Health inspection·January 11, 2024

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few her bed, awake. Resident #59 stated to call for assistance she used the call light. Resident #59 searched for the call light at the left side of her bed but did not find it. Resident #59 said she could not find it. Resident #59 added she would wait for somebody to come to ask her if she needed something. Observation and interview with CNA G on 01/10/2024 at 7:36 AM, CNA G stated the call lights should always be within the reach of the residents. CNA G said the call lights were very important for the residents because the call lights were used by the residents to call the staff if they needed something or if they needed assistance. CNA G said if the residents did not have their call lights, the residents might fall trying to reach for the call light. Without the call lights, the needs of the residents would not be addressed. CNA G went back inside Resident #59's room and picked up the call light and clipped it near the resident. CNA G said all staff were responsible in ensuring call light were within reach of the residents. Interview with RN J on 01/10/2024 at 7:45 AM, RN J stated the residents used their call lights to let the staff know they needed assistance. RN J said without the call lights, the staff would not know if the residents needed the staff or were in need of something. She said the needs could be wanting to go to the bathroom or wanting to go out of the room. RN J added the residents might fall trying to get up to get the call light or trying to get somebody to help them. RN J added she would make a round to make sure the call lights were within the reach of the residents. RN J added all staff should monitor if the call light was with the residents. 2. Record review of Resident #77's face sheet, dated 01/04/2023, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #77 had relevant diagnoses which included difficulty in walking, other abnormalities of gait and mobility, and muscle wasting. Record review of Resident #77's Quarterly MDS Assessment, dated 12/11/2023, reflected the resident was cognitively intact with had a BIMS score of 13. Resident #77 required one-person physical assist for bed mobility, transfer, eating, and toilet use. Record review of Resident #77's comprehensive care plan, dated 12/24/2023, reflected the resident had an ADL self-deficit performance deficit related to disease process and one of the interventions was to encourage the resident to use bell to call for assistance. Record review of Resident #77's Comprehensive Care Plan, dated 10/14/2023, reflected the resident had a high risk for fall related to impaired cognition, communication deficit, and actual fall. One of the interventions listed was to ensure resident's call light was within reach and encourage the resident to use the call light for assistance. Record review of Resident #77's Fall Risk Assessment, dated 12/09/2023, reflected the resident had a high risk for fall with a score of 8.0. Observation and interview with Resident #77 on 01/10/2024 at 9:15 AM revealed the resident was sitting on his recliner located on the right side of the bed. Resident #77's call light was hanging on the left side of the bed. Resident #77 said he was already old and walking a short distance could make him tired. The resident stated if he needed assistance from staff there was a cord with a red push button at the end. Resident #77 started to look for his call light on the bed and said the staff forgot to put it on top of the bed. Resident #77 added he would just wait for a staff to give him his call light. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676367 If continuation sheet Page 2 of 14 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676367 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Belterra Health & Rehab 2170 North Lake Forest Drive McKinney, TX 75071 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 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Observation and interview with CNA A on 01/10/2024 at 9:38 AM, CNA A stated the call lights were very important for the residents. She said residents used their call lights to call the staff if they needed some assistance or if they needed the nurse because they were not feeling well. CNA A added if the residents did not have their call lights, the residents might be frustrated or mad because they could not tell somebody they needed something. CNA A further said the residents could fall in the process of getting the call light or getting the things they needed. CNA A went inside Resident #77's room pulled the call light from the right side of the bed, and placed the call light on top of the bed where the resident could reach it. In an interview with LVN P on 01/10/2024 at 10:39 AM, LVN P stated he did not notice the call light was far from the resident when he checked on Resident #77. LVN P said the call lights must be within the reach of the residents at all times. LVN P said the call lights were used by the