the lids were placed back on them. In an interview on 06/12/25 at 9:17 AM, Housekeeping R stated he had been at the facility for 2 years. He was shown pictures of the concerns Resident room [ROOM NUMBER], #2, #3, #4, #5, #6, #7, #8, #9, and #10. He stated housekeeping was responsible for cleaning the air filters in the room and when he works Wednesdays, Thursdays, and Fridays, he cleaned them. He stated he had reported to the Housekeeping Supervisor about his peers not cleaning the room thoroughly. He stated he also reported the concerns of the room floors and the shower floors needing a machine to scrub the built-up dirt. He stated the Housekeeping Supervisor told staff that the personal fans in resident rooms were not to be touched by housekeeping. He stated not cleaning the room thoroughly could result in residents getting an infection. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676248 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 676248 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/12/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Founders Plaza Nursing & Rehab 721 S Hwy 78 Wylie, TX 75098 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 - Some In an interview on 06/12/25 at 9:17 AM, the Housekeeping Supervisor stated she had been at the facility for 3 years and in her role as supervisor for 9 months. She stated staff were responsible for cleaning the entire room, from top to bottom. She stated maintenance was responsible for cleaning the air condition unit filters and the vents of the units but they were responsible for wiping down the outside of the units. She stated housekeeping cleaned the floors in the resident rooms and bathrooms. She stated she deep cleaned the floors at least once a month. She stated they were probably supposed to clean the personal fans in the resident rooms, but her staff had not been cleaning them. She was shown pictures of Resident room [ROOM NUMBER], #2, #3, #4, #5, #6, #7, #8, #9, and #10. She stated maintenance was responsible for deep cleaning the shower floors or repainting them and she had let them know. She stated the risk of not cleaning the areas mentioned could impact the resident's living experience. In an interview on 06/12/25 at 9:17 AM, the Director of Maintenance [NAME] stated he had been at the facility for 2 years. He stated housekeeping was responsible for cleaning the air filters and they cleaned the air condition units. He stated housekeeping was responsible for scrubbing the floors. He was shown pictures of the concerns observed in Resident room [ROOM NUMBER], #2, #3, #4, #5, #6, #7, #8, #9, and #10, and he stated housekeeping was responsible for cleaning the floors and they were responsible for reporting any maintenance concerns such as the air filter missing in the air condition units so he could replace them. He stated maintenance cleansed the air condition units and he checked them once a month. He stated if the areas were not addressed, it could impact their allergies. In an interview on 06/12/25 at 10:45 AM, the Administrator stated he had spoken with his housekeeping supervisor about the concerns observed in Resident room [ROOM NUMBER], #2, #3, #4, #5, #6, #7, #8, #9, and #10. He stated housekeeping was responsible for ensuring the rooms wereare thoroughly cleaned, including the room and bathroom floors. He stated housekeeping was responsible for cleaning the air filters, but maintenance was responsible for ensuring the air condition unit was cleaned. He stated he would have maintenance include to their schedule to clean the air condition units on a more regular basis. He stated they would try to deep clean the bathroom shower floors to see if they can clean it or repaint it if needed. He stated the trashcans in the dining rooms were maintained by the kitchen staff, but the nursing staff should be monitoring them during the meals to ensure the trashcans had a lid on them throughout the resident's dining experience. He stated the concerns mentioned could impact the resident's homelike experience and it could be a biological hazard for them. Record review of the facility's policy on Environment That Preserves Dignity-Resident Right For 11/01/2017) reflected The facility staff will provide the patient/resident with the right to an environment that preserves dignity and contributes to a positive self image. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676248 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 676248 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/12/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Founders Plaza Nursing & Rehab 721 S Hwy 78 Wylie, TX 75098 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure that residents' environment remained free of accident hazards as was possible for 1 of 6 residents (Residents #53) reviewed for accident prevention. The facility failed to ensure HA D would not transfer Resident #53 using a Hoyer lift (a mechanical lift used to transfer an individual with limited mobility) by herself on 06/10/2025. These failures could prevent the residents from having an environment that was free and clear of accidents and hazards. Findings include: Record review of Resident #53's Face Sheet, dated 06/10/2025, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with amyotrophic lateral sclerosis (a disorder that affects the brain and the spinal cord that results to loss of movement to both upper and lower extremities). Record review of Resident #53's Comprehensive MDS Assessment, dated 04/18/2025, reflected the resident was unable to complete the interview to determine the BIMS score. The Comprehensive MDS Assessment indicated that the resident had amyotrophic lateral sclerosis, used a wheelchair, was dependent on staff for transfer, and required two or more helpers to complete the transfer. Record review of Resident #53's Comprehensive Care Plan, dated 4/11/2025, reflected the resident required the use of Hoyer lift to transfer and one of the approaches was ensure 2 X staff assist transfer. Record review of Resident #53's Physician Order, dated 04/10/2023, reflected TRANSFER with assist X 2 via Hoyer lift. Observation and interview on 06/10/2025 at 9:42 AM revealed HA D was done dressing Resident #53. She said she would transfer the resident to his wheelchair using the Hoyer lift. HA D rolled the resident and fixed the Hoyer sling onto the resident's back. After fixing the Hoyer sling, she went to the resident's wheelchair parked at the base of the resident's roommate bed and lowered the backrest of the wheelchair. She then hooked the loops of the Hoyer sling to the sling attachment points of the Hoyer lift and started to raise the resident by holding the