Health inspection·January 26, 2023

F 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interview on 01/25/23 at 11:52 AM and 1:02 PM Dietary Manager stated the kitchen was using Styrofoam containers for lunch today. She stated she was short on dietary staff in the kitchen and did not have a staff member to run the dishwasher. She stated dish machine had been fixed since 01/08/23 but the facility was using Styrofoam containers for meals due to short staff. She stated to be fully staffed would be to have 3 dietary staff in the kitchen and right now the kitchen had only 2 dietary staff. She stated she was assisting to help in the kitchen as needed. Observation on 01/25/23 at 1:24 PM revealed a lunch test tray served in a Styrofoam container with lid containing a regular diet of country fried steak with gravy, beans and stewed okra/tomatoes and bread. The test tray was received with food warm. Interview on 01/25/23 at 12:55 PM Maintenance Director stated he had been only working at facility for about a week. He was unaware of any issues with dish machine not working. Follow-up interview on 01/25/23 at 1:32 PM with Dietary Manager revealed residents had been complaining about cold food since they started using Styrofoam about a week and half ago. She stated the facility had just hired a dish washer starting on Friday so they will be able to start using regular dishes including plates and warmers. She stated the managers should be assisting with passing out meal trays so residents could get their meals sooner. Record Review revealed Dish Machine repair dated 01/05/23 reflected Representative from Consultant Company reflected Machine down. Not filling. 01/05/23 summary reflected Machine is now up and running. Replaced water solenoid valves, replaces rinse thermometer, and cleaned and trained on cleaning wash arms. Interview on 01/25/23 at 3:25 PM with Administrator stated they had just hired two dietary staff and as soon as they have been through orientation they will be able to work in the kitchen. He stated he had only authorized Styrofoam containers use for meals while the dish machine was down and stated he had not had a chance to communicate with Dietary Manager about using Styrofoam containers this week. He stated he was not aware of residents complaining about cold food. Review of facility's policy Resident Rights revised December 2016 reflected Employees shall treat all residents with kindness, respect and dignity .These rights include the resident's right to: .e. self-determination FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676352 If continuation sheet Page 2 of 15 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 676352 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Stonemere Rehabilitation Center 11855 Lebanon Road Frisco, TX 75035 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 0635 Provide doctor's orders for the resident's immediate care at the time the resident was admitted. 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 have Physician Orders for the resident's immediate care for one (Resident #194) of three resident reviewed for admission Physician Orders. Residents Affected - Few The facility failed to have Physician orders for the use of Oxygen and the amount to be administered to Resident #194 upon her admission to the facility. This failure could place residents who received oxygen therapy at risk of receiving an incorrect amount of oxygen and the risk of oxygen toxicity. Findings included: Review of Resident #194's Face Sheet, dated 01/25/23, reflected she was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included chronic respiratory failures, hypertension heart disease with heart failure and sepsis. Review of Resident #194's Hospital Facility Transfer Orders dated 01/14/23 reflected, .Oxygen GuidelinesContinuous .Titrate oxygen delivered to keep SaO2 percentage above 90% . with a start date of 01/05/23. Review of Resident #194's Nursing admission Assessment, dated 01/14/23 and completed by ADON A, reflected, Reason for admission: Respiratory Failure with Hypoxia .Respiratory .Oxygen- Yes .Oxygen volume (liters/min)-2 lpm .Oxygen deliver- Nasal canula . Review of Resident #194's Physician Order Summary, dated from 01/25/23, reflected no orders for Oxygen. Review of Resident #194's Weights and vital sign report dated from 01/15/23 through 01/23/23 reflected O2 Sats were monitored daily. There were no Sats below 94%. Observation on 01/24/23 at 10:05 a.m. revealed CNA E assisted Resident #194 from the bathroom to her bed. Resident #194 was using O2 via a nasal cannula at 2 liters per minute. In an interview Resident #194 on 01/24/23 at 10:06 a.m. she stated she was always using her O2. Observation on 01/25/23 at 12:25 p.m. revealed Resident # 194 sitting up in her wheelchair in her room with O2 via nasal cannula in use. O2 was set at 2 liters per minute. Interview on 01/25/23 at 12:30. p.m. with LVN F stated any resident with oxygen had to have an order with the number of liters per hour to be delivered. She stated they check every resident's O2 Sats when they get their daily vital signs. She stated she knew she was on 2 liters of O2 because she had read the resident's hospital summary so she would know the resident's history. She stated she had not noticed there were no orders for the Oxygen. She stated the admitting nurse was responsible for obtaining the admission orders when a new resident comes into the facility. She stated Oxygen was considered a medication and a nurse could not provide it without an order. She stated giving too much oxygen or providing oxygen that was not needed could make the residents breathing worse. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676352 If continuation sheet Page 3 of 15 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 676352 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Stonemere Rehabilitation Center 11855 Lebanon Road Frisco, TX 75035 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 0635 Level of Harm - Minimal harm or potential for actual harm Interview with ADON A on 01/26/23 at 8:50 a.m. stated she had done the admission assessment and orders for Resident #194. She stated she had only put in the medication orders and must have overlooked the Oxygen. She stated if the hospital discharge orders does not address how much Oxygen a resident requires, they have to clarify it with the physician to determine the amount and frequency the Oxygen is to be delivered. She stated giving to much Oxygen could be toxic to a resident. Residents Affected - Few In an interview with the DON on 01/16/23 at 09:26 a.m. stated any resident who required oxygen had to have an order from the physician which stated the number of liters to be delivered. She stated it was a requirement that the physician determine how much supplemental oxygen someone needed and was not a nurse's judgement. She stated the nurses were supposed to assess the resident's respiratory status, including ensuring the Oxygen was delivered at the prescribed rate. She stated giving to much oxygen could lead to Co2 build up and respiratory decline. Review of the facility's policy titled, Reconciliation of Medications on Admission, revised on July 2017, reflected, The purpose of this procedure is to ensure medications safety by accurately accounting for the resident's medications, routes and dosages upon admission or readmission to the facility .Medication reconciliation is the process of comparing pre-discharge medications to post-discharge medications .that includes the drug name, dosage, frequency, route, and indication for use .If there is a discrepancy or conflict in medications, dose route or frequency, determine the most appropriate action to resolve the discrepancy, For example .Contact the nurse from the referring facility .Contact the physician from the referring facility .Contact the resident's primary physician in the community .Contact the admitting and/or Attending Physician . Review of the facility's policy titled, Oxygen Administration and Therapeutics, dated November 2022, reflected, The facility requires that a physician's order be obtained prior to the administration of oxygen via nasal cannula. The orders for oxygen via nasal cannula must state the: Liter flow- Duration of use (PRN, continuously, etc,) or Specific weaning criteria, for example, maintain oxygen saturation between_ and _% as applicable . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676352 If continuation sheet Page 4 of 15 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 676352 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Stonemere Rehabilitation Center 11855 Lebanon Road Frisco, TX 75035 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, interview, and record review the facility failed to ensure residents who needed respiratory care were provided such care, consistent with professional standards of practice and the comprehensive person-centered care plan for two (Residents #11 and #14) of five residents reviewed for respiratory care. Residents Affected - Some 1. The facility failed to ensure Resident #11's oxygen tubing and humidifier were not on the floor. The facility failed to ensure oxygen tubing and humidifier were changed weekly. 2. The facility failed to obtain a physician order for the use of oxygen therapy via trach and trach care for Resident #14. These failures could place residents at risk of receiving incorrect amount of oxygen therapy and not receiving the respiratory care they needed. Findings included: 1. Review of Resident #11's Significant Change MDS assessment dated [DATE] reflected Resident #11 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of heart failure, hypertension, kidney disease, chronic obstructive pulmonary disease and palliative care . Resident #11 had a BIMS of 15 indicating she was cognitively intact. Resident #11 required supervision to limited assistance with ADLs. Resident #11 required oxygen therapy. Review of Resident #11's Consolidated Physician Orders dated 01/25/23 reflected Resident #11 had a Physician Order dated 07/26/22 for oxygen 2 liters via nasal cannula for shortness of breath daily. Review of Resident #11's licensed nurse administration record dated 01/25/23 reflected no physician order for oxygen tubing or humidifier change for Resident #11 to be completed. Observations on 01/24/23 at 01:23 PM and 1:26 PM revealed Resident # 11's oxygen humidifier dated 12/26/22 and nasal cannula tubing were on the floor to the right of his bed. Interview on 01/24/23 at 1:26 PM LVN H revealed Resident #11's oxygen tubing and humidifier should not be on floor and will have to be changed. LVN H told Resident # 11 if she did not change it could lead to resident getting an infection since it was on the floor. LVN H stated the oxygen humidifier was dated 12/26/22 but oxygen tubing was not dated. Interview on 01/24/23 at 1:27 PM Resident #11 revealed he had noticed his oxygen tubing on the floor this morning but did not know how long it had been on the floor. Interview on 01/24/23 at 1:31 PM LVN H stated the oxygen tubing and humidifier should be changed weekly. LVN H stated she will change both humidifier and oxygen tubing for Resident #11. LVN H stated Resident #11 was on hospice services and oxygen was a PRN physician