residents to call the attention of the staff if they needed something or if they needed help. LVN P said without the call lights, the staff would not know if the residents needed something, wanted to go to the bathroom, or had any discomfort. LVN P added the residents might fall trying to get the call light or trying to get somebody to help them. LVN P said he would go check on Resident #77 and see if the resident's call light was within his reach. In an interview with the DON on 01/10/2024 at 1:41 PM, the DON stated the call lights must be within reach of the residents at all times. The DON said the residents used the call lights as a means of communication with the staff. The DON added the residents used the call lights if they needed help or to alert the staff they were not feeling well. The DON stated a lot of things could happen if the call lights were not with the residents. The residents might try to get up on their own and fall on the process. The staff would not be able to attend to the resident's needs during emergencies. The DON said all the staff were responsible in placing the call lights within reach. The DON said all the staff must zoom in on every detail inside the room. The DON said monitoring call light placement should be done during department heads, during nurses' rounds, and during CNAs rounds. The DON said the expectation was for the staff to make sure the call lights were within the reach of the residents. The DON said she would make an in-service about the call lights and would ensure staff adherence to placing the call lights within the reach of the residents. Interview with the Administrator on 01/10/2024 at 1:55 PM, the Administrator stated the call lights should always be within the reach of the residents at all times because the call lights were their form of communication. The Administrator said there must be conscious efforts from the staff in making sure the call lights were with the residents so the needs of the residents were met. He said the expectation was call lights be with the residents at all times. Record review of the facility's policy Resident Call Light System, revised 6/2023, reflected Purpose: The purpose of this procedure is to respond to the resident's request and needs . General Guidelines . 4. Ensure that the call light is easily reachable by the resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676367 If continuation sheet Page 3 of 14 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676367 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Belterra Health & Rehab 2170 North Lake Forest Drive McKinney, TX 75071 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for one (Resident #102) of two residents reviewed for incontinence care. The facility failed to ensure CNA B provided appropriate perineal care for Resident #102 after an incontinent episode when she failed to wipe from the base of the labia towards and extending over the resident's buttocks. This failure could place residents at risk for the development and/or worsening of urinary tract infections and skin breakdown. Findings include: Record review of Resident #102's 5-day MDS assessment, dated 12/24/23, reflected a [AGE] year-old female with an admission date of 12/21/23. Resident #102 had a BIMs of 11, which indicated she was moderately cognitively impaired. She required extensive assistance of one-to-two-persons with all ADLs and was always incontinent of bowel and bladder. Her diagnoses included diabetes and malignant neoplasm (cancer) of the right lung. Record review of Resident #102's care plan, dated 12/21/23, reflected, . The resident has an ADL self-care deficit .Interventions .Personal hygiene and Toilet use- Resident is totally dependent An observation on 01/10/27 at 01:30 p.m. revealed CNA B entered Resident #102's room preparing to provide incontinence care. CNA B washed her hands and put on gloves and unfastened Resident #105's brief to reveal the resident was incontinent of urine. CNA B took a peri-wipe and cleaned residents' perineal area, wiping from front to back and assisted the resident to roll on her side. CNA B took a peri-wipe and wiped each of the residents' buttocks from her lower back down toward the resident's labia. CNA B did not wipe the resident's rectal area, only her buttocks. With the same gloves, CNA B applied barrier cream to a chafed area on the residents' right buttocks and then removed the soiled brief and placed a clean brief under the resident and assisted her to roll back onto her back and fastened the brief. CNA B removed her gloves and washed her hands. Review of CNA B's skill checks dated 10/15/23 reflected she was competent in performing peri-care and hand hygiene. In an interview with CNA B on 03/01/23 at 10:15 a.m. she stated she was supposed to wash her hands before and after performing incontinent care and change her gloves when she finished. She stated she was supposed to clean the resident from front to back and then on her buttocks she was to clean from back to front. CNA B then stated she should have cleaned the resident's rectal area opposite of what she had done after she thought about it. She stated she knew the importance of properly cleaning a resident and by not doing so, placed them a risk of infections. In an interview with DON on 01/10/24 at 02:00 p.m., she stated staff were to clean residents from front to back during incontinence care. She stated by not following proper peri care it placed residents at risk of urinary tract infections. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676367 If continuation sheet Page 4 of 14 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676367 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Belterra Health & Rehab 2170 North Lake Forest Drive McKinney, TX 75071 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 0690 Level of Harm - Minimal harm or potential for actual harm Record review of the facility's policy titled, Perineal care, revised October 2010, reflected, .Wash and dry hands thoroughly .put on gloves .wash perineal are, wiping from front to back .Separate labia and wash area downward from front to back . Assist the resident to turn on her side .Wash the rectal area thoroughly, wiping from the base of the labia towards and extending over the buttocks .Rinse and dry thoroughly Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676367 If continuation sheet Page 5 of 14 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676367 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Belterra Health & Rehab 2170 North Lake Forest Drive McKinney, TX 75071 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** Immediate Supervisor: [NAME] Alfafara Residents Affected - Few Based on observation, interview, and record review, the facility failed to ensure that a resident, who needed respiratory care, was provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one of three residents (Resident #72) reviewed for respiratory care. The facility failed to ensure Resident #72's nebulizer tubing was changed weekly as scheduled. This failure could place the resident at risk for respiratory infection and not having their respiratory needs met. Findings include: Record review of Resident #72's face sheet, dated 01/10/24, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #72's relevant diagnoses which included atrial fibrillation (slow heartbeat) and chronic obstructive pulmonary disease (lung disease). Record review of Resident #72's Comprehensive MDS Assessment, dated 10/31/2023, reflected Resident #72's BIMS score was 13, which indicated the resident was cognitively intact. Resident #72's primary medical conditions were COPD and an unspecified cough. Record review of Resident #72's Care Plan, dated 11/05/2023, reflected the resident was care planned for COPD and one of the interventions was Give aerosol or bronchodilators as ordered. Monitor/document any side effects and effectiveness. Record review of Resident #72's physician order, dated 01/15/2024, reflected, Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG/3ML inhale orally every 6 hours as needed for SOB or Wheezing related to chronic obstructive pulmonary disease. In an observation on 01/09/24 at 10:49 AM of Resident #72's Nebulizer near her bed, revealed the tubing on the machine was dated 1-1-24. In an interview and observation on 01/09/24 at 01:15 PM with RN J in Resident #72's room. She was shown the tubing connected to Resident #72's Nebulizer, dated 1-1-24, and she stated the tubing should have been changed on 01/07/24 by the night nurse. She stated all tubing for respiratory machines were scheduled for changing every Sunday evening by the night nurse. She stated she was unsure why it was not done and not doing so could result in the resident getting an infection. RN J was observed changing out the tubing. In an interview on 01/11/24 at 10:30 AM with ADON H, she stated she was advised by RN J of Resident #72's tubing was not changed when scheduled, and she stated the tubing should have been changed on 01/07/24 by the Sunday night nurse. She stated all tubing for respiratory machines were changed out weekly on Sunday nights by the night nurse. She stated not changing the tubing as scheduled could result in the resident getting a respiratory infection. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676367 If continuation sheet Page 6 of 14 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676367 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Belterra Health & Rehab 2170 North Lake Forest Drive McKinney, TX 75071 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 - Few In an interview on 01/11/24 at 10:50 AM with the DON, she stated she was advised by ADON H of Resident #72's tubing not changed this past Sunday. She stated the tubing should have been changed on 01/07/24 by the Sunday night nurse. She stated that all tubing for respiratory machines were scheduled to be changed out weekly on Sunday nights by the night nurse. She stated she had already met with the ADON to in-service the weekend nurses of all