Health inspection·January 12, 2023

F 0558 Including maintenance and housekeeping. Level of Harm - Minimal harm or potential for actual harm Interview with DON on 01/11/23 at 10:00 AM revealed she was familiar with Resident #43's history of falls, and she stated that the resident had suffered a fall on 12/24/22. She stated that the resident was legally blind and often attempts to get out of her bed to assist herself if no one responds to her. She stated that when the resident was in her bed, it was to be lowered to its lowest position, her call light should be in reach, and she stated that she observed that the resident had a fall mat folded in the corner of room, and it should have been placed alongside her bed. She stated that the risk to the resident if these safety measures were not in place, could result in her injuring herself. Residents Affected - Few Interview with ADON revealed that she had only been at the facility for a short period of time and her last day at the facility was 01/13/23. ADON was asked if she was familiar with Resident #43, and she stated that she was. She admitted that the resident was a fall risk and her bed had to be lowered to the lowest position, fall mat placed alongside her bed, and her call light in reach. She stated that staff is supposed to make rounds at least every two hours and should be checking for these things. She stated that the risk to the resident of not adhering to the resident's care plan is that she may not receive the medical attention needed. Interview with the Administrator on 01/12/2023 at 3:00 PM revealed, he had only been at the facility a month. He was asked about the frequency of staff checking on residents and what are they checking for. He advised that leadership conducted Angel Rounds in the morning, and they were supposed to check on residents to see if they were clean, room were clean, call light in place, etc. The Administrator was advised of Resident #43 and the findings observed. He stated that staff was required to frequent resident's rooms at least every two hours and one of their responsibilities was to ensure call lights were in place, and in the case of Resident #43, they should ensure all safety precautions were in place for the resident. She stated that the risk of the resident not having her call light within reach and safety precautions, such as fall mat in place, are that the resident could try to get out of bed and hurt herself. Review of the facility's policy on Answering the Call Light, dated October 2010, revealed When the resident is in bed or confined to a chair, be sure the call light is within easy reach of the resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676448 If continuation sheet Page 2 of 15 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676448 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Reserve at Richardson 1610 Richardson Dr Richardson, TX 75080 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to ensure residents' Care Plan being implemented for 1 of 10 residents (Resident #43) reviewed for Care Plans, and the facility failed to develop a Care Plan for 2 of 10 (#36 & #105) residents reviewed for Care plans. 1. The facility failed to ensure Resident #43's fall mat was placed alongside the resident's bed. 2. The facility failed to ensure Resident #36's diagnosis of Pelvic and Perineal pain was addressed on her Care Plan. 3. The facility failed to ensure Resident #105's diagnosis for intravenous access care was addressed on her Care Plan These failures could place residents at risk of needs not being met. Findings include: Review of Resident #43's face sheet dated 01/11/23 revealed she was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included Blindness of Right eye and Low Vision of Left Eye. Review of Resident #43's quarterly Minimum Data Set (MDS) dated [DATE], revealed she required a two -person physical assist for all Activities of daily Living Assistance (ADL), the use of a wheelchair, had Severely impaired vision, and was cognitively impaired. Review of Resident #43's Care Plan dated 01/11/2023, revealed a fall occurred on 12/24/22. Resident #43's Care Plan also revealed that the resident had impaired visual functioning and was legally blind. Resident #43's intervention included placing call light button within easy reach, reminding the resident to call for assistance, responding promptly to calls for assistance, and fall mat at bedside. Observation and interview with Resident #43 on 01/10/2023 at 11:00 AM revealed, she was observed in her bed, and she was in distress. She was asked if there was anything wrong and she stated that she needed help and she said, They always forget about me. Resident #43's bed was raised to a high position, and her fall mat was observed folded and leaning against a wall. Interview with DON on 01/11/23 at 10:00 AM revealed that she was familiar with Resident #43 history of falls, and she stated that the resident had suffered a fall on 12/24/22. She stated that the resident was legally blind and often attempted to get out of her bed to assist herself if no one responded to her. She stated that when the resident was in her bed, it was to be lowered to its lowest position, her call light should be in reach, and she stated that she observed the resident had a fall mat folded in the corner of room, and it should have been placed alongside her bed. She stated that the