order. Interview on 01/25/23 at 11:15 AM DON stated Resident #11's oxygen tubing and humidifier should be changed weekly by nursing for his oxygen concentrator. She stated when Resident #11 is not using his oxygen concentrator the oxygen tubing should be bagged. She stated the oxygen tubing and humidifier should not be on the floor. She stated Resident #11's oxygen humidifier dated 12/26/22 is not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676352 If continuation sheet Page 5 of 15 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 676352 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Stonemere Rehabilitation Center 11855 Lebanon Road Frisco, TX 75035 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 acceptable and they date when changed the humidifier. She stated there should be physician orders in Resident #11's MAR to indicate to nursing to show when oxygen tubing and humidifier should be changed. 2. Review of Resident #14's Face Sheet dated 01/26/23 reflected Resident #14 was a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of encephalopathy (brain disease that alters brain function or structure), acute respiratory failure with hypoxia, quadriplegia (paralysis of both legs and both arms) malignant neoplasm (tumor) of brain, dysphagia (swallowing difficulties), aphasia (language disorder when you have brain damage) and attention to tracheostomy. Review of Resident #14's Comprehensive Care Plan initiated on 02/11/16 with target date of 04/19/23 reflected Resident #14 had tracheostomy in place. Interventions included Give humidified oxygen as prescribed. Review of Resident #14's admission Evaluation dated 01/19/23 reflected Resident #14's respiratory status of oxygen at 5 liters per trach. Review of Resident #14's Consolidated Physician Orders dated 01/25/23 reflected no physician order for oxygen therapy via trach for Resident #14. In addition, there was no physician order for trach care for Resident #14. Record Review of Resident #14's Licensed Nurse Administration record dated 01/25/23 reflected no physician order for oxygen administration at 5 Liters via trach and no orders for trach care. Observation on 01/24/23 at 1:05 PM revealed Resident # 14 was lying in bed with 5 Liters on oxygen via trach. Interview on 01/24/23 at 1:10 PM with LVN H revealed Resident #14 was readmitted from the hospital last week and she was on 5 Liters of oxygen via trach prior to hospitalization. She stated Resident #14 was currently on 5 Liters of oxygen continuous via trach. Interview on 01/25/23 at 11:15 AM with DON revealed Resident #14 should have a physician order for her oxygen therapy via trach and about the trach care. DON stated Resident #14 was on oxygen via trach at 5 Liters prior to when she went to the hospital and was readmitted . She stated when Resident #14 was readmitted from the hospital the oxygen therapy physician order via trach must have been overlooked. DON stated she or the ADON are responsible for viewing resident physician orders when admitted ensuring physician orders are in resident's chart. Review of facility's policy Physician Orders undated reflected at the time each resident is admitted , the facility will have physician orders for their immediate care .1. Obtain one of the following types of physician orders: verbal, telephone order, transmitted by facsimile machine, written by the physician 2. Assure physician's orders including the drug or treatment and a correlating medical diagnosis or reason. 3. Assure medication orders include: a. Route b. Dosage c. Frequency d. Strength e. Reason for administration f. Stop date .13. Confirm the accuracy of all orders. Review all orders daily in the Clinical meeting to assure accuracy in transcription and errors od omission. Review of facility's policy Oxygen Concentrators' revised 01/13/23 reflected The oxygen concentrator will be used in the place of an oxygen cylinder (in non-emergency situation). It extracts oxygen (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676352 If continuation sheet Page 6 of 15 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 676352 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Stonemere Rehabilitation Center 11855 Lebanon Road Frisco, TX 75035 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 FORM CMS-2567 (02/99) Previous Versions Obsolete from room air and provides the resident with continuous flows of oxygen enriched air. The oxygen concentrator is a method of supplying oxygen to a resident .Filters, tubing and machines/bubble humidifiers are to be cleaned/changed once per week by facility. Review of facility's policy Oxygen administration and Therapeutics revised November 2022 reflected under procedure .8. to label nasal cannula (also humidifier) with patient name, dated and liter flow .10. Document the date, time and service rendered in the medical record. Event ID: Facility ID: 676352 If continuation sheet Page 7 of 15 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 676352 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Stonemere Rehabilitation Center 11855 Lebanon Road Frisco, TX 75035 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 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that residents who require dialysis receive such services, consistent with professional standards of practice, for one (Residents #21) of one resident reviewed for dialysis. Residents Affected - Few LVN G failed to review Resident #21's Dialysis Communication Form and to document his assessment of vital signs, access site and mental status after Resident #21 returned from dialysis treatment. This failure places residents in the facility who