scheduled required services for the residents, which included respiratory machine services. She stated not changing the tubing as scheduled could result in the resident getting a respiratory infection. Record review of the facility's Oxygen Administration, Policy/Procedure - Nursing Services, rev. 07/2022, reflected Policy: It is the policy of this facility that oxygen therapy is administered by licensed nurse as ordered by the physician . PURPOSE: The purpose of the oxygen therapy is to provide sufficient oxygen . will include: 1. That oxygen is to be administered; 2. When and how often oxygen is to be administered; 3. The type of oxygen device to use (i.e., mask, nasal). Oxygen concentrators should be cleaned according to manufacturer recommendations. Change or clean oxygen concentrator filters according to manufactures' recommendations. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676367 If continuation sheet Page 7 of 14 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676367 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Belterra Health & Rehab 2170 North Lake Forest Drive McKinney, TX 75071 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 observation, interviews and record reviews the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety for the facility's kitchen, reviewed for kitchen sanitation. The facility failed to ensure food in the facility's walk-in refrigerator was covered. The facility failed to ensure the ice machine was clean and sanitized. The facility failed to ensure the tea was covered with a lid. These failures could place residents at risk for cross contamination and other air-borne illnesses. Findings included: Observation on 01/09/2023 from 9:05 AM to 09:20 AM in the facility's kitchen revealed: 1. Two tea dispensers inside the kitchen with tea were not covered. 2. The ice machine inside the kitchen had a brown residue on the side wall. 3. The walk-in refrigerator had mandarin orange slices in a tray without any coverings. An interview with the Dietary Manager on 01/11/2024 at 12:46 PM, she stated the expectation of the kitchen staff was to make the tea an hour before the meal service and the tea dispenser was supposed to be covered during and after the brewing process. She stated the tea was prepared by her staff that day around 7:30 AM which was earlier than expected and both tea dispensers were not covered. She stated she was responsible to ensure the tea dispensers were covered. She stated preparing the tea early would lose its freshness, not covering the tea dispenser may cause cross contamination and could lead to sickness among residents. The Dietary manager stated she expected the ice machine to be clean, free of residue and her staff were to wipe it down daily. She stated an unclean ice machine may cause contamination and make a resident sick . She stated she was responsible to ensure the ice machine was cleaned. The Dietary Manager stated all the food items stored in the refrigerator ready for serving should be covered. She stated the mandarins in the tray were not covered and that may cause contamination and make a resident sick . She stated she was responsible to ensure all food were covered. The Dietary Manager stated she was responsible for the tea dispenser, ice machine and walk-in refrigerator in the kitchen. Interview with the Administrator on 01/11/2023 at 01:18 PM, he stated the expectation was to cover the tea during and after the brewing process. The Administrator stated he did not know the risk for residents because the tea was not covered . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676367 If continuation sheet Page 8 of 14 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676367 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Belterra Health & Rehab 2170 North Lake Forest Drive McKinney, TX 75071 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 The Administrator stated he expected the ice machine to be clean and sanitary at all times. He stated he did not know of any health risk the brown residue inside the ice machine may cause to a resident . The Administrator stated he did not think the sliced mandarin oranges stored inside the walk-in refrigerator in a tray needed to be covered since it was going to be served that afternoon. He did not think uncovered sliced oranges could cause any health risk to the residents . Record review of the facility policy, dated July 2014, reflected food shall be received and stored in a manner that complies with safe food handling practices. Food services or other designated staff will maintain clean food storage areas at all times. All food stored in refrigerator and freezer will be covered, labelled and dated. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676367 If continuation sheet Page 9 of 14 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676367 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Belterra Health & Rehab 2170 North Lake Forest Drive McKinney, TX 75071 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 five (Resident #310, Resident #102, Resident #21, Resident #83, and Resident #68) of eight residents reviewed for infection control. Residents Affected - Some 1. RN C failed to prevent cross contamination of Resident #310's Insulin pen when he placed a soiled glucometer next to the pen and then administered insulin to the resident with the soiled pen. 2. CNA B failed to perform hand hygiene during incontinence care for Resident #102. 3. The facility failed to prevent Resident #21's catheter bag, that was connected to her urostomy (an opening in the belly to redirect urine flow from the urinary system to the outside of the body), from contact with the floor. 4. MA D failed to sanitize the blood pressure cuff between uses on Resident # 83 and Resident # 68. Theses failures could place residents at risk for infection and cross contamination. Findings include: 1. Record review of Resident #310's face sheet, dated 01/24/24, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #310 had a diagnosis which included type 2 diabetes mellitus. Observation during medication pass on 01/10/24 at 11:00 a.m. revealed RN C placed a whole bottle of test strips, 2 lancets, 2 needles, 2 glucometers, and Residents #310's Novolog insulin Pen on a tray. RN C entered Resident #310's room and placed the tray of supplies on the resident's bedside table. RN C performed hand hygiene and put on gloves and performed a fingerstick blood sugar check. RN C then placed the soiled glucometer with the test strip still in place, next to the insulin pen on the tray. RN C removed his soiled gloves, performed hand hygiene, and left the room to go to the medication cart and determined the amount of insulin the resident required. RN C returned to the room performed hand hygiene and re-gloved. RN C picked up the insulin pen, that was still next to the soiled glucometer, and primed the pen and then dialed in 6 units of insulin and administered the insulin to Resident #310. RN C gathered the supplies and disposed of the lancet and needle in the sharp's container located in the resident's bathroom, and returned to the medication cart where he removed his gloves and performed hand hygiene, re-gloved and pulled out a germicidal wipe and wiped down the bottle of test strips, the insulin pen and both glucometers. In an interview with RN C on 01/14/24 at 11:20 a.m., he stated he carried in 2 glucometers and the whole bottle of strips in case one glucometer did not work or if he needed more test strips. He stated he should not have taken in the insulin pen and by placing the dirty glucometer next to the pen had potentially cross contaminated which could cause the risk of infection to the resident. He stated he should have only taken in the necessary supplies he needed to perform the fingerstick blood sugar test. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676367 If continuation sheet Page 10 of 14 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676367 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Belterra Health & Rehab 2170 North Lake Forest Drive McKinney, TX 75071 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 Record review of RN C's competency checks, dated 12/19/23, reflected he was competent in administering subcutaneous injections and blood glucose monitoring. In an interview with the DON on 01/10/24 at 11:35 a.m., she stated performing fingerstick blood sugars and administering insulin was a two-step process. She stated staff were not following the facility procedure if they were carrying in multiple supplies to check a resident's blood sugars. She stated they were only to carry in the necessary supplies needed to check a blood sugar, then perform hand hygiene and retrieve the required insulin and perform hand hygiene before and after giving the insulin. She stated taking in the whole bottle of test strips which was used for multiple residents was not acceptable and by taking in the insulin pen and placing the used glucometer next to it cross contaminated the pen. She stated the staff were to complete the fingerstick monitoring and then proceed with the insulin administration if needed. She stated failing to follow the correct procedure placed residents at risk of cross contamination and infections. Record review of the facility's policy, Obtaining a Fingerstick Glucose level, dated October 2011, reflected .Assemble equipment and supplies needed .Obtain blood sample .Dispose of the lancet in the sharps disposal container .discard disposable supplies in the designated containers .Clean and disinfect reusable equipment between uses according to the manufacturer's instructions and current infection control standards of practice .remove gloves and discard into designated container .Wash hands Record review of the facility's policy, Insulin Administration, dated September 2014, reflected .Wash hands .Check blood glucose per physician order or facility protocol .Remove Insulin vial from storage point .Select an injection site .Depress the plunger and remove the needle .dispose of the