Health inspection·April 10, 2025

F 0641 Date Initiated: 03/26/2025 Level of Harm - Minimal harm or potential for actual harm Created by: DON Revision on: 03/26/2025 Residents Affected - Few Revision by: MDS Nurse 1 Goals: Resident #11 will maintain optimal quality of life within the limitations imposed by my visual deficits through the review date. Date Initiated: 03/26/2025 Created by: DON Revision on: 03/26/2025 Revision by: MDS Nurse 1 Target Date: 03/24/2025 Interventions/Tasks: Activities or designee assists me with completing menus weekly. Resident #11 is oriented to his meal tray as needed. Date Initiated: 03/26/2025 Revision on: 03/26/2025 Revision by: MDS Nurse 1 Arrange consultation with eye care practitioner as required. Date Initiated: 03/26/2025 Created by: DON . Ensure appropriate visual aids are available to support my participation in activities. Date Initiated: 03/26/2025 Created by: DON Revision on: 03/26/2025 Revision by: MDS Nurse 1 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676352 If continuation sheet Page 2 of 17 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 04/10/2025 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 0641 Resident #11 is able to: negotiate his familiar environment using my rollator. Level of Harm - Minimal harm or potential for actual harm Date Initiated: 03/26/2025 Created by: Social Worker Residents Affected - Few Revision on: 03/26/2025 Revision by: MDS Nurse 1 Monitor and report to MD any changes in vision Date Initiated: 03/26/2025 Created by: DON Revision on: 03/26/2025 Revision by: MDS Nurse 1 During an observation and interview on 03/08/25 at 11:10 AM of Resident #11 in his room revealed the resident was alert and sitting on his bed. Resident #11 stated that he had been at the facility for several years. Resident #11 stated that he was legally blind, and he could not see anything. Resident #11 stated that he used a cane for assistance with walking around the facility. Record review of Resident #14's Face Sheet, dated 04/10/25, revealed the resident was a [AGE] year-old female originally admitted to the facility on [DATE], readmitted to the facility on o 03/28/18 and 08/31/24. The resident's diagnoses included: encephalopathy (refers to any brain disease, damage, or malfunction, resulting in altered brain function), quadriplegia (paralysis that affects all a person's limbs), anterior cord syndrome at the C1 and C2 level of the cervical spinal cord, sequela, indicates a condition resulting from a previous injury where the anterior spinal artery (ASA) was affected at the C1 and C1 levels, hydrocephalus (the buildup of fluid in cavities called ventricles deep within the brain), chronic respiratory failure, encounter for attention to tracheostomy , dysphagia (difficulty breathing ), bacterial infection, stiffness, and contracture of muscles, multiple sites. Record review of Resident #14's Quarterly MDS assessment, dated 12/07/24, revealed the resident's BIMS score was empty indicating that the BIMS interview was not successful. The MDS revealed, Section O Special Treatments, Procedures, and Programs revealed Resident #14 has Respiratory Treatments, Section C1: Oxygen Therapy, Section D1: Suctioning, Section E1. Tracheostomy care was blank. Section Z Assessment Administration was signed by SW Assistant for Sections C, D and E on 11/20/24. Section Z Signature of RN Assessment Coordinator Verifying Assessment Completion was electronically signed by the DON on 12/08/2024. Record review of Resident #14's Quarterly MDS assessment, dated 03/09/25, revealed the resident had a BIMS score that was empty indicating she had Severe Cognitive Impairment and may require more support for daily living and activities. The MDS revealed, Section O - Special Treatments, Procedures, and Programs revealed Resident #14 has Respiratory Treatments, Section C1: Oxygen Therapy, Section D1: Suctioning, Section E1. Tracheostomy care was blank. Section Z - Assessment Administration was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676352 If continuation sheet Page 3 of 17 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 04/10/2025 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 0641 signed by SW Assistant for Sections C, D and E on 02/25/25. Section Z - Signature of RN Assessment Coordinator Verifying Assessment Completion was electronically signed by the DON on 03/10/2025. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #14's Care Plan, dated 01/16//25, revealed the following: Residents Affected - Few Focus: Resident #14 has tracheostomy in place Date Initiated: 01/16/2025 Revision on: 01/16/2025 Revision by: MDS Nurse 1 Goal: Resident #14 will have clear and equal breath sounds bilaterally (having or relating to two sides; affecting both sides) through the review date. Date Initiated: 01/16/2025 Revision on: 01/16/2025 Revision by: MDS Nurse 1 Intervention/Tasks: Ensure that trach ties are secured at all times. Date Initiated: 01/16/2025 Revision on: 01/16/2025 Revision by: MDS Nurse 1 Give humidified oxygen as prescribed. Date Initiated: 01/16/2025 Focus: Resident #14 uses physical restraints (B/L handmitts) r/t being at risk to decannulate self secondary to involuntary movement (thrashing and flailing arms), confusion