Health inspection·February 13, 2025

F 0755 supplies. Level of Harm - Minimal harm or potential for actual harm Record review of the facility's policy titled Storage of Medications, with a revision date of [DATE], revealed The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner and discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. Residents Affected - Some 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 02/13/2025 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 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents were free of any significant medication errors for one (Resident #29) of 19 residents reviewed for medication errors. Residents Affected - Some The facility failed to ensure Clonazepam (a drug used to control seizures and/or anxiety) was administered to Resident #29 as ordered from 9/10/2024 until 2/12/2025 (155 days). This failure could place residents at risk for not receiving medications as ordered by their physician and not receiving the intended therapeutic benefit of the medications. Findings included: Record review of Resident #29's Annual MDS assessment dated [DATE] revealed Resident #29 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of anxiety disorder and seizure disorder. The MDS also revealed a BIMS score of 13 (it suggested cognition was intact). Record review of Resident #29's care plan revised on 1/24/2025 revealed Resident #29 had a seizure disorder and interventions were to give seizure medications as ordered by the doctor. The care plan also revealed Resident #29 had an anxiety disorder and interventions included administering anti-anxiety medications as ordered by the physician. Record review of Resident #29's physician order summary revealed on 8/12/2024 a new order for clonazepam was entered as clonazepam 0.5 mg with directions to give 0.5 tablet by mouth three times a day and included in directions give ½ tablet to equal 0.25 mg. Record review of Resident #29's Narcotic Record logs from 8/11/2024 to 9/09/2024 revealed clonazepam 0.5 mg ½ tablet was signed out and marked as given. Record review of Resident #29's Narcotic Record logs from 9/10/2024 until 01/12/25, revealed clonazepam 0.5 mg one tablet was signed out and marked as given. Record review of Resident #29's MARs from 09/10/24, until 01/12/25 revealed clonazepam was administered three times a day by 15 different staff members over a total of 155 days. In an observation on 2/11/2025 at 1:40 p.m., MA C administered one tablet of clonazepam 0.5 mg to Resident #29. Resident #29 was sitting up in his chair and answered MA C's questions appropriately. Resident #29 swallowed the medication and MA C left the room. In an interview and observation on 2/12/2025 at 11:29 a.m., MA C removed Resident #29's clonazepam from the medication cart and stated she administered one whole tablet when she gave the medication. MA C pointed to the directions on the medication card itself which revealed directions to give 0.5 mg one tablet three times a day. MA C opened Resident #29's MAR on her computer screen and read the directions listed for clonazepam which were to give 0.5 tablet. MA C stated that the whole tablet was 0.5 mg and the MAR said to give 0.5 mg. MA C replaced the medication on the locked cart and left to retrieve the ADON to review the medication. In an interview and observation on 2/12/2025 at 11:33 a.m., ADON B reviewed the clonazepam (continued on next page) 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 02/13/2025 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 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some medication located on the cart and stated the directions were to administer one 0.5 mg tablet three times a day. ADON B then reviewed Resident #29's MAR and stated the directions were to administer ½ tablet to equal 0.25mg. ADON B then explained to MA C that the 0.5 tablet meant ½ tablet and not 0.5 mg. ADON B also demonstrated on the computer screen how to expand the directions for the medication which then revealed to give ½ tablet to equal 0.25 mg. ADON B stated staff should have been administering ½ tablet, but the medication was delivered wrong by the pharmacy. ADON B stated staff should have checked the dose before administering the medication. ADON B stated the risks to the residents if not receiving the ordered dose depended on the medications, but it could cause sedation. In an interview on 2/12/2025 at 3:20 p.m., the DON stated Resident #29's clonazepam was increased in September due to a transcription error. The DON reported that the nurse that entered the order was not available for interview and was currently off work. The DON stated everyone that administered medications should have followed the five rights of medication administration and monitored the order and dose. The DON stated the pharmacy consultant was also responsible for monitoring medications because she checked the MARs and medications monthly for any concerns. The DON reported staff received training for medication administration upon hire and annually. The DON also stated the risk to the residents if the incorrect dose of medication was given depended on the medication but could be sedation or altered mental status. In an interview on 2/13/2025 at 11:43 a.m., NP D stated she gave an order to increase the clonazepam from 0.25 mg to 0.5 mg, but there must have been a transcription error. NP D stated she did not have any issues or concerns with the facility following orders. NP D also stated there was no risk to the resident because the resident received the intended dose. Review of the facility's policy titled Administering Medications, with a revision date of April 2019, revealed The Director of Nursing Services supervises and directs all personnel who administer medications, and Medications are administered in accordance with prescriber orders. 