remote control using her right hand. When the Hoyer sling with the resident on it was up, she started to move the Hoyer lift away from the bed and towards the wheelchair located at the base of the resident's roommate. Once the Hoyer lift was near the wheelchair, she spread the legs of the Hoyer lift, and continued to push the Hoyer lift towards the wheelchair. HA D then lowered the resident to the wheelchair with the right hand holding the remote control and with the left hand guiding the Hoyer sling as it descends to the wheelchair. Once the resident was already in the wheelchair, she unhooked the loops of the Hoyer sling from the Hoyer lift, and pulled the Hoyer lift away from the wheelchair. She did not call any staff to help her transfer the resident using a Hoyer lift. In an interview on 06/10/2025 at 9:51 AM, HA D stated she did transfer Resident #53 to his (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676248 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 676248 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/12/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Founders Plaza Nursing & Rehab 721 S Hwy 78 Wylie, TX 75098 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few wheelchair after giving him a bath using a Hoyer lift. She said she did not call any staff to help her because she could do it by herself. She said nobody told her that she should call another staff when transferring the resident. In an interview and observation on 06/10/2025 at 9:54 AM, LVN B stated HA D should have called her or another aide when she was ready to transfer Resident #53 from bed to wheelchair to make sure that the transfer was safe and no injuries would happen to the resident. She said the staff always helped HA D when she called them for any assistance like if she was ready to transfer the resident via Hoyer lift. She said she would talk to HA D about the risk of transferring a resident via Hoyer lift by herself. LVN B went inside the resident's room and talked to HA D. In an interview on 06/12/2025 at 6:29 AM, the ADON stated he was made aware by HA D about the issue in transfer. He said two aides were required every time a resident was transferred using a Hoyer lift to ensure safety of the resident during the transfer. He said one staff would operate the lift and the other one would handle the resident. He said the resident might fall out of the sling and the staff would not be able to catch the resident. He said the facility was responsible in making sure all the staff caring for the residents were trained in using the Hoyer lift, even though they were from an outside agency, like Hospice. He said they would also check for the competency of staff from outside agency. He said the DON already called the Hospice agency to report what happened and started an in-service about safe transfer to inhouse staff. He said the expectation was for all the staff would follow the considerations of transferring via Hoyer lift to any safety issues pertaining to transfer. In an interview on 06/12/2025 at 7:00 AM, the DON stated she was made aware by LVN B regarding HA D transferring Resident #53 using a Hoyer lift by herself. She said it was a no-no to transfer a resident using a Hoyer lift with just one staff. She said the facility's staff said they always assist HA D everytime she called for help with transfer or repositioning Resident #53 so she did not know why HA D did not call anybody when she transferred the resident. She said one-person transfer via Hoyer lift could present safety issue to the resident and to the staff also. She said the resident might fall that could result to injuries. Or the machine could tilt to one side and fell on the staff. She said she already reported HA D to Hospice DON. She said she already made a plan on how to check the competency of the the staff from outside agency. She said she already instructed a head-to-toe assessment for Resident #53. She said the expectation was for all the staff to be knowledgeable on how to transfer the resident and that she already started an in-service about the said issue. In an interview on 06/12/2025 at 7:29 AM, the Administrator stated he already knew the incident about the transfer and they already started an in-service about safe transferring. He said even though the staff was from an external agency, the facility was still responsible in ensuring that all the staff caring for the resident were competent and were compliant with the procedure of safe transfer. He said the expectation was residents would be transferred safely, not only using the Hoyer lift but also using the other forms of transfer. Record review of the facility's policy, MECHANICAL LIFTS: GENERAL GUIDELINES Nursing Policies and Procedures revised May 05, 2023 revealed POLICY: The Facility may employee the use of mechanical lifts to assist with transfers to ensure the safety of patients, residents, and staff . PROCEDURE . 3. Prior to initiating use of mechanical lift . C. Determine how many caregivers are necessary to safely lift the patient or resident. In most cases and for safety, a minimum of 2 caregivers is recommended. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676248 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 676248 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/12/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Founders Plaza Nursing & Rehab 721 S Hwy 78 Wylie, TX 75098 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 0695 Provide safe and appropriate respiratory care 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 observations, interviews, and record review the facility failed to ensure that residents, who needed respiratory care, were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for two (Resident #15 and Resident #222) of 14 residents reviewed for respiratory care. Residents Affected - Some 1. The facility failed to ensure Resident #15's breathing mask (used to receive medications by breathing in mist through nose and mouth) was properly stored when not in use on 06/10/2025 and that there was an order to assess the resident before and after the breathing treatment. 