and anxiety. Striking trach area causing potential decannulation Date Initiated: 01/16/2025 Revision on: 01/16/2025 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676352 If continuation sheet Page 4 of 17 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 04/10/2025 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 0641 Revision by: MDS Nurse 1 Level of Harm - Minimal harm or potential for actual harm Goal: Residents Affected - Few Resident #14 will remain free of complications related to restraint use, including contractures, skin breakdown, altered mental status, isolation or withdrawal through review date. Date Initiated: 01/16/2025 Revision on: 01/16/2025 Revision by: MDS Nurse 1 Target Date: 04/16/2025 Intervention/Tasks: Anticipate and intervene for potential causes which have precipitated prior falls or accidents. Date Initiated: 01/16/2025 Revision on: 01/16/2025 Revision by: MDS Nurse 1 Discuss and record with Resident #14/family/caregivers, the risks and benefits of the restraint, when the restrains should/will be applied, routines while restrained and any concerns or issues regarding restraint use. Date Initiated: 01/16/2025 Revision on: 01/16/2025 Revision by: Nurse 1 Ensure that I am positioned correctly with proper body alignment Date Initiated: 01/16/2025 Revision on: 01/16/2025 Revision by: MDS Nurse 1 Monitor/document/report to MD PRN changes regarding effectiveness of restraint, less restrictive device, if appropriate; any negative or adverse effects noted, including: decline in mood, change in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676352 If continuation sheet Page 5 of 17 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 04/10/2025 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 0641 behavior, decrease in adl self-performance, decline in cognitive ability or communication, contracture formation, skin breakdown, s/sx of delirium, falls/accidents/injuries, agitation, weakness. Level of Harm - Minimal harm or potential for actual harm Date Initiated: 01/16/2025 Residents Affected - Few Revision on: 01/16/2025 Revision by: MDS Nurse 1 Focus: Resident #14 will have Oxygen Therapy r/t tracheotomy, Resident #14's husband performs my trach care at times Date Initiated: 01/16/2025 Revision on: 01/16/2025 Revision by: MDS Nurse 1 During an observation of Resident #14 on 04/08/25 at 10:40 AM revealed she was lying in bed in her room. Resident #14 was non-verbal and had a tracheostomy. Record review of Resident #50's face sheet, dated 04/10/25, revealed the resident was a [AGE] year-old male originally admitted to the facility on [DATE], readmitted to the facility on o 01/15/22 and 08/25/23 Resident #50's diagnoses included: thyrotoxicosis without a thyrotoxic crisis or storm (a condition where the thyroid gland produces too much thyroid hormone), diabetes mellitus with hyperglycemia, where hyperglycemia (the presence of high blood sugar, could occur due to various underlying conditions), blindness of left eye Category 3, (specific level of visual impairment based on visual acuity), unspecified visual loss, and hypertensive heart disease. Record review of Resident #50's Quarterly MDS assessment, dated 01/24/25, revealed the resident had a BIMS score of 15 indicating her cognition was intact. Resident #50 could demonstrate normal cognitive abilities and likely require minimal assistance related to memory and cognitive skills. Section B - Hearing, Speech, and Vision revealed in Section B1000. Vision: Ability to see in adequate light (with glasses or other visual appliances) was Coded as 0, which indicate that Resident #50, sees fine detail, such as regular print in newspapers/books. Section Z - Assessment Administration was signed by SW Assistant for Section B for Vision on 01/16/25. During an observation of Resident #50 on 04/09/25 at 12:30 PM revealed that he was walking in hallway with staff. Resident #50 was observed using a white walking cane to detect obstacles and navigate his surroundings in the hallway. In an observation and interview with Resident #50 on 04/10/2025 at 11:35 AM, he stated that he lost his vision many years ago due to his diabetes. He stated that diabetes ran in his family and his A1C levels were extremely high, and it led him to losing vision in his eyes. Resident #50 stated that he was diagnosed by his doctor as being legally blind. He stated that he could walk around the facility without any assistance of staff but used his white cane for assistance. He reported that he had (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676352 If continuation sheet Page 6 of 17 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 04/10/2025 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 0641 not had any falls at the facility due to his blindness. Level of Harm - Minimal harm or potential for actual harm In an interview with LVN F on 04/10/25 at 11:20 AM in Resident #14's room, she stated that Resident #14 received tube feeding and had a trach. She stated that she was not aware that Resident #14's MDS Assessment did not reveal that she had a trach. She stated that she cares for Resident #14 frequently and she knows that she had a trach. LVN F stated that Resident #14, and Resident #50 were both legally blind. She