resident does have a fall mat in her Care Plan. She stated that the risk to the resident if these safety measures were not in place, could result in her injuring herself. Interview with ADON revealed that she had only been at the facility for a short period of time and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676448 If continuation sheet Page 3 of 15 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676448 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Reserve at Richardson 1610 Richardson Dr Richardson, TX 75080 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few her last day at the facility was 01/13/23. ADON was asked if she was familiar with Resident #43 and she stated that she was. She admitted that the resident was a fall risk and her Care Plan included bed being lowered to the lowest position, fall mat placed alongside her bed, and her call light in reach. She stated that staff is supposed to make rounds at least every two hours and should be checking for these things. She stated that the risk to the resident of not adhering to the resident's care plan is that she may not receive the medical attention needed. Interview with the Administrator on 01/12/2023 at 3:00 PM revealed, he had only been at the facility a month. He was asked about the frequency of staff checking on residents and what are they checking for. He advised that leadership conducted Angel Rounds in the morning, and they were supposed to check on residents to see if they were clean, room were clean, call light in place, etc. The Administrator was advised of Resident #43 and the findings observed. He stated that staff was required to frequent resident's rooms at least every two hours and one of their responsibilities was to ensure fall mats were in place, and in the case of Resident #43, they should ensure all safety precautions were in place for the resident. She stated that the risk of the resident not having fall mat in place, is that the resident could try to get out of bed and hurt herself. Review of Resident #105's Face Sheet on 01/12/23 at 10:47am revealed she was a [AGE] year-old female re-admitted on [DATE] from the hospital. Relevant diagnoses included lung failure causing loss of breath, seizures, cerebrovascular disease (restricted blood flow), cellulitis (bacetrial skin infection) of right lower limb, acute kidney failure, pressure ulcer of right heel, type 2 diabetes, and dementia (memory impairment) Review of Resident #105's MDS on 01/12/23 at 10:53am from her previous admission dated 12/19/23 stated she was cognitively intact with a BIMS score of 13. She required extensive assistance of one staff with bed mobility, toileting, and personal hygiene. Review of Resident #105's physician orders dated 01/06/23 revealed: Change PICC/Midline dressing using sterile technique every 7 days and PRN . every 7 day(s) for Midline dressing change started 01/07/23 at 6:00am. Ceftriaxone Sodium Solution Reconstituted 2 GM . Use 2 gram intravenously one time a day for infection for 9 days to start 01/07/23 at 9:00am. Review of Resident #105's most recent hospital discharge documents, titled Updates [Resident #105].pdf dated 01/06/23, stated she had a midline IV, inserted 01/04/2023. Review of Resident #105's progress notes dated 01/06/23 at 9:48pm revealed .IV/ABT Ceftriaxone/Midline RUA patent and in place . Record Review of Resident #105's Comprehensive Care Plan on 01/12/23 revealed it did not address the resident's intravenous access care. Interview with DON B on 01/12/23 at 12:59pm, she stated care for Resident #105's intravenous access was not included on the comprehensive care plan. She stated that it was her responsibility to manage resident care plan and she stated that upon her recent re-admission, she did not enter it into the care plan for the resident. She stated that if resident care plans were not updated and accurate reflecting care required, there can be errors, and it can affect care. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676448 If continuation sheet Page 4 of 15 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676448 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Reserve at Richardson 1610 Richardson Dr Richardson, TX 75080 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Observation on 01/24/23 at 10:30 AM revealed Resident #36 heard yelling out from her room that she was in pain. Staff was observed coming to her assistance, and asking Resident #36 what was wrong and she stated she was in pain. Review of Resident #36's face sheet dated 01/11/23 revealed she was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included Pelvic and Perineal pain. Review of Resident #36's quarterly Minimum Data Set (MDS) on 01/11/23, dated 12/26/22 revealed she had unclear speech, Assist for all Activities of daily Living Assistance (ADL), the use of a wheelchair, Stroke, Pelvic and Perineal pain. Review of Resident #36's Care Plan dated 01/11/2023, revealed it did not address her Pelvic and Perineal pain. Interview on 01/12/23 at 11:00 AM, with the DON and ADON revealed the DON was been employed at the facility for two months. DON was asked about Resident #36 and her medical diagnosis, and she stated that the resident did take at least 3 different medications relating to pain. She was asked if there was a care plan for pain management for the resident and she stated that she did not know if there was