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 02/13/2025 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and record review the facility failed to ensure all drugs and biologicals were labeled in accordance with currently accepted professional principles and secured properly for two (500 hall medication cart and 200 hall medication cart) of four medication carts reviewed for medication labeling and storage. 1. The facility failed to ensure eye drops stored on the 500-hall medication cart were labeled with open dates for two bottles of timolol eye drops, one bottle of dorzolamide eye drops, one bottle of brimonidine eye drops, and one bottle of latanoprost eye drops. 2. The facility failed to ensure medications were secured or attended by authorized staff when the medication cart in hall 200 was left unlocked and unattended in the hallway with a pill in a medicine cup on top of the cart. These failures could place residents at risk of misappropriation of medications or harm due to accidental ingestion of unprescribed mediations and of not receiving the intended therapeutic effects of prescribed medicine. Findings included: 1. In an interview and observation on 2/11/2025 at 9:46 a.m., the 500-hall medication cart contained two bottles of timolol eye drops, one bottle of dorzolamide eye drops, one bottle of brimonidine eye drops, and one bottle of latanoprost eye drops that were open and did not have open dates. MA C reported eye drops needed an open date because they were good for 30 or 45 days after being opened. MA C stated the MAs monitored the dates on the medications and wrote open dates on the bottles when they opened them. When asked what the risks were if open dates were not on eye drops, MA C responded they just had to have an open date. In an interview on 2/11/2025 at 10:21 a.m., ADON B stated staff administering medications were supposed to put open dates on eye drops because they were only good for so many days. ADON B stated the risk would be that they would not know how long the medication had been open, and it would depend on the manufacturer as to what side effects occurred. ADON B stated the staff administering the medications should have monitored the dates, and she spot checked the carts two to three times a month. In an interview on 2/12/2025 at 3:20 p.m., the DON stated eye drops needed an open date, so they would know when they were opened. The DON stated she expected the staff to use the manufacturer's expiration date but was not sure at that time. The DON stated the pharmacy consultant was responsible for monitoring the dates on medications in the medication carts, and all staff that administered medications should have checked the dates. The DON stated she expected staff to dispose of expired medications, and that the risk of using expired medications would just depend on the medication. The DON (continued on next page) 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 02/13/2025 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 0761 did not state the risk for using expired eye drops or for eye drops not having an open date. Level of Harm - Minimal harm or potential for actual harm In an interview on 2/12/2025 at 3:40 p.m., the DON stated she spoke with her pharmacy consultant, and they did not have to date eye drops. The DON reported they would use the manufacturer's expiration date. Residents Affected - Some In an interview on 2/12/2025 at 3:48 p.m., the pharmacy consultant reported that there were no specific guidelines for artificial eye drops, and they did not require an open date. The pharmacy consultant reported that the length of time other eye drops were good depended on the manufacturer's expiration date or their guidelines. In an interview on 2/12/2025 at 4:04 p.m., the DON stated they would use the manufacturer's expiration date for all eye drops except for Xalatan (latanoprost) because they were only good for a certain number of days after opening. The DON did not state how many days. In an interview on 2/12/2025 at 4:15 p.m., MA E stated prescription eye drops are good for six weeks, and pharmacy consultant told him to throw them away after six weeks. MA E stated he did not know what the risk would be if the eye drops did not have an open date or were used longer that six weeks. MA E stated they put the open dates on the eye drops so that did not happen. MA E also stated that everyone that passed medications was responsible for monitoring the dates on medications in the carts. In an interview and observation on 2/12/2025 at 4:28 p.m., LVN F stated eye drops had open dates, but (HE/SHE) was not sure how long they were good for. Observed LVN F ask LVN G, and LVN G stated eye drops were good for 30 days after opening. In an interview and record review on 2/12/2025 at 4:30 p.m., MA H reported some eye drops were good for 30 days and some were good for 45 days. MA H stated he did not always remember, so he used the information sheet located in the narcotic binder on the medication cart. MA H opened a binder on his medication cart and revealed a sheet titled Medications with Shortened Expiration Dates. This sheet listed several different eye drops and the amount of days the medication could be used after opening. Eye drops that were listed on this sheet included latanoprost and he stated those eye drops were good for 42 days after being opened or removed from the refrigerator. The informational sheet did not specify how many days timolol, dorzolamide, or Brimonidine were good after opening if not mixed with another medication. In an interview on 2/12/2025 at 5:41 p.m., the DON stated they use the information sheet located on the medication cart for prescription eye drops. The DON stated they did not need an open date for over-the-counter eye drops. 