Inspection·March 21, 2024

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident #5 in a group meeting along with the administrator but did not have communication with Resident #51 regarding her food choices one on one yet. In an interview with RN A on 03/21/24 at 10:05 AM revealed Floor Nurses do not actively participate in care plan meetings. RN A stated that Resident #51 had complained about facility food not tasting good; but she was not aware Resident #51 had food intolerances. RN A stated care plans were important as the staff was aware of Resident's care. In an interview with ADON on 03/21/24 at 10:12 AM revealed she had been working in the facility for the last 18 months. She stated that she was not actively involved in care planning meetings. She stated Resident #51 ordered food from local stores frequently that included soups, snacks. She stated care plans were important to determine patient care and risk of not care planning was lack of consistent care. In an interview with the social worker on 03/21/24 at 10:28 AM revealed that Resident #51 had lot of issues and the facility was aware she had several food restrictions. She was not sure why her dietary restrictions were not care planned and stated that the DON was responsible for writing all the care plans. She also stated that care plans are done every 90 days, annually and as needed. She stated risk of not care planning can lead to decreased quality of care to the residents. In an interview with the DON on 3/21/2024 at 11:56 AM revealed she was aware of Resident #51's dietary preferences from other staff but also stated that Resident #51 had never complained to her directly regarding food. She stated care plans were updated quarterly and annually. She also stated that the previous dietary manager held several conversations with resident # 51 and agreed that her food preferences should have been care planned. The DON stated the facility did not have a MDS coordinator in-house for the past one month and the Corporate MDS was filling in. She stated that the corporate MDS and herself were responsible for writing the care plans in the EHR. The DON added Care plans were important because they direct the care for the residents and Resident #51's food choices and intolerances should have been care planned for providing quality care to the residents. The facility policy titled Assessments dated November 2017 revealed that Comprehensive, person-centered plan of care , consistent with resident rights must be completed by 21st day after admission . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676369 If continuation sheet Page 2 of 9 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 676369 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hollymead 4101 Long Prairie Road Flower Mound, TX 75028 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 0790 Provide routine and 24-hour emergency dental care for each resident. 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 assist residents in obtaining routine and 24-hour emergency dental care for one of 5 residents (Residents #29) reviewed for dental services. Residents Affected - Few The facility failed to provide a timely dental service referral for Resident #29. This failure could place residents at risk of oral infection, dental pain, and diminished quality of life. Findings include: Record review of Resident #29 MDS dated [DATE] revealed she was an [AGE] year-old female admitted on [DATE] diagnoses of major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest), type-2 diabetes (high blood sugar levels), reduced mobility, lack of coordination, hypertension (high blood pressure), hyperlipidemia (fats in blood) and a BIMS score of 13 (cognition intact). Observation on 03/20/2024 at 2:00 PM of Resident #29 revealed she had multiple missing teeth to both sides of her jaw and on the upper and lower portion of her jaw with dark, black, grey, and yellowed areas on the remaining teeth. Interview on 03/20/2024 at 2:01 PM with Resident #29 revealed the resident asked for dental referral when she first arrived at facility about 2 years ago. She stated there was a different social worker, and she requested the referral when she first transferred to the facility. Resident stated about a year later she asked the new Social Worker about the status of the dental referral and was told she was moving up the wait list. Resident stated she had not been informed about any future dental visits, she experienced discomfort when eating, and the teeth were missing on the top and bottom of her jaw which limited what she ate. Resident stated she had a pressure ulcer and found it difficult to eat enough protein due to not being able to chew well. Resident stated that her teeth shifted due open spaces, and she was concerned about loose teeth. Interview on 03/20/2024 at 3:20 PM with Social Worker revealed she care planned resident needs quarterly and sent referrals as needed based on the assessment. The Social Worker stated that she was not aware that Resident #29 had not been seen by dental services and remembered the resident requested a dental referral because her teeth felt loose. Social Worker stated she had worked at facility for about a year. The Social Worker stated she emailed a dental referral for Resident #29 on 07/24/2023 because she complained of teeth feeling loose and she did not think the resident was seen until a pain assessment on 12/07/2023 and there was no