one or not. The ADON was observed reviewing the Care plan online and she stated that the resident did not have pain management as a focus on her care plan but that it should be. She stated that the risk to the resident not having pain focused on her care plan is that the resident may not receive the proper care for pain management and be in pain. She stated that they have not had an MDS nurse in quite a while, and she and the DON tried to keep them updated. She stated that they had hired an MDS nurse. Interview with DON on 01/12/23 at 12:00 PM DON revealed that she was not completely knowledgeable of the care needed for Resident #36. She was advised that the resident was diagnosed with pelvic and perineal pain and was asked of this was a diagnosis that should have been focused on pain management and she stated yes. She stated that the risk to the resident not having pain focused on her care plan is that the resident may not receive the proper care for pain management and be in pain. She stated that they have not had an MDS nurse in some time but one will be staring in February 2023. Interview with the Administrator on 01/12/2023 at 3:00 PM revealed, Administrator was advised of the findings regarding Resident #36's Care Plan and he was asked the risk of the resident not having an accurate Care plan. He stated that the resident could miss out on receiving the proper care, which could result in her having pain. Review of the facility's policy on Care Planning, dated September 2013, revealed A Comprehensive, person- centered care plan that includes measurable objectives and timetables to meet resident's physical, psychosocial and functional needs is developed and implemented for each resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676448 If continuation sheet Page 5 of 15 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676448 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Reserve at Richardson 1610 Richardson Dr Richardson, TX 75080 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to ensure resident's environment was free from accident hazards as is possible, and received adequate supervision and assistance devices to prevent accidents for 1 of 5 residents (Resident #43) reviewed. The facility failed to ensure Resident #43's call light was within reach, fall mat was placed next to her bed, and her bed was in lowest position . This failure could place resident #43 at risk for falls and serious injuries. Findings include: Review of Resident #43's face sheet dated 01/11/23 reflected she was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included Blindness of Right eye and Low Vision of Left Eye. Review of Resident #43's quarterly Minimum Data Set (MDS) dated [DATE] reflected she required two -person physical assist for all Activities of daily Living Assistance (ADL), the use of a wheelchair, had Severely impaired vision, and was cognitively impaired, and BIM Score of 9. Review of Resident #43's Care Plan dated 01/11/2023, revealed a fall occurred on 12/24/22. Resident #43's Care Plan also revealed the resident had impaired visual functioning and was legally blind. Resident #43's intervention included placing call light button within easy reach, reminding the resident to call for assistance, responding promptly to calls for assistance, and fall mat at bedside. Observation and interview with Resident #43 on 01/10/2023 at 11:00 AM revealed, she was observed in her bed, and she was in distress. She was asked if there was anything wrong and she stated that she needed help and she said, they always forget about me. Resident #43's bed was raised to a high position, a fall mat was observed folded and leaning against a wall, and call light was not visible. Interview with LVN E on 01/10/2023 at 11:01 AM revealed, she had been employed at the facility for a month and she had worked the 300 Hall. She was advised that the resident was in distress and is unable to request assistance because she was unable to locate her call light. LVN E was observed entering Resident #43's room and attempted to locate her call light button. She was observed tugging at the call light cord because it was stuck under the bed side table. LVN E was able to get the call light button dislodged and placed it next to the resident. LVN E was asked if the resident was a fall risk and she stated that she did not know. LVN E was asked the risk to the resident if they did not have their call light available and she stated that the resident could have complications and need help. She stated that all staff is to ensure that residents have their call lights available, Including maintenance and housekeeping. Interview with DON on 01/11/23 at 10:00 AM revealed she was familiar with Resident #43's history of falls, and she stated that the resident had suffered a fall on 12/24/22. She stated that the resident was legally blind and often attempts to get out of her bed to assist herself if no one responds to her. She stated that when the resident was in her bed, it was to be lowered to its lowest position, her call light should be in reach, and she stated that she observed that the resident had a fall (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676448 If continuation sheet Page 6 of 15 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676448 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Reserve at Richardson 1610 Richardson Dr