2. In an observation on 2/11/2025 at 1:35 p.m., RN D entered a resident's room to administer medications. The medication cart was left approximately three feet in front of the resident's door, unlocked, and had a medicine cup sitting on top of the cart with a pill in it. RN D entered the resident's bathroom inside their room and washed her hands with the door closed. The medication cart was not visible from inside the bathroom. RN D then exited the bathroom and walked next to the resident's bed. The medication cart remained out of view until RN D returned to the cart at 1:39 p.m. (4 minutes later). No residents or visitors were observed in the area of the medication cart while it was unlocked. (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 02/13/2025 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some In an interview on 2/11/2025 at 1:39 p.m., RN D stated she should have locked the cart or pulled it all the way up to the door. RN D stated she also should not have left medication on the top of the cart. RN D stated the risks were that someone could have taken the medication from inside the cart or the pill on top of the cart. In an interview on 2/12/2025 at 5:50 p.m., the DON stated medication carts should always be locked and medications should not be left unattended. The DON stated the carts can be unlocked while passing medications if they were all the way against the resident's door. The DON stated the risks were that medications could go missing, and the staff administering medications should be monitoring that the carts were locked. The DON also stated all staff should help monitor and ensure carts were locked. Record review of the facility's policy titled Administering Medications, with a revision date of April 2019, revealed when opening a multi dose container, a date will be put on the container, and during the administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse or aide. Record review of the facility's policy titled Storage of Medications, with a revision date of April 2019, revealed Unlocked medication carts are not left unattended. 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 02/13/2025 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, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's main kitchen reviewed for food safety. 1. The facility failed to ensure food items in the refrigerator and dry storage room were labeled and stored in accordance with the professional standards for food service. 2. The facility failed to discard items stored in refrigerator or dry storage that were not properly labeled or past the 'best buy', discard by or expiration dates. 3. The facility failed to have dietary staff wash hands or change gloves when they touched other surfaces while handling food or upon re-entering the kitchen. 4. The facility failed to have the handwashing sink trash receptacles function properly. These failures could place residents at risk for food-borne illness and cross contamination. Findings Included: Observation of the Kitchen on 02/11/25 at 10:00 AM revealed the following: -Handwashing sink #1's (next to ice machine) trash receptacle did not function properly. When the foot pedal was pressed the small metal cylindrical trash receptacle leaned forward, coming off of the floor and the lid did not open fully. Observations of Reach-in refrigerator on 02/11/25 at 10:07 AM revealed the following: -Left side: -1-64 oz plastic container of Prune juice dated 12/7/24, previously opened on 01/28/25 there was no discard by date. Observations of Walk-in refrigerator on 02/11/25 at 10:12 AM revealed the following: -Left side, first shelf, 2nd row from the top: -1 small zip top bag with a half of a tomato and approximately a quarter of a red onion (both previously opened), dated 2/7/25 and under the used by label on the bag, dated 2/8/25. There was no label of item descriptions, no clear discard by date and unclear if a date was for each item when placed in the bag. -2 extra-large bags of coleslaw salad mix, dated 01/26/25. Manufacturer's 'best by' date 02/07/25. -1 extra-large bag had a half dollar sized brown spot at the top of the product on the back side of the bag. -1 large zip top bag containing a previously opened 5 lbs. bag of salad blend, opened 02/06/25 and discard by date 02/09/25. -Third row from the top:-1 extra-large gray plastic bin filled with red onions had two labels one dated 10/10/24 and the other dated 12/30/24. There was no item of label description and no discard by (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 02/13/2025 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 date. Level of Harm - Minimal harm or potential for actual harm -Bottom row: -1 extra-large clear plastic bin with approximately 13 heads of cabbage dated 01/02/25. There were 4 heads of cabbage that had dried, withered, darkened areas and or yellowed areas on the outer leaves. There was