stated that when she was assigned a resident, she would check the resident's POC, doctor's orders and care plan to confirm what kind of care the resident needs from her. She stated that she did not have access to a resident's MDS Quarterly Assessment, therefore she did not believe that there could be any risk of harm to Resident #14 due to her MDS Assessment being incorrect. Residents Affected - Few In an interview with MDS Nurse 1 on 04/10/25 at 12:45 PM, she stated that she was responsible for completing the MDS Assessment for Section E1. Tracheostomy Care. She stated that she was not aware that the Section E1. Tracheostomy Care for Resident #14 was blank. She confirmed that Resident #14 had a trach and that Section E1. Tracheostomy Care should be marked with an x. She stated that there was a risk to a resident if the MDS Assessment was not completed correctly. She stated that a resident could aspirate (the drawing of fluid or tissue from a body cavity by suction). In a telephone interview on 04/10/25 at 3 PM with Resident #14's family member, he confirmed that Resident #14 was non-verbal and had a trach due to some health issues, which caused Resident #14 to have a stroke a couple of years ago. He stated that he did not have any concerns regarding the care Resident #14 was receiving at the facility. In an interview with the SW Assistant on 04/10/25 at 1:05 PM, she had her laptop and was able to review the MDS Assessments for Resident #11, Resident #14, and Resident #50. She stated that Resident #11 and Resident #14 were both legally blind. She stated that the Section B - Hearing, Speech, and Vision revealed in Section B1000. Vision: Ability to see in adequate light (with glasses or other visual appliances) was Coded as 0, which indicate that Resident #11 and Resident #48, sees fine detail, such as regular print in newspapers/books. She confirmed that she signed, Section Z of the MDS - Assessment Administration was signed by SW Assistant for Section B for Vision. She stated that she made an error in coding the MDS Assessment for both resident's vision. She stated that she would correct the MDS Assessments for both residents. She reported that she did not think there was any risk or harm for the MDS Assessments for both residents being coded incorrectly. In an interview with the DON on 04/10/25 at 3 PM, she stated that she had been employed at the facility for 2 ½ years. She stated that she was informed by the SW Assistant that there were issues with the MDS Assessments for 3 residents, Resident #11, Resident #14, and Resident #50. The DON stated that Resident #14 had a trach. She stated that the Resident #11 was considered legally blind but could find his way around the facility by himself without any assistance and she was unsure how much he could truly see. She stated that Resident #50 had total blindness, and he recognizes her by the sound of her voice. She reported that Resident #50 could walk around the facility unassisted by staff and uses his walking cane for assistance. She stated that the Social Worker and the SW Assistant were responsible for ensuring that the Vision Section of MDS Assessments were completed correctly for each resident. She reported that the facility had 2 MDS Coordinators (1 for short term residents and 1 for long term residents). She reported that the MDS Coordinators were responsible for ensuring that the MDS Assessments were completed for each resident. She stated that all 3 residents were long term care residents at the facility. DON stated that a nurse or CNA was not going to see the MDS Assessment for a resident, therefore she did not think that there was any risk or harm to Resident #11, Resident #14, and Resident #50 due to the information not being on the MDS Assessment. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676352 If continuation sheet Page 7 of 17 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 04/10/2025 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 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few The DON further stated there was not time to go through each residents' assessment. A nurse or CNA was not going to see the MDS and the POC and they would not see it and they did not have a lot to do with each other. MDS oversight would not make a difference in what they do. She stated that the facility did not hire agency and did not have a high turnover with staff and leadership. She reported that there would be some auditing of the MDS Assessments, and reeducation and retraining of the staff that were responsible for their Sections on the MDS Assessments to ensure that nothing like this would happen again. She stated that she felt that there was not any risk to any of the residents with the care there were receiving from the staff at the facility because the facility did not hire any agency staff and staff were familiar with the residents they care for. She stated that back in the day, when she was on the floor paperwork would be used to check of everything and she would have been able to catch the errors. She stated that there was no difference in the care the residents were receiving by staff based on the MDS errors due to the nursing staff reviewing the residents care plans, plan of care and doctor's