Richardson, TX 75080 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few mat folded in the corner of room, and it should have been placed alongside her bed. She stated that the risk to the resident if these safety measures were not in place, could result in her injuring herself. Interview with ADON revealed that she had only been at the facility for a short period of time and her last day at the facility was 01/13/23. ADON was asked if she was familiar with Resident #43, and she stated that she was. She admitted that the resident was a fall risk and her bed had to be lowered to the lowest position, fall mat placed alongside her bed, and her call light in reach. She stated that staff is supposed to make rounds at least every two hours and should be checking for these things. She stated that the risk to the resident of not adhering to the resident's care plan is that she may not receive the medical attention needed. Interview with the Administrator on 01/12/2023 at 3:00 PM revealed, he had only been at the facility a month. He was asked about the frequency of staff checking on residents and what are they checking for. He advised that leadership conducted Angel Rounds in the morning, and they were supposed to check on residents to see if they were clean, room were clean, call light in place, etc. The Administrator was advised of Resident #43 and the findings observed. He stated that staff was required to frequent resident's rooms at least every two hours and one of their responsibilities was to ensure call lights were in place, and in the case of Resident #43, they should ensure all safety precautions were in place for the resident. She stated that the risk of the resident not having her call light within reach and safety precautions, such as fall mat in place, are that the resident could try to get out of bed and hurt herself. Review of the facility's policy on Answering the Call Light, dated October 2010, revealed When the resident is in bed or confined to a chair, be sure the call light is within easy reach of the resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676448 If continuation sheet Page 7 of 15 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676448 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Reserve at Richardson 1610 Richardson Dr Richardson, TX 75080 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 0694 Provide for the safe, appropriate administration of IV fluids for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure parenteral fluids were administered consistent with professional standards of practice and in accordance with physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 1 residents (Resident #105) reviewed for intravenous care. Residents Affected - Few The facility failed to ensure Resident #105 received intravenous access dressing change between 5-7 days per policy during her re-admission. This deficient practice could place residents at risk of serious illness and/or infection. Findings Included: Review of Resident #105's Face Sheet, dated 01/12/23, revealed she was a [AGE] year-old female re-admitted on [DATE] from the hospital. Relevant diagnoses included lung failure causing loss of breath, seizures, brain disease, cellulitis (bacterial skin infection) of right lower limb, acute kidney failure, pressure ulcer of right heel, type 2 diabetes, dementia, and schizophrenia . Review of Resident #105's MDS from her previous admission dated 12/19/23 stated she was cognitively intact with a BIMS score of 13. She required extensive assistance of one staff with bed mobility, toileting, and personal hygiene. Review of Resident #105's most recent hospital discharge documents, titled Updates [Resident #105].pdf dated 01/06/23, stated she had a midline IV, inserted 01/04/2023. Review of Resident #105's progress notes dated 01/06/23 at 9:48pm revealed .IV/ABT Ceftriaxone/Midline RUA patent and in place . In interview with DON B on 01/12/23 1:48pm, she stated there was no admission assessment that reflected her IV line as part of the admission checklist. Review of Resident #105's physician orders dated 01/06/23 revealed: Change PICC/Midline dressing using sterile technique every 7 days and PRN . every 7 day(s) for Midline dressing change started 01/07/23 at 6:00am. Ceftriaxone Sodium Solution Reconstituted 2 GM . Use 2 gram intravenously one time a day for infection for 9 days to start 01/07/23 at 9:00am. Review of Resident #105's MAR and TAR on 01/12/23 at 11:22am revealed there was no documentation in the TAR that a dressing change to the intravenous access site was completed. In Interview and Observation of Resident #105 on 01/12/23 at 9:46am revealed a single lumen midline access on the resident's left upper arm. The IV appeared clean, dry, and intact. Resident #105 was receiving an infusion of Ceftriaxone Sodium Solution Reconstituted 2 GM. The date on the dressing revealed 01/04/23. Resident #105 stated she did not recall when the intravenous access last dressing change was performed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676448 If continuation sheet Page 8 of 15 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676448 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Reserve at Richardson 1610 Richardson Dr Richardson, TX 75080 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 0694 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few In interview