current dental referral. Social Worker stated she failed to follow up with Resident #29 because she was unable to upload any documents into the electronic health record and she did not have a plan to keep track of and follow up with residents who had dental referrals. Social Worker stated she would not know if a resident had not been seen by dental, missed an appointment, or if resident needed dental services unless the resident or family member or representative of the resident informed Social Worker or if the nurses informed Social Worker of dental concerns. Social Worker stated she and nursing services were responsible to ensure residents were provided timely dental referrals. Social Worker stated she was responsible for emailing dental referrals and resident consents. Social Worker stated she depended on nurses to let her know if residents needed dental referrals. Social Worker stated the resident risk for not having timely dental (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676369 If continuation sheet Page 3 of 9 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 676369 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hollymead 4101 Long Prairie Road Flower Mound, TX 75028 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 0790 referrals was mouth pain, infection, and difficulty eating. Level of Harm - Minimal harm or potential for actual harm Interview on 03/21/2024 at 8:57 AM with DON revealed the Social Worker was responsible for dental referrals she was not aware that Resident #29 wanted to see a dentist and had not received dental services. DON stated the Social Worker obtained consents from residents and dental services typically came every 90 days unless there were emergency needs. DON stated the risk to residents who didn't receive timely dental referrals or follow up was mouth pain and difficulty eating. Residents Affected - Few Interview on 03/21/2024 at 12:45 PM with Administrator revealed he was unaware Resident #29 was in need of dental services and had not been seen. Administrator stated that the expectation was for residents to receive timely dental referrals and the Social Worker was responsible for referrals and ensured follow up was done. Administrator stated risk to resident was pain or infection from missed dental visits. Record review revealed an email from Social Worker to dental services dated 07/24/2023 and listed Resident #29 with the complaint of loose teeth. Record review of dental schedule dated 12/07/2023 revealed Resident #29 was seen by dental services on 12/07/2023 for a pain assessment. Record review of dental referral policy titled Dental Services revised December 2023 revealed the facility had a contract with dentist that provided dental services monthly, and the facility was maintained the complete record of the resident's dental care including services that were completed and that all dental services provided were recorded in the resident's medical record. The Social Services Director was responsible for referrals to social service and maintained regular progress and follow up notes. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676369 If continuation sheet Page 4 of 9 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 676369 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hollymead 4101 Long Prairie Road Flower Mound, TX 75028 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 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure each resident received food that accommodated their preferences for one (Resident #51) of four residents reviewed for dietary services. The facility failed to honor Resident #1's preferences which stated no pork, no fish, no eggs, and no lettuce. This failure could place residents at risk for not having their choices and food preferences accommodated, and a diminished quality of life. Findings include: Record review of Resident #51 Quarterly MDS dated [DATE] revealed that Resident #51 was a [AGE] year-old female admitted to the facility on [DATE]. Relevant diagnoses included Deep vein thrombosis (occurs when a blood clot forms in one or more deep veins in the body) , cerebrospinal fluid leak ( fluid leaking through a tear or hole surrounding the brain), and depression (common mental disorder). Record review revealed that Resident #51 did not have a care plan for food preferences and food intolerances. Record review of Resident #51 Diet order dated 3/28/2023 revealed Resident #51 was on Regular diet with a note of no pork, no fish, no eggs, and no lettuce. Observation on 3/19/2024 at 11:02 AM revealed that Resident #51 had her Breakfast tray from the morning still in her room. The tray had oatmeal that was untouched, pancake with 2 small bites eaten, one individually wrapped small tub of breakfast syrup, and one individually wrapped small tub of margarine spread. The meal ticket on the tray read Tuesday Breakfast 3/19/2024 - Muffin, oatmeal, Milk, orange juice , no pork, no eggs. In an interview with the Resident #51 on 03/19/24 at 11:03 AM revealed she was intolerant to pork, fish , eggs, and lettuce. She stated she has a history of bariatric surgery (timeframe unknown) and hence had limited food choices. She stated that she had to order hamburger for meals at least four times a week. She stated that she got pancake for breakfast on 3/19/2024 and had 2 small bites of it because the pancake did not taste good but tasted eggy. She stated she had asked for muffins for