orders. She stated that she felt that there were not any risks or harm could have been done to the residents due to the discrepancies that were found on their MDS Assessments. During a telephone interview on 04/14/25 at 2:10 PM with the SW, she stated that she had been employed at the facility for 2 years. She stated that the facility was quite large and difficult to tackle all the tasks required for her to do, therefore the SW Assistant helps her complete of job tasks including reviewing and completing the MDS Assessments. She stated that she was ultimately responsible for ensuring that Sections B, C, D, E, and Q were completed on the MDS Assessments. She stated that the SW Assistant completed the MDS Assessments for Resident #11, and Resident #50. She stated that the SW Assistant knows that Resident #14 had a trach and Resident #11and Resident #50 were both legally blind. She stated that error on the MDS Assessments was an oversight and an error and once the error was brought to the attention of the SW Assistant by the surveyor, she reopened the MDS Assessment and made modifications for all 3 residents and fixed the mistakes on their MDS Assessments. She stated that going forward, she would go over the list of MDS Assessments that were completed by the SW Assistant on a weekly basis to ensure that everything that had been entered on the residents' MDS' were correct. The SW reported that she would also perform quarterly audits on the MDS Assessments before everything was locked and transmitted. The SW reported that Resident #11 and Resident #50 have the same optometry services offered to them relating to their diagnoses of blindness, but there was not anything that would assist them with vision since they were blind. She stated that Resident #11 was very independent and would take the elevator downstairs and walk to the café to get his coffee every afternoon. She stated that Resident #11 knows his way around the facility without any issues. She stated that Resident #50's vision was highly impaired and could ambulate throughout the facility and his environment properly. She stated that she did not think that there was any risk or harm to Resident #11 and Resident #14 due to their MDS Assessments being incorrectly coded by the SW Assistant. The SW reported that the MDS Coordinators were responsible for completing the Section E of the MDS Assessment relating to Resident #50. Record review of the facility's Assessment Frequency/Timelines policy dated 2001, reviewed/revised 12/2024 revealed, Policy: The purpose of this policy is to provide a system to complete standardized assessments in a timely manner, according to the current RAI Manual. Policy Explanation and Compliance Guidelines: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676352 If continuation sheet Page 8 of 17 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 04/10/2025 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 0641 1. The MDS/RAI Coordinator will be responsible for tracking due dates for all MDS assessments . Level of Harm - Minimal harm or potential for actual harm a. A calendar of scheduled assessments, including type of assessment and assessment reference date, will be communicated to those individuals responsible for completing Residents Affected - Few portions of the MDS on a monthly basis . 4. A quarterly review assessment will be completed no less than once every 3 months . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676352 If continuation sheet Page 9 of 17 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 04/10/2025 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 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASRR) Level I assessment accurately reflected the resident's status for two (Resident #15 and Resident #34) of five residents reviewed for PASRR Screenings. Residents Affected - Some 1. The facility failed to ensure the accuracy of the PASRR Level 1 screen for Resident #15. The resident did not receive a PASRR Level II assessment Evaluation. 2. The facility failed to ensure the accuracy of the PASRR Level 1 screen for Resident #34. The resident did not receive a PASRR Level II assessment Evaluation. This failure could place residents who had a mental illness at risk of not receiving individualized specialized service to meet their needs. Findings included: Record review of Resident #15's quarterly MDS assessment, dated 01/27/2025, reflected the resident was an [AGE] year-old female admitted to the facility on [DATE]. The resident's BIMs score was 12 indicating the resident's cognition was moderately impaired. Her diagnoses included Anxiety, Depression, Bipolar II, and Schizoaffective - Bipolar Type. Record review of Resident #15's Care Plan reflected: *02/06/2025: The resident was taking psychotropic medications to manage symptoms of schizoaffective disorder *02/06/2025: The resident was taking medications to manage symptoms of depression. Record review of Resident #15's PASSR level 1 screening, dated 05/01/2023, reflected the resident did not have a serious mental illness and serious mental illness was checked as no. Record review of Resident #15's Electronic Health Record revealed no PASSR level 2 evaluation was completed. Record review of Resident #34's