received dialysis at risk of not receiving proper care and coordination of care. Findings included: Review of Resident #21's admission MDS assessment dated [DATE] reflected Resident #21 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of hypertension, end stage renal disease, diabetes, thyroid disorder, dementia and stroke. Resident #21 required extensive assistance to total dependence with ADLs. Resident #21 had a BIMS of 6 indicating he was severely cognitively impaired. Resident #21 required dialysis services. Review of Resident #21's Comprehensive Care Plan dated 01/06/23 reflected Resident #21 need for dialysis (hemo-dialysis) r/t renal failure. Interventions include Check and change dressing daily at access site and Obtain vital signs and weight per protocol. Report siginificant changes in pulse, respirations and BP immediately. Review of Resident #21's Dialysis Communication Forms for January 2023 reflected the following: Dialysis Communication Form dated 01/04/23 at 10 AM Resident #21's vital signs were taken, and access site assessed by LVN H, Resident #21's medication list and dialysis nurse completed their section, but facility nurse section 3 (after dialysis) was not completed of vital signs, access site, dressing and mental status. Dialysis Communication Form dated 01/06/23 at 11:30 AM Resident #21's vital signs were taken, and access site assessed by LVN H, Resident #21's medication list and dialysis nurse completed their required section, but facility nurse section 3 (after dialysis) was not completed of vital signs, access site, dressing and mental status. Dialysis Communication Form dated 01/09/23 Resident #21's vital signs were taken, and access site assessed by LVN H, Resident #21's medication list and dialysis nurse completed their required section, but facility nurse section 3 (after dialysis) was not completed of vital signs, access site, dressing and mental status. Dialysis Communication Form dated 01/13/23 at 10:30 AM Resident #21's vital signs were taken, and access site assessed by LVN H, Resident #21's medication list and dialysis nurse completed their required section, but facility nurse section 3 (after dialysis) was not completed of vital signs, access site, dressing and mental status. Dialysis Communication Form dated 01/16/23 at 10 AM Resident #21's vital signs were taken, and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676352 If continuation sheet Page 8 of 15 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 676352 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Stonemere Rehabilitation Center 11855 Lebanon Road Frisco, TX 75035 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 0698 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few access site assessed by LVN H, Resident #21's medication list and dialysis nurse completed their required section, but facility nurse section 3 (after dialysis) was not completed of vital signs, access site, dressing and mental status. Dialysis Communication Form dated 01/18/23 at 11:30 AM Resident #21's vital signs were taken, and access site assessed by LVN H, Resident #21's medication list and dialysis nurse completed their required section, but facility nurse section 3 (after dialysis) was not completed of vital signs, access site, dressing and mental status. Dialysis Communication Form dated 01/20/23 at 11 AM Resident #21's vital signs were taken, and access site assessed by LVN H, Resident #21's medication list and dialysis nurse completed their required section, but facility nurse section 3 (after dialysis) was not completed of vital signs, access site, dressing and mental status. Dialysis Communication Form dated 01/23/23 Resident #21's section 1 completed by facility nurse prior to dialysis was not completed including vital signs, access site and medications given prior to dialysis. Dialysis nurse completed their sections of medication given during treatment, pre and post treatment weights, pre and post vital signs and if any access problems. Section 3 (after dialysis) was not completed by facility nurse when returned from dialysis which included vital signs, access site, dressing and mental status. Review of Resident #21's Licensed Nurses' Administration Record for January 2023 printed 01/26/23 reflected the following: Licensed Nurses' Administration Record Start date 12/16/22: to monitor dialysis access site: for bruit/thrill every shift for 6 A to 6 P and 6 P to 6 A It was completed except on 01/13/23 and 01/15/23 for 6 A to 6 P shift. Licensed Nurses' Administration Record Start date 12/16/22: vital signs per facility policy every shift for 6 A to 6 P and 6 P to 6 A shifts was completed except on 01/13/23 on both shifts and 01/15/23 for 6 A to 6 P shift. The vital signs included blood pressure, temperature, pulse, respirations and 02 stats. Review of Resident #21's Progress Notes for January 2023 reflected the following about dialysis: Progress Note dated 01/02/23 at 8:05 AM Resident refused to go to Dialysis today because he did want to get early in the morning. Resident Dialysis was rescheduled for 12:30 chair time Mon/Wed/Fri. Next scheduled date will be Wed 1/4/23 @ 12:30 pickup time 11:30. Progress Note dated 01/06/23 at 2:30 PM by LVN H Resident refused all of his morning medications today before dialysis. HCP (health care provider/practitioner), ADON and family notified. HCP prescribed Cipro 250 mg po in the evening for seven days. Orders initiated. There were no Progress Notes about assessment of Resident #21's dialysis pre or post assessment by nursing. Review of Resident #21's January 2023 vitals reflected the following on dialysis