needle in a designated container .Wash hands 2. Record review of Resident #102's 5-day MDS assessment, dated 12/24/23, reflected a [AGE] year-old female with an admission date of 12/21/23. Resident #102 had a BIMs of 11, which indicated she was moderately cognitively impaired. She required extensive assistance of one-to-two-persons with all ADLs and was always incontinent of bowel and bladder. Her diagnoses included diabetes and malignant neoplasm (cancer) of the right lung. Record review of Resident #102's care plan, dated 12/21/23, reflected . The resident has an ADL self-care deficit .Interventions .Personal hygiene and Toilet use- Resident is totally dependent . An observation on 01/10/27 at 01:30 p.m. revealed CNA B entered Resident #102's room preparing to provide incontinence care. CNA B washed her hands, put on gloves, and unfastened Resident #105's brief to reveal the resident had been incontinent of urine. CNA B took a peri- wipe and cleaned the resident's perineal area, wiping from front to back and assisted the resident to roll on her side. CNA B took a peri-wipe and wiped each of the resident's buttocks from her lower back down toward the resident's labia. With the same gloves, CNA B applied barrier cream to a chafed area on the resident's right buttocks and then removed the soiled brief and placed a clean brief under the resident and rolled her back onto her back and fastened the brief. CNA B removed her gloves and washed her hands. In an interview with CNA B on 01/10/27 at 01:45 p.m., she stated she was supposed to wash her hands before and after performing incontinent care and change her gloves when she finished. She stated she should have changed her gloves after she cleaned the resident, before applying the barrier cream and clean brief. She stated failure to 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: 676367 If continuation sheet Page 11 of 14 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676367 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Belterra Health & Rehab 2170 North Lake Forest Drive McKinney, TX 75071 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 Record review of CNA B's skill checks dated 10/15/23 reflected she was competent in performing peri-care and hand hygiene. In an interview with the DON on 01/10/24 at 02:00 p.m., she stated staff were to change their gloves and perform hand hygiene after they performed incontinence care, before applying the barrier cream and clean brief. She stated by not following proper hand hygiene it placed residents at risk of urinary tract infections. Record review of the facility's policy titled, Infection Control Guidelines for All Nursing Procedures, dated August 2013, reflected, .Employees must wash their hands .when hands are visibly dirty or soiled with blood or other body fluids .after removing gloves .before moving from a contaminated body site to a clean body site during resident care .after removing gloves 3. Record review of Resident #21's face sheet, dated 01/11/2024, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #21's relevant diagnoses included flaccid neuropathic bladder (the muscles of the bladder lose the ability to contract), obstructive and reflux uropathy (inability of the urine to flow causing the urine to flow back to the blader), and pyuria (pus in the urine). Record review of Resident #21's Quarterly MDS Assessment, dated 11/03/2023, reflected Resident #21 was cognitively intact with a BIMS score of 15. The Quarterly MDS Assessment also indicated the resident had an urostomy. Record review of Resident #21's Comprehensive Care Plan, dated 11/07/2023, reflected the resident had a urostomy bag (a pouch attached to the opening in the belly to collect the urine) related to neuromuscular dysfunction of bladder, flaccid neuropathic bladder, and obstructive and reflux uropathy. The interventions were to ensure the urinary catheter tubing was anchored and secure . the catheter bag related to when the resident moved around in the bed at times causing the catheter bag to dislodge or fall onto floor. Record review of Resident #21's Physician Order dated 08/25/2023 indicated, Urinary catheter ensure tubing anchor and privacy bag is intact and secure. Observation and interview with Resident #21 on 01/10/2024 at 9:07 a.m. revealed Resident #21 was on her bed, awake. Resident #21 had a catheter bag connected to her urostomy. The catheter bag was noted on the floor. Resident #21 stated she had a urostomy bag that was connected to a catheter bag. She said she had the urostomy and catheter bag set-up since the last quarter of the year. Resident #21 was advised her catheter bag was on the floor. Resident #21 stated the CNAs usually hooked the catheter bag on the side lowest part of the bed or on the knob of the last drawer of the right-side table. Observation and interview with LVN P on 01/10/2024 starting at 10:01 a.m., LVN E stated the proper care of the catheter was making sure it was off the floor. LVN P said the catheter bag should be off the floor because