quarterly MDS assessment, dated 01/18/2025, reflected the resident was a [AGE] year-old female originally admitted to the facility on [DATE]. The resident's Cognitive Skills for Daily Decision Making was coded at a 3 which is severely impaired. Her diagnosis included Major Depressive Disorder, Recurrent, Mild, and Generalized Anxiety Disorder. Record review of Resident #34's Care Plan reflected: *02/13/2025 The resident was taking medications to manage symptoms of depression. Record review of Resident #15's PASSR level 1 screening, dated 05/01/2023, reflected the resident did not have a serious mental illness and serious mental illness was checked as no. Record review of Resident #34'ss Electronic Health Record revealed no PASSR level 2 evaluation was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676352 If continuation sheet Page 10 of 17 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 04/10/2025 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 0645 completed. Level of Harm - Minimal harm or potential for actual harm An interview on 04/09/2025 at 1:35 p.m. with MDS Nurse 1 revealed Resident #15 had a negative PASSR Level 1 because of her diagnosis of dementia. When asked to clarify that diagnosis, MDS Nurse 1 stated Resident #15 had a cerebrovascular stroke which causes vascular dementia. When asked again to clarify the dementia diagnosis, she stated she is trying to clarify with Resident #15's physician to see if she has dementia. Residents Affected - Some An interview on 04/09/2025 at 1:35 p.m. with MDS Nurse 2 revealed in May of 2023 the facility switched over to a new system and she had to redo all residents PASSR assessments. She reported Resident #15's PASSR was most likely a mis-entry. When asked if Resident #15 has a diagnosis of dementia she stated no. An interview on 04/10/2025 at 2:00 p.m. with the DON revealed around May of 2023 the facility started a new program in which all resident charts were switched over. She reported that the MDS department told her when those charts were switched over it may have resulted in a glitch in the system resulting in incorrectly entered PASSR evaluations. The DON reported she cannot speak specifically on resident's PASSR evaluations since she does not do them. Review of the facility's policy and procedure PASSR Requirements Level 1 & Level II dated March 2022 reflected, Procedure: 1. During the admissions process, Business Development will communicate with the facility regarding prospective admissions. A Level 1 PASSR will be provided prior to admission to the Skilled Nursing Facility. The facility administration will confirm that a Level I review has been completed prior to transfer to the SNF setting. Procedure: 2. Determine if a serious mental illness &/or intellectual disability or a related condition exists while reviewing the PASSR from completed by the Acute Care Facility. (Trigger for Level II Completion. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676352 If continuation sheet Page 11 of 17 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 (X3) DATE SURVEY COMPLETED A. Building 04/10/2025 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen safety. 1. The facility failed to ensure food in the facility's dry storage, and refrigerator areas were labeled and dated according to guidelines. 2. The facility failed to seal open items in plastic bags in the dry storage pantry, and refrigerator areas. 3. The facility failed to ensure that expired items in the dry storage pantry were removed. These deficient practices could affect residents who received meals and/or snacks from the main kitchen and place them at risk for cross contamination and other food-borne illnesses. Findings Included: Observation of the kitchen during the brief initial tour of the kitchen on 04/08/2025 at 9:10 AM, revealed the following: * 3 boxes of 15 oz. raisins with an expiration date of 09/13/24. * 1 box of unsealed 15 oz. raisins with an expiration date of 09/13/24. * 2 packages of 24 oz. cherry gelatin mix with an expiration date of 06/23. * 2 packages of 24 oz. raspberry gelatin mix with an expiration date of 06/23. * 2 packages of 24 oz. stawberry gelatin mix with an expiration date of 06/23. * 4 boxes of 40 oz. hasbrown potatoes with an expiration date of 03/16/25 * 1 package of peanut topping in a plastic zip top bag without label and use by date. * 2 unsealed packages of vanilla pudding mix that was exposed to air, without any use by dates. * 1 package of lemon gelatin with a hole in the package was exposed to air. * 2 unsealed plastic containers with blue lids labeled Oats and exposed to air. * 1 box of puree rice was unsealed and exposed to air. * 2 packages of pasta noodles were unsealed and exposed to air. * 1 opened package of powdered dry milk was unsealed and exposed to air. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676352 If continuation sheet Page 12 of 17 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 04/10/2025 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 0812 * 1 opened package of breadcrumbs was unsealed and exposed to air. Level of Harm - Minimal harm or potential for actual harm * 1 plastic container of 13 oz. mediterranean style ground oregano was unsealed and exposed to air. * 1 plastic container of 30 oz. dill weed seasoning was unsealed and exposed to air. Residents Affected - Some * 1 plastic container of sugar was unsealed and exposed to air. * 1 plastic container of flour was unsealed and exposed to air. Refrigerator area: * 1 package of sliced ham was unsealed in an unsealed clear plastic zip top bag and exposed to air. * 1 package of scambled eggs was not labeled and dated with an expiration date. * 1 clear plastic container labeled Jalapenos 04/02/25 @ 7:05 pm was unsealed and exposed to air. * 1 clear plastic container with blue lid labeled strawberries was unsealed and exposed to air. In an interview with the Executive Chef on 04/08/25 at 10:26 AM, he stated that he had been employed at the facility for 2 years. He was informed about the findings of the initial brief tour of the kitchen, which included expired and unsealed items in the dry storage, and refrigerator areas. He stated that all items that were unsealed would be discarded and thrown in the trash. He reported that all staff were responsible for ensuring that there were not any expired and unsealed items in the dry storage, refrigerator, and freezer areas. He reported that he would now make rounds of the aforementioned areas to make sure that there were here were not any expired and unsealed items in the dry storage, refrigerator, and freezer areas in the kitchen. The Chef stated that he had a total of 8 staff members that he supervises, and they work various shifts. He stated that the kitchen had new staff members, and he had done several in-service trainings with his staff regarding food storage and checking for expired items throughout the kitchen area. He reported that training his new staff was a work in progress, but he would have to give them some reeducation via in-service trainings relating to the findings of the initial brief tour of the kitchen. He stated that he gives his staff in-service trainings about three times per month. The Chef stated that if staff find anything such as expired items, he expectation for them was that they immediately throw away the item and then tell him about it. He stated that if there was something that was not labeled and/or dated, his expectation was for his staff to tell him about it and then he would reeducate and retrain the staff via an in-service training. He reported that all the staff in the kitchen to ensure items in the kitchen's dry pantry, refrigerator, and freezer areas were not expired, unsealed, labeled and dated. He stated that the items found in the kitchen by the surveyor was a mishap and he would continue to provide education to his staff to ensure that everyone was on the same page with his expectations and the facility's policy on Food Storage. He stated that his expectation for his staff, was that they use the FIFO procedures to ensure that there were not any expired food items throughout the kitchen. He stated that his last in-service training with his staff on Food Storage was about 2 weeks ago. He stated that both residents, visitors and staff eat food that was served from the kitchen. He stated that if anyone eats food from the kitchen that was expired or comes from unsealed containers or bags, they could have the risk of becoming sick, which could cause them to have issues with their stomach. In an interview with [NAME] D on 04/08/25 at 10:45 AM, he stated that he had been employed as the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676352 If continuation sheet Page 13 of 17 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 04/10/2025 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some cook at the facility for 2 years. He stated that he was unaware that there were expired and unsealed items in the dry storage, and refrigerator areas. He stated that all the staff were responsible for labeling and storing the items on the shelf and checking the expiration dates on everything in the dry storage, refrigerator, and freezer areas of the kitchen. [NAME] D stated that he had taken in-service trainings on food preparation and storage and his last in-service training was about 2 or 3 weeks ago. He reported that the in-service training he had taken in the past mentioned that staff were always to make sure that everything in the kitchen areas, such as the dry pantry, refrigerator and freezer areas were labeled (to include the date it was placed in the refrigerator and a use by date) and sealing of plastic containers and bags. He stated that if a staff member sees any item(s) that were expired, the staff member was to throw the item away in the trash can and then inform the Chef what they threw away. [NAME] D stated that with any exceptions, everything in the dry storage, freezer and refrigerator areas should be labeled and dated. [NAME] D stated that if someone ingested food that had been cross-contaminated, there was a risk that someone could die. He stated that if anyone eats food that came from the kitchen's dry pantry, refrigerator and freezer areas that were unsealed, and expired items it could cause someone become sick. He stated that if someone gets sick, it could cause them have stomach aches, headaches, and diarrhea. In an interview with the [NAME] E on 04/08/25 at 11:02 AM, he stated that he had been