days: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676352 If continuation sheet Page 9 of 15 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 676352 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Stonemere Rehabilitation Center 11855 Lebanon Road Frisco, TX 75035 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 0698 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Vitals dated 01/04/23 10:09 blood pressure 123/68 pulse 70 bpm by LVN H, 22:00 blood pressure 126/66 pulse 72 bpm by LVN G. -Vitals dated 01/06/23 07:19 blood pressure 148/84 pulse 68 bpm by LVN H, 22:10 blood pressure 138/66 pulse 72 bpm by LVN G. -Vitals dated 01/09/23 09:59 blood pressure 134/63 pulse 73 bpm, 18:59 blood pressure 136/68 pulse 76 bpm by LVN G. -Vitals dated 01/13/23 10:16 blood pressure 133/50 pulse 60 bpm by LVN H. Vitals dated 01/16/23 01:21 blood pressure 130/70 pulse 70, 7:18 blood pressure 142/74 pulse 86 by LVN H, 22:17 blood pressure 144/72 pulse 76 bpm by LVN G. Vitals dated 01/18/23 10:45 blood pressure 159/82 by LVN H, 20:22 blood pressure 144/72 pulse 76 bpm by LVN G. Vitals dated 01/20/23 10:37 blood pressure 162/75 pulse 75 bpm, 23:20 blood pressure 142/68 pulse 72 bpm by LVN G. Vitals dated 01/23/23 01:27 blood pressure pulse 128/70 pulse 74 bpm, 08:56 blood pressure 160/78 pulse 70 bpm by LVN H. Interview on 01/26/23 at 10:25 AM ADON A stated facility nurses were expected to do vitals and check dialysis site before and after Resident # 21's dialysis treatment. ADON A stated all she could find in Resident #21's clinical record were vital signs completed by nursing and the Licensed Nurse Administration Record which reflected to monitor access site each day twice daily. She stated Resident #21 took his dialysis communication forms with him in a binder when he went to dialysis. ADON A was not aware of facility's dialysis policy of where facility nurses should be documenting on dialysis days on their pre and post dialysis assessments. Interview on 01/26/23 at 11:43 AM LVN H stated she completed the dialysis communication form on Resident #21's dialysis days which are Mondays, Wednesdays and Fridays. LVN H stated she accessed Resident #21 prior to dialysis including vital signs, access site and medication aide completed the medications taken before treatment. LVN H stated Resident #21 took his dialysis communication forms with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676352 If continuation sheet Page 10 of 15 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 676352 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Stonemere Rehabilitation Center 11855 Lebanon Road Frisco, TX 75035 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 0698 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few him in a binder to dialysis. LVN H stated Resident #21 did not return on her shift which was over at 2 pm. LVN H stated the dialysis communication forms were where she documented her assessment prior to Resident #21's dialysis treatment. Interview on 01/26/23 at 1:00 PM LVN G stated he did check Resident #21's vitals including temperature, o2 stats, blood pressure and sometimes blood sugar. LVN G stated he assessed Resident #21's access site when Resident #21 returned from dialysis for bleeding. LVN G stated he documented vitals under vitals tab in resident's electronic record. LVN G stated he did not know he was supposed to review the dialysis communication forms when Resident #21 returns from dialysis and was not informed need to complete section 3 of the form. LVN G stated the only task triggered on licensed nurse administration record for nursing is to monitor dialysis access site twice daily but this was the same for dialysis and non-dialysis days. LVN G stated he did not document his assessment in the nurse's progress notes about dialysis post-assessment. Interview on 01/26/23 at 1:15 PM DON stated after reviewing Resident #21's Dialysis Communication Forms for January 2023 the facility nurse section 3 was not completed on these forms. DON stated this was where the facility nurse should have documented once Resident #21 returns from dialysis the vital signs and assess the access site. DON stated the facility nurse should review the dialysis communication form completed by the dialysis nurse. DON stated she will ensure LVN G was in-serviced on the facility's dialysis policy, assessing resident post dialysis and documenting his assessment on the dialysis communication form prior to working his next shift. DON stated moving forward the ADONs will be educated about the dialysis policy and they will be responsible for ensuring facility nurses are completing the dialysis communication forms on Resident #21's dialysis days, assessing resident pre and post dialysis and documenting their assessment on the dialysis communication forms. Review of facility's policy Dialysis Management undated reflected The facility has designed and implemented processes which strive to ensure the comfort, safety, and appropriate management of hemodialysis residents/patients regardless if the procedure is performed at the dialysis or a facility .4. The facility will initiate a communication log prior to transferring the patient to the dialysis center. This form will serve as the general communication method between the two entities .Clinical responsibilities include, but are not limited to, the following: .12. Assure daily assessment and documentation of fistula or graft site (i.e. assessment of bruit and thrill) 13. Monitor resident/patient's weight as ordered (dry weight post dialysis) .17. Evaluate for and manage post dialysis complications. Under Dialysis Communication Tool the purpose is