no label of item description, no discard by date. Residents Affected - Some -Left side, second shelf, 2nd row from the top: -1 extra-large zip top bag with 10 plus beef hot dogs in a box labeled beef hot dogs dated 01/26/25, opened 02/10/25, with no discard by date. Second shelf, 3rd row from the top: approximately ¾ of a loaf of a deli meat ham, previously cut, dated 02/06/25, opened 02/10/25. There was no discard by date. -1- 5 lbs. bag of ground pork dated 02/10/25, there was no label of item description, no manufacturer's 'best by' date, or discard by date. - 1 large zip top bag of sliced lunch meat (1 bologna and approximately 10 chopped ham), dated 02/04/25 and 02/07/25 remained in refrigerator. There was no label of item description. -Bottom shelf: -1 extra-large box of skinless boneless chicken on a tray, dated 02/06/25. There was no discard by date. Right side, first shelf, 3rd row from the top: 1- extra-large zip top bag of grated cheese dated opened 02/03/25, discard by dated 02/28/25. There was no label of item description. -1 extra-large bag of shredded light-yellow cheese dated opened 02/04/25, discard by date 03/04/25. No label of item description. -2 -48 oz (3 lbs.) white plastic containers of Ricotta cheese dated 01/20/25. Manufacturer's used by date 02/01/25. -3rd row from the top: -1 small square plastic container with lid of salad dressing, previously opened dated 02/10/25. There was no label of item description and no discard by date. -1 large square plastic container with lid of ranch dressing, previously opened, dated 02/11/25. There was no label of item description and no discard by date. -1 medium square metal container of ranch dressing, previously opened, dated 02/10/25. There was no label of item description and no discard by date. -4th row from the top: -1 large cylindrical clean plastic container, without a lid, dated 01/25/25, of approximately 42 boiled eggs. There were 3 sealed clear plastic bags containing 12 eggs each and no discard by date; 1 bag previously opened. The opened bag was open to air, containing 6 eggs. There was no opened date and no discard by date. -Second shelf, 3rd row from the top: -1 large zip top bag of approximately 25 pecan halves, previously opened, dated 1/30/25. There was no label of item description and no discard by date. Observations of Dry Storage Room on 02/11/25 at 10:55 AM revealed the following: (continued on next page) 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 02/13/2025 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 -Left side, shelf near door, 2nd row: -1 large clear square plastic bin with lid of dry oat circular cereals, previously opened, dated 02/10/2025. There was not label of item description, no discard by date. -1 large clear square plastic bin with lid of dry corn flake cereal, previously opened, dated 02/10/25. There was not label of item description, no discard by date. Residents Affected - Some -1 large zip top bag with a 4 lbs. bag of cheese cake dry mix, previously opened, dated 10/30/24. There was no discard by date. - 1 large zip top bag with a 24 oz. bag of crispy fried onions, previously opened, dated 12/02/24. There was no discard by date. -1 large zip top bag with a 5 lbs, bag of cornbread mix, previously opened, dated 02/10/25. There was no discard by date. -1 large zip top bag with a 13.75 oz box of mashed potato flakes, previously opened, dated 02/11/25, no discard by date. Observations of the Kitchen on 02/13/25 at 11:56 AM revealed the following: -AIT wearing a hairnet walked in the kitchen and did not wash his hands. He went to the Reach-in refrigerator and opened it. He then walked across the area between the steam table and stove to the other side of the kitchen. He left out of the kitchen through a door (with a handle) into the receiving side of the line. He looked at some of the tickets on a stack of trays near the door then came back into the main kitchen space. He did not wash his hands, sanitize his hands, or don gloves. -At 12:09 PM, the [NAME] walked off the line (serving side of the steam table), wearing gloves. She went to get a bowl of fruit from the walk-in refrigerator. Then she walked off the line again to get a spoon and tongs but did not change into new gloves after either departure and return to serving line. -At 12:19 P, the ADM wearing a hairnet, walked into the kitchen (receiving side) then through the 2nd door into the main kitchen space. He walked through the area between the serving side of the steam table and the stove over to the stack of 8 oz cups with handles. He too the cup back across the kitchen to the coffee machine, got some coffee then left out of the kitchen. He did not wash his hands upon entering the kitchen or don gloves. In an interview on 02/11/25 at 10:27 AM with the DM, she stated the ground meat that was in the refrigerator was ground pork, and they put the date on box it came in, but the box was usually kept in the freezer except for when the ground pork was being used for a dish. The one in the refrigerator had been set out to be used for baked ziti. She stated that is why [NAME] B put it there. In an interview on 2/13/25 at 01:56 PM with the DM, she stated previously opened liquids in the refrigerator were kept until the date (manufacturer's best by date) on the bottle or box. She stated if it is mixed like nectar thick liquids then it kept for 7 days. For premade salad mixes/blends, she stated they kept it until the 'best by' date but opened salad mixed are kept for 7 days