2. The facility failed to ensure a sign was placed outside of Resident #222's room to indicate oxygen was in use on 06/10/2025. These failures could place residents at risk for respiratory infection and not having their respiratory needs met. Findings included: 1. Record review of Resident #15's Face Sheet, dated 06/10/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with heart failure (condition in which the heart cannot pump blood well enough to meet the body's needs), shortness of breath, and anxiety (intense or excessive fear or worry). Record review of Resident #15's Quarterly MDS Assessment, dated 05/07/2025, reflected the resident was cognitively intact with a BIMS score of 14. The Quarterly MDS Assessment indicated the resident had heart failure, shortness of breath, and anxiety. Record review of Resident #15's Comprehensive Care Plan, dated 05/09/2025, reflected the resident had congestive heart failure and shortness of breath and the approaches were to monitor for shortness of breath and administer medications as ordered. Record review of Resident #15's Physician's Order, dated 06/25/2024, reflected Ipratropium-albuterol solution for nebulization 0.5 mg-3 mg(2.5 mg base)/3 mL Shortness of breath 1 VIAL VIA NEBULIZER (a machine that converts liquid medication into fine mist) TWO TIMES A DAY AS NEEDED. There was no order to assess the resident's breath sound, respiratory rate, and oxygen saturation before and after the administration of the breathing treatment. Record review of Resident #15's Progress Notes, dated 05/30/2025 reflected Resident c/o SOB, V/S 118/67, 74, 97.6, 18,92% RA. DuoNeb administered as prn ordered O2 sat 94% RA. Observation and interview on 06/10/2025 at 9:20 AM revealed Resident #15 was sitting at the side of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676248 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 676248 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/12/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Founders Plaza Nursing & Rehab 721 S Hwy 78 Wylie, TX 75098 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 0695 Level of Harm - Minimal harm or potential for actual harm her bed. It was observed that the resident had a nebulization machine on her side table with a breathing mask attached to it. The breathing mask was not bagged and was on top of reading material on a chair beside the side the table. She said she seldom used the breathing mask. She said if she could remember it right, she only used the breathing mask two weeks ago because she experienced shortness of breath. She said the breathing mask had been on the chair since then. Residents Affected - Some Observation and interview on 06/10/2025 at 9:37 AM, LVN B stated Resident #15 had an as needed breathing treatment but only used it once. She said if the resident was not using the breathing mask, it should be inside a clean plastic bag to ensure cleanliness for the next use. She went inside the resident's room and saw the breathing mask on the chair. She disconnected the breathing mask and threw it in the trash can and said she did not notice it when she did her morning round. She said she would get another one and make sure it was inside the plastic bag to prevent any respiratory infection. In an interview on 06/11/2025 at 9:12 AM, Resident #15 stated they replaced her breathing mask and put it in a plastic bag. She said it only made sense that her breathing mask would be clean in case she would need it again. Observation and interview on 06/11/2025 at 11:08 AM, LVN B stated when a resident was administered a breathing treatment, the staff should assess the resident before and after the treatment to see if the treatment was effective. She opened Resident #15's profile and saw that the resident only had a physician's order to administer the breathing treatment and did not have a separate order to assess for breathing sound, respiratory rate, and the oxygen saturation before and after the treatment. She said an order for the assessment could be added or incorporated on the instruction part of the order for the breathing treatment. She said if the staff needed to assess the breathing sound, respiratory rate, and the oxygen saturation, then there should be order for the assessment. Observation and interview on 06/11/2025 at 2:26 PM, RN A stated she did not notice that Resident #15's breathing mask was not bagged when she made her round. She said the resident seldom used it but when she was not using it, it should be inside a plastic bag to prevent it from being dirty. She transcribed the resident's order for the breathing treatment in connection to her anxiety. She said an assessment should be done before and after the treatment to check the effectiveness of the breathing treatment. She said the assessment should be done for routine and as needed breathing treatment. She then opened the resident's profile and added to assess the breath sound, respiratory rate, and oxygen saturation before and after the treatment on the instruction box of order for the treating treatment. In an interview on 06/12/2025 at 6:05 AM, LVN C stated Resident #15 was administered a breathing treatment due to shortness of breath. She said she was the one who assessed for the effectiveness of the treatment. She said she checked the resident after treatment was done. She said according to the shift report on 05/30/2025, the resident was complaining of shortness of breath that was why she was given a breathing treatment. She said there should be an order to evaluate the effectiveness of the breathing treatment before and after the treatment's administration to see if the treatment was effective. She also said that she did not notice that the resident's breathing mask was on the chair and was not inside a bag on 06/10/2025. She said it should be bagged to maintain cleanliness of the mask for future use. In an interview on 06/12/2025 at 6:29 AM, the ADON stated the breathing mask should be stored properly inside a plastic bag if the residents were not using them to prevent cross contamination and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676248 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 676248 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/12/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Founders Plaza Nursing & Rehab 721 S Hwy 78 Wylie, TX 75098 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some respiratory infections. He said the staff were responsible in monitoring if the breathing mask was bagged. He said the resident should be assessed before and after giving the breathing treatment to. He said there should be a separate order for the assessment of the breathing treatment or should be incorporated in the order for the breathing treatment. He said the result of the assessment should be recorded in the resident's vital signs documentation. He said the expectation was for the staff to be mindful and bag the breathing mask and make sure there was an order for the assessment. He said the nurses were responsible for bagging the breathing mask as well as transcribing tie order. he said he was responsible in overseeing that they were compliant. He said they already started an in-service about bagging the breathing mask as well as