To maintain communication between the dialysis provider & facility clinical staff. Frequency: The dialysis communication tool should be utilized each time the resident is sent to dialysis from the nursing facility .Procedure: The nurse assigned to the resident/patient scheduled for dialysis will assure a dialysis communication form is completed & sent with the resident to the dialysis unit .Communication form: The facility will utilize the communication tool attached to this standard & guideline to facilitate communication between the dialysis center and facility clinical staff: Section 1 (completed by the facility nurse): Name of the facility, a facility contact number, the resident's/patient's name and the date of the dialysis treatment, medications provided with 6 hours of dialysis, facility nurse's review of the access site, the presence or absence of a bruit/thrill, sign or symptom of infection, indicate whether there was bleeding after the resident's last dialysis treatment, time of the resident's/patient's last meal and the facility clinician will sign & date the form .Section 3 (completed [NAME] the facility nurse) vital signs including (temperature, pulse, respirations & blood pressure, bruit/thrill present, dressing dry and intact, document mental status, The clinical will sign/date/time the bottom of the communication form .The dialysis communication form will become part of the permanent medical record and scanned . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676352 If continuation sheet Page 11 of 15 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 676352 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Stonemere Rehabilitation Center 11855 Lebanon Road Frisco, TX 75035 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to 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 four (Resident #195, Resident #77, Resident # 190, and Resident # 191) of seven residents observed for infection control in that: Residents Affected - Some 1. CNA E failed to perform hand hygiene during incontinent care for Resident #77. 2. CNA D failed to perform hand hygiene during incontinent care for Resident #191 and failed to perform hand hygiene before leaving Resident #191's room after providing care. 3. RN B failed to remove her gloves and perform hand hygiene before exiting Resident # 190's room after she had performed a FSBS on the resident and failed to sanitize the Glucometer after obtaining a FSBS with an approved disinfectant. 4. LVN D failed to prevent cross contamination of a bottle of testing strips used to obtain a fingerstick blood sugar on Resident's #195 and failed to allow the sanitized glucometer air dry to allow for adequate disinfectant before returning to the medication cart. Theses failure could place residents at risk for cross contamination and the development and transmission of communicable diseases and infections. Findings included: 1. Review of Resident #77's Face Sheet dated 01/25/23 reflected a [AGE] year-old female with an admission date of 12/21/22. Primary diagnoses included lack of coordination, diabetes, morbid obesity, and major depressive disorder. Review of Resident #77's Care Plan dated 01/23/23 reflected, . [Resident #77] has an ADL self-care performance deficit r/t limited mobility, pain .Interventions .Toilet use .totally dependent on staff for toilet use . [Resident #77] .bladder incontinence r/t history of UTI, impaired mobility .Intervention .Check (q 2hrs) and as required for incontinence. Wash, rinse, and dry perineum Observation on 01/24/23 at 10:15 a.m. revealed CNA E entered Resident #77's room to provide incontinence care. CNA E washed her hands and put on gloves. CNA E unfastened Resident #77's wet brief to reveal the resident had been incontinent of urine and bowel. CNA E pushed the soiled brief down between the resident's legs toward her buttocks and cleaned her peri area from front and had rolled the resident onto her side and wiped from front to back until all bowel movement had been removed. CNA E then removed the soiled brief and without changing gloves and performing hand hygiene then placed the clean brief under the resident and had her roll back onto her back. CNA pulled the clean brief between the resident legs and fastened the brief and then adjusted the cover. CNA E then removed her gloves and washed her hands. Interview on 01/25/23 at 10:30 a.m. CNA E stated she was supposed to change gloves when going from dirty to clean. She stated she had done this for several years and knew the proper procedure, but just got nervous. She stated failing to change her gloves and perform hand hygiene placed the resident at risk of infections. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676352 If continuation sheet Page 12 of 15 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 676352 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Stonemere Rehabilitation Center 11855 Lebanon Road Frisco, TX 75035 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 Review of CNA E Nurse Aide Competency Checks dated 12/28/22 reflected she was competent in hand hygiene and peri care/incontinent care. 2. Review of Resident #191's Face Sheet dated 01/25/23, reflected an [AGE] year-old female with an admission date of 01/19/23. Her diagnosis included repeated falls and fracture of left pubis. Residents Affected - Some Review of Resident #191's Care Plan dated 01/20/23, . [Resident #191] has an ADL self-care performance deficit .Interventions .Toilet use .require extensive assistance of 1 staff participation to use toilet . Observation on 01/24/23 at 10:35 a.m. revealed CNA D entered Resident #191's room to transfer