from opened date. She stated the beef hot dogs, since opened, are kept 7 days from opened date but 1-2 months if kept in the freezer. The DM sated if the ground pork is kept 7 days in the refrigerator, but if it (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 02/13/2025 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 had been opened then kept for 3 days. She stated the bag with the tomato & onion should not have been labeled like that, with no clear date the harm is it could cause a resident to get sick since you do not know the clear date opened or discard by. For the skinless boneless chicken, the DM stated if she is going to use it within the week then she does not freeze the chicken, so the date that was seen on the box was the date it came in. For dairy and other items with a manufacturer's date she stated they usually go by the expiration date on the container but if it is opened, then 3 days. For items previously opened and left opened to air, the DM stated that can lead to foodborne illness and residents getting sick. She mentioned they have a food guideline sheet they use to know how long to keep items in the kitchen. When she was told about the observations of staff hand hygiene concerns, she stated that is something she talks about a lot and it can result in making the residents sick. In an interview on 02/13/25 at 03:46 PM with the ADM, when he came to the conference room to ask about concerns in the kitchen, he stated his dietician came in every Monday. He stated as a favor to him, she inspects the kitchen. He said, the kitchen, I can't believe it. He stated he was just thinking the citation was just for unlabeled cheese. The surveyor mentioned other items specifically found in the kitchen. The ADM sated he understood it could cause harm to the residents. Review of the facility's Nutrition Services Policy dated 2001: Revision July 2014, reflected Food Storage Policy: Foods shall be received and stored in a manner that complies with safe food handling practices. Policy Interpretation and Implementation: 1. Food Services, or other designated staff, will maintain clean food storage areas at all times. 6. 6. Dry foods that are stored in bins will be removed from original packaging, labeled and dated (use by date). Such foods will be rotated using a first in-first out system. 7. 7. All foods stored in the refrigerator or freezer will be covered, labeled and dated (''use by date). 13. d. Beverages must be dated when opened and discarded after twenty-four (24) hours. e. Other opened containers must be dated and sealed or covered during storage. Review of the U.S. FDA Food Code 2022 reflected: Chapter 2 . section 2-301 Hands and Arms. 2-301.11 Clean Condition. Food Employees shall keep their hand and exposed portions of their arms clean. 2-301.12 Cleaning Procedure. (C). To avoid recontaminating their hands or surrogate prosthetic devices, food employees may use disposable paper towels or similar clean barriers when touching surfaces such as manually operated faucet handles on a Handwashing Sink or the handle of a restroom door. 2-201.14 When to Wash. Food Employees shall clean their hands and exposed portions of their arms as specified under section 2-301.12 immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single service and single-use articles. and: . (E) After handling soiled equipment or utensils; (F) During food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; . (H) Before donning gloves to initiate a task that involves working with food; and (I) After engaging in other activities that contaminate the hands. Section 2-301.15 Where to Wash. Food Employees shall clean their hands in a Handwashing Sink or approved automatic handwashing facility and may not clean their hands in a sink used for food preparation or warewashing, or in a service sink or a curbed cleaning facility used for the disposal of mop water and similar liquid waste. Chapter 3 . section 3-201.11 Compliance and Food Law: . C. Packaged Food shall be labeled as specified in LAW, including 21 CFR 101 Food Labeling [* .(b) A food which is subject to the requirements of section 403(k) of the act shall bear labeling, even though such food is not in package form. (c) A statement of artificial flavoring, artificial coloring, or chemical preservative shall be placed on the food or on its container or wrapper, or on any two or all three of these, as may be necessary to render such statement (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 02/13/2025 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 likely to be read by the ordinary person under customary conditions of purchase and use of such food. The specific artificial color used in a food shall be identified on the labeling when so required by regulation in part 74 of this chapter to assure safe conditions of use for the color additive.], 9 CFR 317 Labeling, [*(a) When, in an official establishment, any inspected and passed product is placed in any receptacle or covering constituting an immediate container, there shall be affixed to such container a label .Marking Devices, and Containers, and 9 CFR 381 Subpart N Labeling and Containers, and as specified under § 3-202.18. Section 3-302.12 Food Storage Containers, Identified with Common Name of Food: Except for containers holding FOOD that can be readily and unmistakably recognized such as dry pasta, working containers holding food or food ingredients that are removed from their original packages for use in the food establishment, such as cooking oils, flour, herbs, potato flakes, salt, spices, and sugar shall be identified with the common name of the food. Section 3-501.17 . Commercial processed food: Open and hold cold . B. 1. The day the original container is opened in the food establishment shall be counted as Day 1. 