it would cause infection. LVN P added he would check Resident #21's catheter if it was still on the floor. LVN P went inside Resident #21's room and hooked the catheter bag on the railings below the bed. Interview with ADON H on 01/10/2024 at 12:25 p.m., ADON H stated the catheter bag should be off the floor. She said the catheter bag should be below the bladder but not on the floor. ADON H said it (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676367 If continuation sheet Page 12 of 14 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676367 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Belterra Health & Rehab 2170 North Lake Forest Drive McKinney, TX 75071 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 could cause infection especially for individuals who were immuno-compromised. ADON H said the expectation was for the staff to make sure the catheter bag was off the floor when the resident was on the bed or in the wheelchair. Interview with the DON on 01/10/2024 at 1:41 p.m., the DON stated the catheter bag should not be on the floor. The DON said it was an infection concern when the catheter bag was on the floor. The DON said if the catheter was on the floor, the catheter bag should be changed and hooked below the bladder. The DON said the nurses were responsible to ensure the catheter was off the floor. The DON added the nurse should start monitoring the catheter bag and should start reminding the staff that every time they would empty the catheter bag, they should hook it and make sure the catheter bag was off the floor. The DON said the expectation was the catheter bags would be off the floor to prevent infection and the staff would ensure they followed the best practice for catheter care. The DON concluded she would do an in-service regarding catheter bags not being on the floor and monitor the staff were doing a routine catheter care per shift. Interview with the Administrator on 01/10/2024 at 1:55 p.m., the Administrator stated the staff should have a conscious effort in preventing infection. The Administrator said the catheter bag should be off the floor to prevent a potential contamination. The Administrator said the expectation was for the staff to ensure the catheter was off the floor and the staff to monitor the catheter bag at the beginning of every shift and throughout their shift. Record review of the facility policy, Catheter Care, Urinary, revised January 3, 2023, reflected Purpose: The purpose of this procedure is to prevent catheter-associated urinary tract infections . Infection Control . 1. Use standard precautions when handling or manipulating the drainage system. 4. Record review of Resident #83's face sheet, dated 01/11/24, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #83 had diagnoses which included dementia and diabetes. Record review of Resident #68's face sheet, dated 01/11/24, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #68 had a diagnosis which included dementia. Observation during medication pass on 01/10/24 at 08:45 a.m. revealed MA D entered Resident #83's room to obtain her blood pressure. After performing the blood pressure reading MA D returned to the medication cart and obtained the resident's morning medications and administered them. MA D returned to the cart and walked to the next hall with the un-sanitized blood pressure cuff. MA D entered Resident #68's room and obtained her blood pressure without sanitizing the blood pressure cuff. MA D returned to the medication cart and obtained the resident's morning medications and administered them. MA D performed hand hygiene but did not sanitize the blood pressure cuff. In an interview with MA D on 01/10/24 at 9:20 a.m., she stated she was supposed to clean the blood pressure cuff with a germicidal wipe after each use. She stated she knew she was supposed to clean all the equipment between residents to prevent the spread of infection, she just forgot. In an interview with the DON on 01/10/24 at 11:20 a.m., she stated the staff were required to clean the equipment used after each use before using it on another resident. She stated failure to do this could potentially spread germs. Record review of the facility's policy titled, Cleaning, Disinfection of Resident-Care equipment, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676367 If continuation sheet Page 13 of 14 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676367 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Belterra Health & Rehab 2170 North Lake Forest Drive McKinney, TX 75071 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 dated October 2018, reflected Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC recommendations .non-critical items are those that come in contact with intact skin but not mucous membranes .items include .blood pressure cuffs .Reusable resident care equipment will be decontaminated between residents according to manufacturer's' instructions Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676367 If continuation sheet Page 14 of 14