resident to bed and provide incontinence care. CNA D washed her hands and put on gloves. CNA D applied the gait belt around the resident's waist and transferred her to bed. CNA D unfastened Resident #191's brief to reveal the resident was dry. CNA D rolled the resident over and wiped her rectal area revealing a small amount of bowel movement. CNA D continued to clean the residents' rectal area and then applied barrier cream without changing gloves and removed the old brief and placed a clean brief under the resident and her roll back onto her back. CNA D then used a wipe and cleaned the barrier cream off her soiled gloves then used a clean wipe to clean the residents' peri-area and then applied barrier cream while wearing soiled gloves. CNA D then fastened the brief, removed her gloves and without performing hand hygiene repositioned the resident's bedside table, adjusted her covers and gathered the trash bags and left the room without performing hand hygiene. Interview on 01/24/23 at 10:45 a.m. CNA D stated she was supposed to perform hand hygiene when she entered a resident's room and before she left a resident's room. CNA D stated she knew she missed a step and forgot to change her gloves when she went from dirty to clean. She stated she would usually remove the dirty glove and then put on a clean glove, but stated she failed to do that. CNA D stated she did not know she had to perform hand hygiene between gloves changes. She stated she should have performed hand hygiene after she took off her gloves after completing care and before she left the room. She stated she knew hand hygiene was important to prevent infections. Review of CNA D's Competency Check completed on 09/12/22 reflected CNA D met criteria for hand hygiene and peri/incontinent care. Interview on 01/25/23 at 09:50 a.m. DON stated staff were to perform hand hygiene when they entered a resident's room, after contact with any bodily fluid, and they were to change their gloves and perform hand hygiene during incontinent care when they went from dirty to clean. She stated by not following standard precautions with hand hygiene it placed residents at risk of infections and cross contamination. 3. Record review of Resident #190's Face Sheet dated 01/25/23, reflected a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included type 2 diabetes mellitus and post COVID-19 condition. Observation on 01/24/23 at 11:15 a.m. revealed RN B at the medication cart preparing to perform Resident #190's finger stick blood sugar (FSBS). RN B removed the glucometer from the medication cart, a lancet, and placed a testing strip into the glucometer. RN B performed hand hygiene, donned gloves, and entered the resident's room to perform the FSBS. RN B pricked Resident #190's finger and obtained a blood sample for FSBS. RN B then left the room, still wearing the gloves worn to obtain the FSBS, walked down the hallway to the medication cart and deposited the testing strip and lancet into (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676352 If continuation sheet Page 13 of 15 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 676352 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Stonemere Rehabilitation Center 11855 Lebanon Road Frisco, TX 75035 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 the sharp's container located on the medication cart. RN B then removed her gloves and performed hand hygiene. RN B then put on gloves and pulled out a small alcohol wipe packet and wiped down the glucometer with one small alcohol wipe, removed her gloves and performed hand hygiene. Interview on 01/24/23 at 11:20 a.m. RN B stated she knew she was not supposed to wear soiled gloves out of the room, but stated she was not sure how she was supposed to disposed of the dirty lancet since there was not sharps container in the resident's room, and she had to return to the medication cart to dispose of the lancet and strip. She stated she had not thought of placing the cart at the resident's doorway. RN B stated she was not aware they had to use a specific germicidal wipe for cleaning the glucometers. She stated she did not know if alcohol wipes were an approved disinfectant or not for cleaning the glucometers. She stated she had started at the facility about 2 weeks ago. Review of RN B's Orientation Check Off Sheet dated 01/10/23 reflected she had received basic orientation on Infection control and exposure, which included blood borne pathogens. She had not been skills checked (trained) on the use of and sanitizing of glucometers. Review of the FDA guidance, titled Letter to Manufacturers of Blood Glucose Monitoring Systems Listed With the FDA, accessed on 01/27/23, at https://www.fda.gov/medical-devices/in-vitro-diagnostics/letter-manufacturers-blood-glucose-monitoring-systems-listed-fda, reflected in part: The disinfection solvent you choose should be effective against HIV, Hepatitis C, and Hepatitis B virus. Outbreak episodes have been largely due to transmission of Hepatitis B and C viruses. However, of the two, Hepatitis B virus is the most difficult to kill. Please note that 70% ethanol solutions are not effective against viral bloodborne pathogens and the use of 10% bleach solutions may lead to physical degradation of your device. Observation on 01/25/23 at 08:15 a.m. revealed LVN C at the medication cart preparing to perform Resident #195's fingers stick blood sugar (FSBS) and morning medication pass. LVN C removed the glucometer from the medication cart, a lancet, an alcohol wipe, gauze pad and a bottle of testing strips and placed them in a plastic cup. LVN C performed hand hygiene, donned gloves, and entered Resident #195's room to perform the FSBS. LVN C opened the bottle of testing strips, pulled one strip out of the bottle, and placed the strip into the glucometer. LVN C wiped the resident's finger with an alcohol wipe and dried it with the gauze pad and placed the used gauze and alcohol pad in the plastic cup. LVN C then pricked Resident #195's finger and obtained a blood sample for FSBS. LVN C then placed the contaminated glucometer and bottle of testing strips in the plastic cup and went to the doorway of the resident's room and deposited the testing strip and lancet into the sharp's container located on the medication cart, sat the cup containing the glucometer and testing strips on top and the cart and removed her gloves and performed hand hygiene. LVN C then donned gloves and pulled a germicidal wipe out of a container and sanitized the glucometer and placed the glucometer on a paper towel to dry. LVN C then removed the bottle of testing strips from the cup which had contained the contaminated glucometer and placed it back into the top drawer of the medication cart without sanitizing the bottle. LVN C then removed her gloves and performed hand hygiene. Interview on 01/25/23 at 10:15 a.m. LVN C stated she should not have carried the bottle of test strips into the room and that by doing so she had contaminated the bottle of strips. She stated she knew this failure could have the potential for cross contamination and would remove the bottle of test strips from the cart. Review of LVN C's Licensed Nurse Competency Skills Check List revealed she had been skills checked (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676352 If continuation sheet Page 14 of 15 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 676352 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Stonemere Rehabilitation Center 11855 Lebanon Road Frisco, TX 75035 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 (trained) on FSBS on 11/02/22. Level of Harm - Minimal harm or potential for actual harm Interview on 01/25/23 at 10:20 a.m. DON stated staff were not to carry in the bottle of test strips into a resident's room for FSBS, since they were used for multiple residents. She stated by doing so, the staff had contaminated the entire bottle of test strips. She stated staff should be using a germicidal wipe that is designated to kill blood borne pathogens. She stated alcohol wipes were not an effective disinfectant. She stated staff were to always perform and hygiene before leaving a resident's room and should never wear dirty gloves when leaving a resident's room. She stated failure to follow the correct procedures could lead to infections and cross contamination. Residents Affected - Some Review of the facility's policy titled, Perineal Care, revised December, 2022, reflected, .Perineal Care refers to the care of the external genitalia and the anal area .Perform hand hygiene and put on gloves .Separate the resident's labia with one hand, and cleanse perineum with the other hand by wiping in directions from front to back ( from pubic area toward anus) .Turn the resident on her side . clean and dry the anal area, starting at the posterior vaginal opening and wiping from front to back .Remove gloves and discard. Perform hand hygiene . Review of the CDC guidelines obtained on 01/27/23 https://www.cdc.gov/cliac/docs/addenda/cliac0313/07B_CLIAC_2013March_Glucose_Monitoring.pdf, reflected, .The Centers for Disease Control and Prevention (CDC) has become increasingly concerned about the risks for transmitting hepatitis B virus (HBV) and other infectious diseases during assisted blood glucose ( blood sugar) monitoring and insulin administration .Unsafe practices during assisted monitoring of blood glucose and insulin administration that have contributed to transmission of HBV or have put person at risk for infection include .Failing to change gloves and perform hand hygiene between fingerstick procedures .A simple rule for safe care .Blood glucose Meters .disinfected after every use .General .unused supplies and medications should be maintained in clean areas separate from used supplies and equipment .Do not carry supplies and medications in pockets .Hand hygiene .Perform hand hygiene immediately after removal of gloves and before touching other medical supplies intended for use on other person's Review of the facility's polity titled, Glucometer Disinfection, revised December, 2022, reflected, .The glucometers should be disinfected with a wipe pre-saturated with and EPA registered healthcare disinfectant that is effective against HIV, Hepatitis C and Hepatis B virus .Procedure .Obtain needed equipment and supplies .Wash hands .put on gloves .Obtain capillary blood sampling .Remove and discard gloves, perform hand hygiene prior to exiting room .Reapply gloves if there is visible contamination of the device or if the resident is HIV or Hepatis B or C positive .Retrieve (2) disinfectant wipes from container .Using first wipe, clean first to remove heavy soil, blood and/or other contaminants left on the surface of the glucometer .After cleaning, use second wipe to disinfect the glucometer thoroughly with the disinfectant wipe, .Perform hand hygiene . Review of the facility's policy titled, Hand hygiene, revised in December 2022, reflected, Staff involved in direct resident contact will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents and visitors .Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standard of practice .The use of gloves does not replace hand washing. Wash hands after removing gloves . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676352 If continuation sheet Page 15 of 15