employed at the facility for 6 months. He stated that he was unaware that there were expired and unsealed items in the dry storage, and refrigerator areas. He stated that all the staff were responsible for labeling and storing the items on the shelf and checking the expiration dates on everything in the dry storage, refrigerator, and freezer areas of the kitchen. He stated that the Chef had hired some new people and had been trying to educate everyone in the kitchen about his expectations, but they were being trained by the Chef. [NAME] E stated that he had taken an in-service training on food preparation and storage and his last in-service training was about 2 weeks ago. He stated that he received education on using the FIFO method in his last in-service training. He stated that if he saw food that was expired in the dry pantry, refrigerator and/or freezer areas, he would throw it away and then notify the Chef about what he found. He stated that if he saw any food in the dry pantry, refrigerator and/or freezer areas that was unsealed, he would throw it away and notify the Chef of what he found. [NAME] E stated that if he saw anything that was not labeled and dated, he would notify the Chef. He stated that if he found something that was not labeled and/or dated, he would immediately throw it away because no one would know when the item was stored and if someone eats it, they could get sick. [NAME] E stated that if someone ingested any food that had been unsealed, and expired they were at risk for salmonella poisoning and the stomach bug. He stated that any ingestion of food that had been unsealed and expired, they could be harmed by being food poisoned. Record review of the facility's policy titled Food Storage: Policy and Procedure dated, 2022 reflected, Policy Sufficient storage facilities will be provided to keep foods safe, wholesome, and appetizing. Food will be stored in an area that is clean, dry and free from contaminants. Food will be stored at appropriate temperatures and by methods designed to prevent contamination or cross-contamination. Procedure: .7. All stock must be rotated with each new order received. Rotating stock is essential to assure the freshness and highest quality of all foods. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676352 If continuation sheet Page 14 of 17 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 04/10/2025 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some a. Old stock is always used first (first in - first out method or FIFO). The person designated to manage stock should be trained to rotate it properly. b. Food should be dated as it is placed on the shelves if required by state regulation. c. Date marking should be visible on all high risk food to indicate the date by which a ready-to-eat TCS food should be consumed, sold or discarded. d. Food will be stored and handled to maintain the integrity of the packaging until ready for use. Food stored in bins may be removed from its original packaging. 8. Plastic containers with tight fitting covers or sealable plastic bags must be used for storing grain products, sugar, dried vegetables and broken lots of bulk foods or opened packages. All containers or storage bags must be legible and accurately labeled and dated . 12. Leftover food should be stored in covered containers or wrapped carefully and securely and clearly labeled and dated before being refrigerated. Leftover food must be used within 7 days or discarded as per the 2022 Federal Food Code . 13. Refrigerated food storage: .f. All foods should be covered, labeled and dated and routinely monitored to assure that foods (including leftovers) will be consumed by their use by dates, or frozen (where applicable) or discarded. 14. Frozen Foods: .c. All foods should be covered, labeled and dated. All foods will be checked to assure that foods will be consumed by their use by dates or discarded . Record review of the U.S. Food and Drug Administration (FDA) Code (2022) revealed, PACKAGED FOOD shall be labeled as specified in LAW, including 21 CFR 101 FOOD Labeling, 9 CFR 317 Labeling, Marking Devices, and Containers, and 9 CFR 381 Subpart N Labeling and Containers, and as specified under § 3-202.18. FOOD shall be protected from contamination that may result from a factor or source not specified under Subparts 3-301 - 3-306. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676352 If continuation sheet Page 15 of 17 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 04/10/2025 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 establish and maintain an infection 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 of 3 residents (Residents #72 and #344) reviewed for infection control. Residents Affected - Few CNA A failed to complete hand hygiene or change gloves when providing incontinent care to Resident #72. CNA B failed to complete hand hygiene or change gloves when providing incontinent care to Resident #344. This failure could place residents at risk for spread of infection and cross contamination. Findings include: Record review Resident #72's face sheet, dated 10/10/25, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #72 had diagnoses which included hypertension, epilepsy, rheumatoid arthritis, lack of