with the LVN A on 01/12/23 at 9:45am, she stated Resident #105 had a left upper arm midline. When asked about the date on the dressing, she stated she has not looked at it. She stated the facility's policy and best practice was to change the dressing every 7 days. She stated timely dressing changes were important so there were no further infections, and stated anything can happen, infiltration, bleeding, or dislodgement. Later in the interview she then stated she did assess the IV this morning but did not change the dressing because she was running around looking after the agency nurses . In interview with DON B on 01/12/23 at 12:59pm, she stated it was her expectations for IV dressings to be changed every 7 days. She stated she is aware that the dressing should have been changed 01/11/23. Stated she was not sure why it was not changed. She stated nursing leadership does audits daily for dressing changes, but she did not catch it this morning because she was busy with other duties at the facility. She stated if dressing changes are not completed within a timely manner, skin breakdown and/or infection can potentially develop. In interview with Administrator on 01/12/23 at 3:30pm, he stated his expectations were for IV dressings to be changed per physician orders and best practices. Stated it was important for infection control purposes. Review of facility's policy Midline Dressing Changes rev. [DATE] stated General Guidelines . 1. Change midline catheter dressing . every 5-7 days . Review on 08/15/22 at 11:26am of the Royal Children's Hospital Melbourne's Clinical Guidelines titled Peripheral intravenous device management, rev 12/2019, stated: Management of complications: There are a range of complications that could occur . Some of these complications can be prevented by . assessing the device as indicated. Common complications are: Infection .Local cellulitis or systemic bacteremia are possible . Phlebitis Vein Irritation . Infiltration/Extravasation. < https://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/Peripheral_Intravenous_IV_Device_Management/> FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676448 If continuation sheet Page 9 of 15 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676448 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Reserve at Richardson 1610 Richardson Dr Richardson, TX 75080 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 one of the 1 of 1 kitchens reviewed. Dietary staff failed to label, date, and store food according to their policy in the dry food pantry. The dry food pantry contained open packages, not sealed, and food with expired dates. Frozen food was observed sitting in the sink and on the counter to thaw. Dietary staff failed to label, date, and securely cover thickener on the food prep table in the kitchen. These failures could place residents at risk of foodborne illness. Findings included: An observation of the facility's kitchen on January 10, 2023, at 9:00 AM with DM revealed the following: 3 white cake mix boxes with expiration dates of (09/7/2022), (11/2022), and (12/30/2022). Decaffeinated coffee was not sealed or closed. 10 cartons of mildly thick nectar consistency with an expiration date of 12/30/2022 1 box of expired corn meal date of expiration 2022. A clear quart-size pitcher containing thickener on the food prep table that was not sealed, labeled, or dated. Red dry seasoning with a blue top was not dated. Thawing sliced ham in a large bowl of water uncovered on metal counter of sink. Chapter 2 Management and Personnel 2-1 SUPERVISION Subparts Responsibility Knowledge Duties Duties 2-103.11 Person in Charge. The PERSON IN CHARGE shall ensure that: (E) EMPLOYEES are visibly observing FOODS as they are received to determine that they are from APPROVED sources, delivered at the required temperatures, protected from contamination, UNADULTERED, and accurately presented, by routinely monitoring the EMPLOYEES ' observations and periodically evaluating FOODS upon their receipt; https://www.fda.gov/media/110822/download (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676448 If continuation sheet Page 10 of 15 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676448 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Reserve at Richardson 1610 Richardson Dr Richardson, TX 75080 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 1 Large tube of ground meat lying in the empty sink without running water to thaw for an unknown period of time. 3-501.13 Thawing. Except as specified in ¶ (D) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be thawed: (A) Under refrigeration that maintains the FOOD temperature at 5oC (41oF) or less; or (B) Completely submerged under running water: (1) At a water temperature of 21oC (70oF) or below, (2) With sufficient water velocity to agitate and float off loose particles in an overflow.Reference Food and Drug Administration 2017 https://www.fda.gov/media/110822 Several boxes of refrigerated foods were stored on the floor outside the refrigerator for an unknown period of time. The boxes were exposed to hot temperatures from the serving line and steam table, which were approximately 12 steps away. Knowledge: 2-102.11 Demonstration. Based on the RISKS inherent to the FOOD operation, during inspections and upon request the PERSON IN CHARGE shall demonstrate to the REGULATORY AUTHORITY knowledge of foodborne