the need for an order for assessing the resident before and after administering the breathing treatment. In an interview on 06/12/2025 at 7:00 AM, the DON stated Resident #15's breathing mask should be inside a plastic bag even though it was sitting in a chair. She said it was not known when the mask had been sitting in the chair. She said the mask should be inside a bag to maintain its cleanliness as well as its patency. She said it was standard for nurses to assess a resident using a breathing treatment before and after the administration to assess the effectiveness of the treatment. She said even though the nurses knew what to do, there should be an order for the intervention because everything done for the residents needed an order. She the nurses were responsible in transcribing the orders in the resident's profile but she was responsible in checking if the order were complete or if the related orders were also included. She said she already started an in-service about bagging the breathing mask and assessing the resident with breathing treatments before and after for breath sound, respiratory rate, and oxygen saturation. If the treatment was not effective, the staff needed to notify the physician so appropriate interventions could be done. In an interview on 06/12/2025 at 7:29 AM, the Administrator stated they were vigilant in reminding the staff to bag the respiratory paraphernalia that the residents were using. He said the breathing mask should be inside a plastic bag when the resident was not using it or remove it and just put a new one when needed. He said the risk of the breathing mask lying on the chair were transfer of the germs from the chair to the breathing mask that could eventually cause any respiratory issues. He said the expectation was for the staff to be mindful that when they do their rounds, they should also check if the breathing mask was bagged. he said the DON already started an in-service pertaining to bagging the breathing mask. He said, since he was not a clinician, the DON would take the lead with regards to the order before and after the breathing treatment. In an interview on 06/12/2025 at 2:56 PM, LVN F stated she administered Resident #15's breathing treatment on the night of 05/30/2025 because the resident verbalized she was having a hard time breathing. She said, in nursing, one of the principles was to assess the resident before administering the breathing treatment so that there would be a comparison after the treatment. She said she did assess the resident but what she was not sure of was if there was an order for it. She said there should be an order to assess before and after the treatment because everything done for the resident should have an order. she said the breathing mask should also be bagged to prevent cross contamination. She said she did not notice that the breathing mask was not bagged on her last shift in the facility. 2. Record review of Resident #222's Face Sheet, dated 06/12/2025, reflected a [AGE] year-old male who admitted to the facility on [DATE]. Resident #222 had diagnoses which anemia (low blood cell count) and immunodeficiency (disorder that prevents immune system from working correctly). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676248 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 676248 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/12/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Founders Plaza Nursing & Rehab 721 S Hwy 78 Wylie, TX 75098 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of Resident #222's Comprehensive MDS Assessment, dated 06/05/2025, reflected the resident had intact cognition with a BIMS score of 14. The Comprehensive MDS Assessment indicated the resident had anemia. Section O (special treatments, procedures, and programs) indicated Resident #222 received continuous oxygen. Record review of Resident #222's Comprehensive Care Plan, dated 11/04/2024, reflected the resident was at risk for shortness of breath related to the disease process. One of the interventions was to administer oxygen as ordered. During an interview and observation on 06/10/2025 at 9:10 AM, revealed Resident #222 was sitting up in bed. Resident #222 stated he had been in the facility for about a week and used oxygen all the time. There was no sign on the door indicating oxygen use in the resident's room. During an interview on 06/11/2025 at 12:45 PM, the ADON stated it was important to have a sign outside the resident's room indicating the use the oxygen in the room. He stated it was dangerous to have anything flammable around oxygen because it risked harm to the resident. During an interview on 06/11/2025 at 2:20 PM, the Administrator stated all residents who used oxygen continuous or PRN should have a sign outside their room reflecting oxygen in use. He stated the nurse who admitted a resident with oxygen was responsible for placing a sign outside the door. The Administrator stated the signs were kept in the room where oxygen tanks were stored. During an interview on 06/12/2025 at 9:02 AM, the DON stated the charge nurse who admitted the resident was responsible for placing a sign outside the resident's room indicating oxygen in use. She stated prior to a resident arriving, the staff knew if a resident was on oxygen. She stated the nurse should have an oxygen concentrator in the resident's room and a sign outside the room indicating oxygen in use. She stated the checklist in the admission packet includes putting a sign on the door if a resident is on oxygen. She stated the ADON and DON look at the admission paperwork also. She stated management should also observe when doing guardian angel rounds. The DON stated everyone was responsible for monitoring and ensuring there were signs outside a room reflecting oxygen in use. Record review of the facility's policy RESPIRATORY TREATMENT, CARE AND SERVICES PROGRAM Nursing Policies and Procedures revised May 05,2023 revealed POLICY: The Facility ensures the safe, appropriate, and effective provision of respiratory treatment, care, and services in accordance with professional standards of practice . PROCEDURES . Infection control practices including standard and transmission-based precautions are . B. Handling of equipment, including cleaning, storage. Review of the facility's policy, Respiratory Policies and Procedures: Oxygen therapy, revised 02/12/2024, reflected Check the patient's/resident's room to make sure it's safe for oxygen administration, place oxygen precautions sign on the door of the patient's/resident's room. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676248 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 676248 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/12/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Founders Plaza Nursing & Rehab 721 S Hwy 78 Wylie, TX 75098 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 - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure all drugs and biological were stored in accordance with currently accepted professional principles for two (Resident #18 and Resident #56) of sixteen residents reviewed for pharmaceutical services. 1. The facility failed to dispose of Resident #8's expired Advair (medication inhaled to treat asthma) dated 05/21/2025. 2. The facility failed to ensure that the amount on Resident #56's Lorazepam (antianxiety medication) container was the same with the amount written on the narcotic sheet on 06/11/2025. These failures could place residents at risk of not receiving the medication's full therapeutic benefits, possible side effects, and not identifying promptly the potential loss of a controlled medication. The findings included: 1. Record review of Resident #8's Face Sheet, dated 06/11/2025, reflected an [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs). Record review of Resident #8's Comprehensive MDS Assessment, dated 05/29/2025, reflected the resident had a severe impairment in cognition with a BIMS score of 03. The Comprehensive MDS Assessment indicated the resident had chronic obstructive pulmonary disease. Record review of Resident #8's Comprehensive Care Plan, dated 05/30/2025, reflected the resident had COPD and one of the approaches was to provide medications as ordered. Record review of Resident #8's Physician's Order, dated 10/11/2024, reflected Advair HFA (fluticasone propion-salmeterol) HFA aerosol inhaler 115-21 mcg/actuation 2 puff. Observation and interview on 06/11/2025 at 11:50 AM revealed an expired Advair on the hall 200 cart. The date on the inhaler was 05/21/2025. LVN B said she did not notice that Resident #8's expired inhaler was still inside the cart. She said resident had a new one and that was what she was administering to the resident. She said the expired one should not be inside the cart so that staff administering the medication would not mistakenly use the expired one. She said the effectiveness of the medication already diminished when it was expired or there could be adverse reactions from the expired medication. She said she would audit her cart to make sure there was no expired medications. She took the inhaler from the cart and went inside the medication room to dispose it. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676248 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 676248 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/12/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Founders Plaza Nursing & Rehab 721 S Hwy 78 Wylie, TX 75098 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 2. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #56's Face Sheet, dated 06/11/2025, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with anxiety disorder. Residents Affected - Some Record review of Resident #56's Comprehensive MDS Assessment, dated 05/15/2025, reflected the resident had a severe impairment in cognition with a BIMS score of 04. The Comprehensive MDS Assessment indicated that the resident had anxiety disorder (intense or excessive fear or worry). Record review of Resident #56's Comprehensive Care Plan, dated 05/21/2025, reflected the resident receives antianxiety medication and one of the approaches was to give medications as ordered. Record review of Resident #56's Physician's Order, dated 05/14/2025, reflected Lorazepam concentrate 2 mg/mL 0.25 give 0.25-1ml q 4hrs PRN Generalized anxiety disorder. Observation and record review on 06/11/2025 at 11:57 AM revealed a bottle of Resident #56's Lorazepam was inside the refrigerator in the medication room. It was observed that the amount remaining in the bottle was approximately between 15 ml and 20 ml while the recorded amount on Resident #56's Lorazepam narcotic sheet was 21.5 ml. There was a discrepancy of approximately 4 ml between the written compared to the amount in the bottle. Observation and interview on 06/11/2025 at 12:04 PM revealed the ADON inspected Resident #56's Lorazepam and saw that the amount inside the bottle was not the same when compared to the written amount on Resident #56's Lorazepam narcotic sheet. With the use of a flashlight from his cellphone, he checked again the amount on the bottle and said it was less than 20 ml. He opened the bottle and made sure that the dropper on the bottle was empty but the amount was still less than 20 ml. He said he would notify the DON and the Administrator about the concern and would also start interviewing the staff regarding the discrepancy. In an interview on 06/11/2025 at 12:15 PM, LVN B stated they always counted the narcotics in the lock box as well as the narcotics inside the refrigerator in the medication room. She said it was an oversight on her part because she did not notice that there was an inconsistency between the actual amount of the Lorazepam and the amount written in the narcotic sheet. She said it was important that both amounts were the same because it seemed like there was a missing medication. She said she did not give Resident #56 's Lorazepam because it was scheduled during bedtime but she was responsible in making sure the amount left was right. She said the incident should never happen again. In an interview on 06/11/2025 at 2:26 PM, RN A stated she would administer Resident #56's Lorazepam at bedtime. She said she did not notice that the amount on the bottle was not the same with what was written in the narcotic sheet. She said they always counted the narcotics during shift change and did not have any excuse for not seeing the discrepancy. She said she would be mindful in checking the narcotics so she could report it immediately to the DON. She also said that she did not see the expired inhaler in the cart. She said there should be no expired medication inside the cart for the basic reason that it was already expired and could not be used for the resident. She said there might be no so harmful effect but the potency of the medication was already less. In an interview on 06/12/2025 at 6:05 AM, LVN C stated she would always count the narcotics with the outgoing nurse and the incoming nurse to make sure that the narcotic count was correct. She said it did not occur to her that there was a discrepancy on the amount of Resident #56's Lorazepam. She (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676248 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 676248 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/12/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Founders