breakfast. She also stated that she had complained regarding her food choices to the previous dietary manager and Administrator, but her food preferences requests were not honored. She also stated that she had eggs in the past on her tray for breakfast, but she was intolerant to eggs and could not eat it. She stated that the facility had done away with soup, grilled cheeses as menu choices since last 2-3 months. She stated that she does not remember if her food choices or preferences were discussed during the care plan meetings. Resident #51 stated she had not met with the new dietary manager one on one regarding her food preferences. In an interview with the Dietitian on 03/20/24 at 1:42 PM revealed that the Dietitian was at the facility once a week. She stated that she was aware of Resident #51's food preferences based on her meeting with Resident #51 after admission to the facility. The Dietitian stated that she added resident's food preferences to resident's charts upon admission, so the kitchen was aware of them. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676369 If continuation sheet Page 5 of 9 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 676369 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hollymead 4101 Long Prairie Road Flower Mound, TX 75028 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 0806 Level of Harm - Minimal harm or potential for actual harm In an interview with the Dietary manager on 03/20/24 at 1:58 PM revealed that she was new to the facility but was aware of Resident #51's food choices only based on the diet order. She stated that she did not have a chance to participate in resident #51's care plan meeting. She stated that she had met Resident #5 in a group meeting along with the administrator but did not have communication with Resident #51 regarding her food choices one on one yet. She stated she did not check the breakfast trays on 3/19/2024. Residents Affected - Few In an interview with the DON on 3/21/2024 at 11:56 AM revealed she was aware of Resident #51's dietary preferences from other staff but also stated that Resident #51 had never complained to her directly regarding food. She stated that facility address resident's food preference upon admission and on as needed basis. She also stated that the previous dietary manager held several conversations with Resident #51 and agreed that her food preferences should have been care planned. The DON stated the facility did not have a MDS coordinator in-house for the past one month and the Corporate MDS was filling in. She stated that the corporate MDS and herself were responsible for writing the care plans in the EHR ( Electronic Health Record). The DON added Care plans were important because they direct the care for the residents and Resident #51's food choices and intolerances should have been care planned and failure to adhere to Resident # 51's food preference can lead to having their choices not being met and decreased quality of care to the residents. The facility policy for food preference was not available for review. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676369 If continuation sheet Page 6 of 9 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 676369 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hollymead 4101 Long Prairie Road Flower Mound, TX 75028 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 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 the facility's only kitchen. Residents Affected - Some 1. The facility failed to label and date food in the walk-in freezer. 2. The facility failed to date food stored in the walk-in refrigerator that should no longer be consumed. 3. Cook B failed to wear effective hair restraint while serving food. These failures could affect residents who received their meals from the facility's only kitchen, by placing them at risk for food-borne illness if consumed, and food contamination. Findings included: Observations on 03/19/24 at 9:45 AM revealed Pie shells in the walk-in freezer were not labeled or dated. Observations on 03/19/24 at 9:49 AM revealed several sausage patties in the walk-in refrigerator were left opened in a plastic bag. Observations on 03/19/24 at 12:22 PM revealed that [NAME] B was wearing a hat with a bun and hair exposed below the hat line while serving food in the kitchen. He was not wearing a hair net to contain the bun. In an interview with [NAME] B on 03/19/24 at 01:25 PM revealed that he was not wearing a hair net under his hat. He also stated that no one had asked him to wear a hair restraint in the past in the current facility. He also stated that it was important to wear hair restraints to prevent hair falling in food, and prevent food borne illnesses. He also stated that either dietary aides or cooks were responsible or dating, labeling, and covering all food items and not following it can led to getting resident sick and possibility of food borne illness. In an interview with Dietitian on 03/20/24 at 1:42 PM revealed that Dietitian was at the facility once a week. She stated that her expectation was all food items in the kitchen must be labeled , dated, and always covered appropriately. She also stated that her expectation was that all employees in the kitchen area should wear hair restraint in a manner that all hair was contained. She stated the risk to residents for either not covering food or not wearing hair restraint appropriately can lead possibly of serving food that was expired or hair getting in the food , can lead to food borne illness. The Dietitian revealed she does not conduct any scheduled in-services in the facility. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676369 If continuation sheet Page 7 of 9 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 676369 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hollymead 4101 Long Prairie Road Flower Mound, TX 75028 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 In an interview with Dietary manager on 03/20/24 at 1:58 PM revealed that she was working in the facility since the last 2 months. She stated her expectation was all food items in the kitchen were labeled, dated, and covered appropriately at all times. She stated everyone in the kitchen including cooks, dietary aides, and herself were responsible for appropriate food storage. She stated that sausage patties were used for Monday dinner and may have been left out. She stated that she threw away the patties in trash on 3/20/24. She revealed her expectation that everyone in the kitchen wear appropriate hair restraint and stated that [NAME] B had hair net under his hat in the morning but may have forgotten to put it back on after the break. She stated inappropriate food storage and not wearing hair restraints correctly can lead to food borne illness. She stated that she was responsible for providing in-services to the kitchen staff on as needed basis. Record Review of the Facility's Food Storage revised 03/2019 revealed 15 Refrigeration: e. All foods should be covered, labeled, and dated 16. Frozen Foods: c. Foods should be covered, labeled, and dated . Record Review of the Facility's Nutrition Services Department Dress code revised 4/19 revealed .l. Hair must be covered with a hairnet/surgical cap, including bangs. Review of the Food and Drug Administration Food Code, dated 2022, reflected, .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 3-305.11 Food Storage.(B) .refrigerated, ready-to eat time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (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 Review of the Food and Drug Administration Food Code, dated 2022, reflected, .Hair restraints 2-402.1. Consumers are particularly sensitive to food contaminated by hair. Hair can be both a direct and indirect vehicle of contamination. Food employees may contaminate their hands when they touch their hair. A hair restraint keeps dislodged hair from ending up in the food and may deter employees from touching their hair. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676369 If continuation sheet Page 8 of 9 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 676369 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hollymead 4101 Long Prairie Road Flower Mound, TX 75028 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 two (Resident #17, and Resident #63) of seven residents reviewed for infection control. Residents Affected - Few - RN A failed to sanitize the blood pressure cuff between uses on Resident # 17 and Resident # 63. Theses failures could place residents at risk for infection and cross contamination. Findings include: -Record review of Resident #17's face sheet, dated 03/21/24, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #17 had diagnoses which included hypertension, type 2 diabetes mellitus, dementia (dementia (loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain). -Record review of Resident #63's face sheet, dated 03/21/24, reflected an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #63 had diagnoses which included hypertension, type 2 diabetes mellitus, dementia. Observation during medication pass on 03/20/24 beginning at 08:07 a.m. revealed RN A entered Resident #17's room to obtain her blood pressure, with the blood pressure cuff around RN A left wrist. After performing the blood pressure reading RN A returned to the medication cart and obtained the resident's morning medications and administered them. NR A returned to the cart put the blood pressure cuff on top of the cart and walked to the next resident's room with the un-sanitized blood pressure cuff. RN A entered Resident #63's room putting the blood pressure cuff around her left wrist and obtained his blood pressure without sanitizing the blood pressure cuff. RN A returned to the medication cart and obtained the resident's morning medications and administered them. RN A performed hand hygiene but did not sanitize the blood pressure cuff. In an interview with RN A on 03/20/24 at 9:08 a.m., she stated she was supposed to clean the blood pressure cuff with a germicidal wipe after each use, and she was not supposed to put the blood pressure cuff around her wrist. She stated she knew that she was supposed to clean all the equipment between residents to prevent the spread of infection, she stated just forget. In an interview with the DON on 03/21/24 at 08:26 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 cause cross contamination. Record review of the facility's policy titled, Cleaning multi use Medical equipment dated March 2019, reflected Multi use medical equipment such as glucometers, blood pressure cuffs, stethoscopes, lifts and other medical equipment that goes in and out of Patient's rooms will be disinfected before and after using the equipment with an antiviral wipe or approved disinfectant solution. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676369 If continuation sheet Page 9 of 9