disease prevention, application of the HAZARD Analysis and CRITICAL CONTROL POINT principles, and the requirements of this Code. The PERSON IN CHARGE shall demonstrate this knowledge by Reference Food and Drug Administration 2017 https://www.fda.gov/media/110822 (4) Explaining the significance of the relationship between maintaining the time and temperature of TIME/TEMPERATURE CONTROL FOR SAFETY FOOD and the prevention of foodborne illness;Reference Food and Drug Administration 2017 https://www.fda.gov/media/110822 (7) Stating the required temperatures and times for the safe refrigerated storage, hot holding, cooling, and reheating of TIME/TEMPERATURE CONTROL FOR SAFETY FOOD; Reference Food and Drug Administration 2017 https://www.fda.gov/media/110822 (8) Describing the relationship between the prevention of foodborne illness and the management and control of the following: (a) Cross contamination, Reference Food and Drug Administration 2017 https://www.fda.gov/media/110822 (14) Identifying CRITICAL CONTROL POINTS in the operation from purchasing through sale or service that when not controlled may contribute to the transmission of foodborne illness and explaining steps taken to ensure that the points are controlled in accordance with the requirements of this Code; Reference Food and Drug Administration 2017 https://www.fda.gov/media/110822 An interview with DM on January 10, 2023, at 9:10 a.m. revealed that the dietary aide placed the thickener on the table undated. DM stated that she did not know who placed the meat out to thaw. She stated that protocol called for the meat to be thawed under cold water. She stated that the dried cake mix, corn meal, and thickened nectar were just ordered and should not be expired. She stated that the DA was responsible for preparing coffee, and she failed to secure the package with tape. She stated that DA C scoops the thickener out for the cook during prep time. She stated that the cling wrap should be secured tightly, labeled, and dated. She stated that DA D was responsible for dating, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676448 If continuation sheet Page 11 of 15 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676448 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Reserve at Richardson 1610 Richardson Dr Richardson, TX 75080 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 labeling, and checking for expiration dates when food was delivered. She stated that all staff, including the DM, were responsible for checking expiration dates on food throughout their shift. She stated that all dietary staff are trained to label and date all food when delivered. She stated that food boxes or storage containers should not be stored on the floor. She stated that storing the boxes on the floor was unsanitary and could lead to food contamination and illnesses among the residents. She stated that the manufacturer placed the delivery boxes on the floor, and all staff were serving residents lunch at the time and could not complete the task. In an interview on 01/12/2023 at 9:30 AM with the facility [NAME] stated that she had been trained on foodborne illnesses and food contamination. She stated that she checks the expiration date on the food when she pulls it from the pantry for food-borne illnesses and contamination. She stated that she checks the expiration date on the food when preparing the menus. She stated that the dietary assistants are responsible for dating and labeling the groceries when they are delivered to the facility. She stated that all meat should be thawed in the refrigerator or under running cold water. She said failing to thaw the food properly could lead to food contamination and residents getting sick. She stated that when food was delivered it is placed on the floor, and the dietary staff may be serving residents and can't complete the task immediately. She stated that as soon as the meals are served, the dietary staff labels, dates, and stores the food. DA C stated in an interview on January 12, 2023, at 9:45 a.m. that she had been trained on foodborne illnesses. She also mentioned that they had in-services for dietary training on a regular basis. She stated that all staff in dietary knew they were supposed to label and date products and check the expiration dates of the food. She stated that they did not use spoiled foods. She stated that sometimes other staff members did not put the labels back where they could be located by other kitchen staff. She stated that she was aware of the dangers of foods that were not labeled or dated, and that residents could become ill as a result. She stated that she did take the thickener from the pantry, wrap it in cling wrap, and date it before putting it on the food prep table. She does not know why the date and label were missing. She stated that all dietary staff are trained to not put any food boxes on the floor. A request for an interview with DA D was made on 01/12/2023 at 10:00 AM, but she did not report for the interview. In an interview on 01/12/2023 at 10:30 AM with AD reealed taht she has not received any complaints from residents about spoiled out dated foods or illnesses from food. In an interview on January 12, 2023, at 2:24 PM, the dietitian stated that all dietary assistants and cooks had been trained on foodborne illness and food contamination. She also stated that the facility completed additional