2. The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety. C. 2. Marking the date or day of preparation, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (A) of this section. 3. Marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (B) of this section. Definitions 3. Food Receiving and Storage - When food, food products or beverages are delivered to the nursing home, facility staff must inspect these items for safe transport and quality upon receipt and ensure their proper storage, keeping track of when to discard perishable foods and covering, labeling, and dating all PHF/TCS foods stored in the refrigerator or freezer as indicated. Chapter 5 . Section 5-205.11 Using a Handwashing Sink (A) A Handwashing Sink shall be maintained so that it is accessible at all times for Employee use. Section 5-501.16 Storage Areas, Rooms, and Receptacles, Capacity and Availability . (B) A receptacle shall be provided in each area of the Food establishment or premises where refuse is generated or commonly discarded, or where recyclables or returnables are placed. Section 5-501.113 Covering Receptacles. Receptacles and waste handling units for refuse, recyclables, and returnables shall be kept covered: . www.fda.gov eCFR- Code of Federal Regulations are indicating within the text by an *- www.ecfr.gov 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 02/13/2025 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 reviews, the facility failed to establish and maintain an Infection Control Program designed to help prevent the development and transmission of disease and infection for one (Resident #85) of three residents reviewed for infection control. Residents Affected - Few The facility failed to ensure RN D used proper infection control precautions when entering the room of Resident #85 who was on droplet precautions due to testing positive for COVID. This failure could place residents at risk for infections. Findings included: Record review of Resident #85's admission MDS assessment dated [DATE] revealed Resident #85 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of diabetes, morbid obesity, and gangrene (dead tissue caused by bacteria or lack of blood flow). The MDS also revealed a BIMS score of 15 (suggested no cognitive impairment). Record review of Resident #85's care plan with a revision date of 2/04/2025 revealed Resident #85 was on strict contact isolation related to COVID and interventions included providing proper protective equipment. Record review of Resident #85's order summary revealed strict (contact/droplet) Isolation; Transmission Based Precaution for (Covid +) was ordered on 2/04/2025. In an observation and interview on 2/11/2025 at 1:28 p.m., RN D was preparing to administer medications to Resident #85. A droplet isolation sign was observed on Resident #85's door and isolation supplies were located outside the door in drawers. RN D put on a N95 mask and stated she did not have to wear a gown as long as she did not touch the resident or provide direct care. RN D entered Resident #85's room wearing an N95 mask and no gown, gloves, or face shield. RN D exited the room less than one minute later and placed a medicine cup with a pill in it on top of the medication cart before reentering Resident #85's room. RN D then exited Resident #85's room with a tray and sat the tray on a short table in the center of the hallway. RN D then discarded her mask and cleansed her hands with hand sanitizer. Resident #85 did not cough or appear to have shortness of breath during this time. In an interview on 2/12/2025 at 12:34 p.m., ADON B reported that staff entering a room with a resident on isolation for COVID, should wear a N95 mask, face shield, gown, and gloves. ADON B stated all PPE should be worn even if not providing direct care. ADON B stated the risk was that COVID could be spread. ADON B also stated that trays should not be removed from isolation rooms and placed on a table in the hallway. ADON B reported that the ADONs monitored infection control and the DON performed in-services with staff. ADON B reported there was also training that was done on the computer for isolation precautions and one was assigned to staff recently. Record review of progress note dated 2/12/2025 at 3:02 p.m., entered by ADON B, revealed Resident #85 had been asymptomatic (no symptoms) and could be removed from isolation at that time. In an interview on 2/12/2025 at 4:04 p.m., the DON reported everyone was responsible for monitoring infection control. The DON stated all staff should always wear N95, gown, gloves, and face shield (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 02/13/2025 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 - Few FORM CMS-2567 (02/99) Previous Versions Obsolete when entering a room with COVID. The DON stated the risk for not wearing appropriate PPE was that the person entering the room could get COVID or spread COVID. Record review of facility's undated policy titled COVID-19 Outbreak-Cheat Sheet, revealed Staff caring for COVID+ patients must wear N95, gown, gloves, and eye protection. All PPE must be discarded and re-applied each time entering COVID room. Event ID: Facility ID: 676367 If continuation sheet Page 14 of 14