Plaza Nursing & Rehab 721 S Hwy 78 Wylie, TX 75098 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 - Some said she overlooked it and would be careful the next time she would count the narcotics that all narcotics were accounted for. She said she was not aware that there was an expired inhaler inside the hall 200 cart. She said it should have been disposed as soon as it expired so the staff would not accidently use it for the resident. In an interview on 06/12/2025 at 6:29 AM, the ADON stated there should not be expired medication inside the carts. He said the nurses and medication aides were responsible in ensuring there were no expired medication. He said he was also responsible in checking and auditing the carts for expired medications. He said the expectation was the staff would really check the count and amount of the narcotics during shift change, report immediately if discrepancies were found, and make sure there was no expired medication inside the carts. In an interview on 06/12/2025 at 7:00 AM, the DON stated she was made aware about the inconsistency on the amount of Resident #56's Lorazepam and she immediately started the in-service. She said she did not how it happened and why it was not discovered during shift change. She said she already talked to the nurses handling the narcotic and they could not explain as well how it happened. She said it was important that the remaining amount in the bottle was the same with what was documented to negate the fact that there were missing Lorazepam. She said the discrepancy should have been noticed during narcotic count every shift change. She said the expired inhaler should not be kept inside the cart so it will not be used for the resident. She said the risk she could mention was that the potency of the medication was already less but one would never know because there might be a harmful effect when an expired medication was used. She said she already started an in-service pertaining to making sure the amount of the narcotics would be the same with what was written in the narcotic sheet and said she would start an in-service that no expired medication be inside the cart. she said her expectation was for the staff to make sure that the count were correct and that the expired medications were disposed accordingly. In an interview on 06/12/2025 at 7:29 AM, the Administrator stated he was made aware by the DON about the narcotic discrepancy and he already reported it to state and also started the investigation. He said when the staff were administering liquid narcotic, they have to make sure that they were giving the exact amount to prevent any discrepancies in the amount. He said he also checked Resident #56's Lorazepam and saw it was below 20 ml in contrast to the amount written which was 21.5 ml. He said he also suggested the use of a syringe instead of a dropper to get the exact amount. He said expired medications should be disposed as soon as it expired. He said he was not a clinician, but one thing he knew, expired medication cannot be used. He said they already started an in-service regarding the making sure the correct remaining amount of the narcotics were the same with what was written. He said he would coordinate with the DON regarding the expired medication. In an interview on 06/12/2025 at 2:56 PM, LVN F stated they do narcotic counts every shift change but since there a discrepancy, then they were not doing a great job in making sure the correct count or amount of Resident #56's Lorazepam was observed. She said she also did notice the expired inhaler inside the cart. She said if the medication was expired, the resident might not receive the full benefit of the medication. Record review of the facility's policy Controlled Substances Pharmacy Services Policies and Procedures revised 04/17/2024 revealed POLICY . 2. The Facility will conduct routine reconciliations of all Controlled Substances to prevent any potential loss or diversion . PROCEDURE . 4. A scheduled reconciliation (shift change count) of controlled substance inventory should be completed at every nursing shift change and documented . D. The oncoming nurse/authorized staff member visually checks this (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676248 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 676248 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/12/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Founders Plaza Nursing & Rehab 721 S Hwy 78 Wylie, TX 75098 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 - Some FORM CMS-2567 (02/99) Previous Versions Obsolete number against the Inventory Record Sheet . E. The nurse/authorized staff should always use the meniscus level of the liquid to estimate the volume of a liquid-controlled substance . F . Any observed discrepancy between the recorded amount and what appears to be remaining in the container should be reported to the DON. Record review of the facility's policy MEDICATION MANAGEMENT PROGRAM Pharmacy Services Policies and Procedures revised May 05, 2023 revealed POLICY: The Facility implements a Medication Management program to meet the pharmaceutical needs of patients and residents . Administering the Medication Pass . D. Checking for expiration dates and removing any expired products. Event ID: Facility ID: 676248 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 676248 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/12/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Founders Plaza Nursing & Rehab 721 S Hwy 78 Wylie, TX 75098 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 - Few 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 observations, interviews, and record review, the facility failed the medication was labeled in accordance with currently accepted professional principles and include the appropriate accessory and cautionary instructions for one (Resident #53) of six residents reviewed for labelling of drugs and biologicals. The facility failed to ensure a change of instruction label was placed on Resident #53's Lorazepam after a change to the order. This failure could place residents at risk of wrong medication administration, mismanagement of care, adverse effects, and physical harm. Findings included: Record review of Resident #53's Face Sheet, dated 06/11/2025, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with anxiety (intense or excessive fear or worry). Record review of Resident #53's Comprehensive MDS Assessment, dated 04/18/2025, reflected the resident was unable to complete the interview to determine the BIMS score. The Comprehensive MDS Assessment indicated that the resident had anxiety. Record review of Resident #53's Comprehensive Care