dietary training on a regular basis. She stated that all dietary staff are aware of the dangers of contamination from not following the policies for dating, labeling, sealing food packaging, and checking for expiration dates on the food. She stated that she expects the DM to monitor the dietary staff and assure that they are following the procedures to prevent illnesses from food contamination. In an interview on January 12, 2023, at 2:45 PM with the DON she started that she had no complaints from residents about food tasting old or spoiled. She has not had any illnesses associated with food illnesses. In an interview with the administrator 01/12/2023 art 3:00 PM he stated that he expected the DM to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676448 If continuation sheet Page 12 of 15 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676448 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Reserve at Richardson 1610 Richardson Dr Richardson, TX 75080 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 monitor and train the dietary staff as well as implement food storage policies for safe foods and contamination prevention. He stated that all dietary staff had been trained on foodborne illness, allergies, and all dietary policies. The administrator stated that all staff had been trained on infection control. He stated that they completed frequent in-services with the dietary staff. He stated that all policies should be followed, including dating and labeling. He stated that there should be no expired foods in the food supply. The administrator stated that he had been trained on the dietary policies and knew that foodborne illness was a risk to residents if the kitchen was not handled. Record review of the facility's policy titled Food Production, dated 12-14-2017, stated the following: Refrigerated foods: It is the responsibility of the Nutrition Services Manager (NSM) to indicate the amount and type of food items to be thawed on the production sheet/pre-prep-at-a-glance sheet. Each food item will be placed in a separate pan at least 2 inches deep in order to collect juices or fluid, which may be released in the thawing process. The pans will be placed on the lowest shelf in the refrigerator so that juices or fluid, which may drip, will not contaminate other foods. All foods will be thawed under refrigeration Sufficient time will be allowed to complete thawing (2-3 days is generally recommended for most meat and frozen pasteurized eggs). Foods, which have not completely thawed by production time, may be thawed under cold running water. o At no time will food be thawed at room temperature, in standing warm water, or in ovens. o Once thawed raw food will not be re-frozen, unless it is thoroughly cooked. Food Storage o Cover all food containers. o Wrap all food well to prevent freezer burn, label with name of contents and date of entry to freezer. o Date all merchandise upon receipt and rotate on a first-in, first-out basis (FIFO). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676448 If continuation sheet Page 13 of 15 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676448 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Reserve at Richardson 1610 Richardson Dr Richardson, TX 75080 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 o Level of Harm - Minimal harm or potential for actual harm Plan the opening of the freezer. Get all that you need out at one time to reduce loss of cold air. o Residents Affected - Some Opened boxes of food must be securely closed to preserve quality. Perpetual Inventory o Foods will be dated with an expiration date. Opened foods will be dated. o An Inventory (physical or perpetual*) is performed on a regular basis to keep the Nutrition o Items will be stored 6 from the floor, 18 from the bottom of the sprinkler head, and should not be directly against the walls. o Store all foods six inches above the floor and eighteen inches below the sprinkler heads, on shelves, racks, dollies, or other surfaces which facilitate thorough cleaning, in a ventilated room, not subject to sewage or wastewater back flow or contamination by condensation, leakage, rodents, or vermin. Store all packaged food, canned foods, or food items in clean and dry place at all times. All cases shall be opened, boxes broken down and discarded. o Label and seal all opened packages. o Inventory will be maintained at appropriate levels required by the facility and based on the current approved menus. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676448 If continuation sheet Page 14 of 15 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676448 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Reserve at Richardson 1610 Richardson Dr Richardson, TX 75080 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 o Level of Harm - Minimal harm or potential for actual harm Check your state regulations on The Nutrition Services Manager (NSM) or RDN should be contacted for questions Residents Affected - Some regarding safe food storage. 2. When food is delivered to the facility it will be inspected for safe transport and quality before being accepted. 7. 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. 8. All foods stored in the refrigerator or freezer will be covered, labeled, and dated (use by date) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676448 If continuation sheet Page 15 of 15