coordination, and repeated falls. Record review of Resident #72's admission Minimum Data Set, dated [DATE] reflected, Resident #72's Brief Interview for Mental Status reflected a score of 14 indicating no cognitive impairment. Resident #72 was occasionally incontinent of bowel and bladder and required assistance with toileting. Record review of Resident #72's care plan, initiated on 02/12/25, reflected Resident #72 had activities of daily living self-care performance deficit. Goal was to improve the function level. Intervention/Tasks reflected Resident #72 required extensive assistance of 1 staff participation to use toilet. Record review Resident #344's face sheet, dated 10/10/25, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #344 had diagnoses which included hypertension, anxiety, dementia, lack of coordination, parkinsonism, and pressure ulcer. Record review of Resident #344's admission Minimum Data Set, dated [DATE] reflected, Resident #344's Brief Interview for Mental Status reflected a score of 03 indicating severe cognitive impairment. Section H on bowel and bladder had not been completed. Record review of Resident #344's care plan, initiated on 04/3/25, reflected Resident #344 had activities of daily living self-care performance deficit. Goal was to improve the function level. Intervention/Tasks reflected Resident #344 required total assistance of 1 staff participation for toileting. In an observation on 04/10/25 at 11:35 AM revealed CNA A providing incontinent care to Resident #72. CNA A entered the resident's room and completed hand hygiene, and then gloved. CNA A then started to provide incontinent care to the resident. After cleaning the resident who was moderately soiled with urine, CNA A took off the dirty brief and then without any form of hand hygiene or change of gloves, CNA A applied the clean brief, positioned the resident in bed and touched the resident's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676352 If continuation sheet Page 16 of 17 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 04/10/2025 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 linens. Then CNA A proceeded to clean her hands after care. Level of Harm - Minimal harm or potential for actual harm In an interview on 04/10/25 at 11:43 AM with CNA A, she stated she had been educated on infection control about one and half months ago. CNA A stated she was only supposed to complete hand hygiene in between care if the gloves were visibly soiled, but if they were not, she did not need to change gloves or complete hand hygiene after cleaning the resident. CNA A stated she was supposed to maintain infection control during patient care to prevent cross contamination. Residents Affected - Few In an observation on 04/10/25 at 12:06 MP reflected CNA B was providing incontinent care to Resident #344. The resident was on enhanced barrier precaution and the staff had gown and gloves on. CNA B positioned the resident and provided incontinent care to the resident, the resident was moderately soiled with urine. After cleaning the resident, CNA B did not complete hand hygiene or change gloves, and with the same gloves CNA B applied the clean brief, positioned the resident, touched the resident's linens and wheelchair, and then took off the gloves. In an interview on 04/10/25 at 12:25 PM with CNA B, she stated she was not aware she was supposed to complete hand hygiene after cleaning the resident. She stated she was supposed to complete hand hygiene before and after care. CNA B stated she had been in-serviced on infection control about 1 week ago, and the in-service was about making sure the staff-maintained infection control to prevent cross contamination. In an interview on 04/10/25 at 12:43 PM with ADON C revealed she was the infection preventionist. ADON C stated the nursing staff had been in-serviced on infection control. Regarding providing incontinent care, the ADON C stated the staff were supposed to complete hand hygiene and change gloves after cleaning the resident before applying the clean brief or touching the resident's linens. The staff were to maintain infection control to prevent cross contamination. ADON C provided the infection control in-serviced completed on reflected CNA A and CNA B had been in-serviced on infection control. In an interviewed on 04/10/25 at 03:14 PM with the DON she stated she expected the aides to complete hand hygiene after cleaning the resident before applying the clean brief due to infection control. She stated the staff had been educated on infection control and the staff were supposed to maintain infection control to prevent cross contamination. Review of the facility policy reviewed December 2024, titled Perineal/Incontinent Care reflected, The purposes of this procedures are to provide cleanness and comfort to the resident, to prevent infection and skin irritation . Review of the facility policy reviewed December 2024, titled Infection Control Guidelines for all Nursing Procedures reflected, To provide guidelines for general infection control while caring for residents. 4. Employee must wash their hands .After contact with blood, body fluids, secretions . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676352 If continuation sheet Page 17 of 17