Plan, dated 4/21/2025, reflected the resident received antianxiety medication and one of the approaches was to give medication as ordered. Record review of Resident #53's Physician's Order, dated 12/20/2024, reflected Lorazepam concentrate 2 mg/mL 0.5 ml Every Day Restlessness and agitation Antianxiety. Observation and interview on 06/11/2025 at 8:02 AM revealed Resident #53's order for Lorazepam was to give every day routinely. There was no order for as needed. It was observed that the order on the medication bottle was to give as needed. LVN B stated the order for the resident's Lorazepam were both routine and as needed. She checked the resident's profile and did not see an order for PRN. She went inside the medication room and said there was no other bottle for the resident's Lorazepam. She said if the staff were still using the Lorazepam with an order for PRN, there should be a sticker on the container notifying the staff that there was a change in instruction. She said or put a note on the container the order was changed to prevent confusion in administering the medication. Observation and interview on 06/11/2025 at 8:09 AM, the ADON stated when administering medications, the staff giving the medications should make sure they were reading the order in the bottle and comparing it with the order in the system. He said if there was change in order, the container should have a note of change of direction to avoid medication error, undermedication, overmedication, or confusion among the staff. The ADON added the nurses could place a change in order instruction on the bottle. He checked Resident #53's Lorazepam and saw that the order in the bottle was to give as needed. He checked the order on the system and saw the order was to give routinely. The ADON concluded he would monitor the staff administering the medications, give re-education, audit the medication carts, and make sure the medications correlate with the eMAR and the order in the package. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676248 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 676248 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/12/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Founders Plaza Nursing & Rehab 721 S Hwy 78 Wylie, TX 75098 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 - Few In an interview on 06/12/2025 at 7:00 AM, the DON stated the staff should have placed a change in order instruction on Resident #53's Lorazepam to avoid confusion. The DON said the staff should have been alerted if they saw there was a difference with the order in the bottle and the order in the system. The DON said the risk were overmedication or undermedication which could have an adverse effect for the residents. The DON said the expectation was to provide the right dosage of medication as per order. She said she already started an in-service regarding proper labelling. In an interview on 06/12/2025 at 7:29 AM, the Administrator stated he would let the clinician answer about the administering medications. The Administrator said whatever the procedure was in giving the medications, it should have been followed to prevent any errors. Record review of the facility's policy MEDICATION MANAGEMENT PROGRAM Pharmacy Services Policies and Procedures revised May 05, 2023 revealed POLICY: The Facility implements a Medication Management program to meet the pharmaceutical needs of patients and residents . Administering the Medication Pass . 5. The authorized staff member validates the following information is documented on the MAR . A. Correct physician's order and diagnosis for each medication . B. Medication and label are correct. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676248 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 676248 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/12/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Founders Plaza Nursing & Rehab 721 S Hwy 78 Wylie, TX 75098 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for two (Resident #53 and Resident #56) of ten residents reviewed for infection control. Residents Affected - Some 1. The facility failed to ensure HA D wore a gown while dressing Resident #53, who had a g-tube (gastrostomy feeding tube: a tube that is surgically inserted through the skin of the belly and into the stomach), and was on enhanced barrier precautions, on 06/10/2025. 2. The facility failed to ensure that LVN H changed his gloves and performed hand hygiene when providing wound care to Resident #56 on 06/11/2025. These failures could place residents at risk of cross-contamination and development of infections. Findings included: 1. Record review of Resident #53's Face Sheet, dated 06/11/2025, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with gastrostomy status (having done a surgical procedure that creates artificial opening into the stomach to provide nutritional support). Record review of Resident #53's Comprehensive MDS Assessment, dated 04/18/2025, reflected the resident was unable to complete the interview to determine the BIMS score. The Comprehensive MDS Assessment indicated that the resident had a feeding tube (medical device that helps deliver nutrition and medication directly to the person's stomach). Record review of Resident #53's Comprehensive Care Plan, dated 04/27/2025, reflected the resident was on enhanced barrier precautions for g-tube and one of the goals was infection control. Record review of Resident #53's Physician Order, dated 04/26/2024, reflected Patient is on ENHANCED BARRIER PRECAUTIONS to help protect the resident from infection every shift. Observation and interview on 06/10/2025 at 9:42 AM, HA D stated she just gave Resident #53 a bath and she was just finishing dressing him. It was observed that the resident had a g-tube and that there was a sign outside the resident's door that enhanced barrier precautions were required when dressing the resident. HA D did not wear a gown while dressing the resident. She said she was not aware that she needed to wear a gown when dressing the resident. In an interview on 06/10/2025 at 9:51 AM, HA D stated she should have worn a gown when he was dressing Resident #53 because he had a g-tube and the gown was used to prevent cross contamination to a resident that was vulnerable. She said she did not know what happened that she forgot to wear a gown. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676248 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 676248 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/12/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Founders Plaza Nursing & Rehab 721 S Hwy 78 Wylie, TX 75098 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 In an interview on 06/10/2025 at 9:54 AM, LVN B stated HA D should wear a gown when dressing Resident #53 because the resident had a g-tube. She said there was sign outside the door to remind the staff that when doing a high contact care like dressing the resident, a gown should be worn to protect the resident from infection. She said the enhanced barrier protection was used to minimize the spread of resistant organisms. She said she would talk to HA D and remind her to wear a gown as ordered. Residents Affected - Some In an interview on 06/12/2025 at 6:29 AM, the ADON stated when a resident had a g-tube, open wound, or catheter, the staff should wear a gown because those residents were on enhanced barrier precautions. He said the purpose of which was to prevent cross contamination and development of infection to resident with indwelling medical devices. He said the expectation was all the staff would wear a gown when performing high contact care to the resident who required enhanced barrier precautions. He said the DON already started an in-service about enhanced barrier precautions as soon as LVN B told them the issue of HA D not wearing a gown when required to. In an interview on 06/12/2025 at 7:00 AM, the DON stated if a resident was on enhanced barrier precautions, the staff should wear a gown when providing care to them. She said residents with feeding tubes required enhanced barrier precautions to decrease their exposure to pathogens that could cause infection. She said the expectation was for the staff wear gowns when caring for residents on enhanced barrier precautions. She said she already started an in-service about enhanced barrier precautions when LVN B made them aware about the issue. She said she would personally monitor the staff's adherence to the policy and procedure of enhanced barrier precautions. She said since HA D was from a hospice agency, she already made a plan on how to check the competency of staff from outside agency. In an interview on 06/12/2025 at 7:29 AM, the Administrator stated that staff must be mindful in preventing spread of germs and development of infection, especially for the vulnerable. He said there was a sign outside the Resident #53's door to remind the staff that they should wear a gown when caring for the resident. He said he was not a clinician and would let the DON take the lead about the issue. He said the DON already started an in-service regarding enhanced barrier precautions. 2. Record Review of Resident #56's Face Sheet, dated 06/12/2025, reflected the resident was a [AGE] year-old male who admitted to the facility on [DATE]. Resident #56 had diagnoses which included malignant neoplasm (cancerous tumor) of the liver (essential organ that filters blood and makes substances needed by the body), hypertension (high blood pressure), and a pressure ulcer (damage to skin caused by prolonged pressure) on the right heel. Record review of Resident #56's Quarterly MDS (tool used to assess functional capabilities and health needs) Assessment, dated 05/15/2025, reflected the resident had severely impaired cognition with a BIMS (tool used to assess cognition) score of 04. Section M (skin conditions) reflected the resident received skin treatment for a pressure ulcer. Record review of Resident #56's Comprehensive Care Plan, dated 08/28/2024, reflected the resident had a pressure ulcer on the right heel. One intervention was to provide wound care as ordered. During an observation and interview on 06/11/2025 at 9:20 AM, revealed LVN H was preparing to provide wound care for Resident #56. LVN H washed his hands in the resident's restroom. LVN H used a sanitizing wipe to clean the resident's bedside table. He removed his gloves, used hand sanitizer, and put on clean gloves. LVN H draped wax paper over the bedside table and placed the wound care supplies (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676248 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 676248 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/12/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Founders Plaza Nursing & Rehab 721 S Hwy 78 Wylie, TX 75098 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 - Some on it. LVN H removed the gloves and used hand sanitizer. LVN H entered Resident #56's room, explained to the resident what he was going to do, and pulled the curtain to provide privacy. LVN H used hand sanitizer and put on clean gloves. LVN H removed the soiled dressing and used moistened gauze to clean the wound on Resident #56's heel. LVN H removed his gloves and did not use hand sanitizer before putting on clean gloves. LVN H used a cotton swab to remove the medicated ointment from a small medicine cup. He applied it to the wound and placed xeroform (non-adherent wound dressing that promotes healing) on the wound. LVN H changed his gloves, used hand sanitizer, and covered the wound with a dry dressing that was dated and initialed. LVN H removed his gloves and used hand sanitizer. LVN stated he should have used hand sanitizer after removing the soiled dressing and cleaning Resident #56's wound. He stated it was important to wash their hands or use hand sanitizer when changing gloves. LVN H stated it was important to prevent contamination from the wound and soiled dressing. During an interview on 06/11/25 at 12:27 PM, the ADON stated LVN H should have cleaned his hands after removing the soiled gloves. He stated it was important to prevent infection. He stated the failure could prevent the wound from healing like it should. During an interview on 06/11/25 at 12:35 PM, the DON stated precautions were in place to add protection for the resident and caregiver, and to prevent the spread of infection. She stated the facility provided mandatory in-services and always talked to staff about infection control. She stated in-services included return demonstration by staff. The DON stated she would immediately provide an in-service on infection control. Record review of the facility's policy, TRANSMISSION BASED STANDARD PRECAUTIONS, AND ENHANCED BARRIER PRECAUTIONS Infection Prevention and Control Policies and Procedures revised May 15, 2023 revealed PROCEDURES: Enhanced Barrier Precautions . Enhanced Barrier Precautions expand the use of PPE (gowns and gloves) during high contact resident care activities . A. EBP will be implemented for all residents . 2) Wounds . feeding tube . B. EBP will be implemented during . 1) Dressing . Review of the facility's policy Hand Hygiene/Handwashing, revised 05/15/2023, reflected Hand hygiene/handwashing is done .H. After removal of medical/surgical or utility gloves. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676248 If continuation sheet Page 21 of 21