Health inspection·February 15, 2024

F 0580 Level of Harm - Minimal harm or potential for actual harm An interview on 02/14/24 at 12:49 PM with the DON revealed she did not know there was no family notification for Resident #12's skin tear. The DON said she was notified about the injury on 02/06/24 by LVN B, but she forgot to follow-up on it. The DON said the physician was notified on 02/06/24, but no orders were written. The DON said the family was not notified until 02/14/24. The DON said the family should have been notified at the time of injury so they would know what was going on. Residents Affected - Few Review of the facility policy, Quality of Care - Change of Conditions, revised May 2017, reflected: Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.) . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676448 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 676448 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. 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 received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for two (Resident #12 and Resident # 135) of three residents reviewed for wounds. Residents Affected - Some 1) Resident #12's skin tear to her right forearm was not monitored after she received it on 02/06/24. 2) LVN E failed to treat Resident# 135's wounds on 02/11/24. This failure could place residents at risk for delays in treatment, developing infections and unidentified deterioration of their wounds. Findings included: 1) Review of Resident #12's MDS quarterly assessment, dated 01/03/24, reflected she was a [AGE] year-old female admitted to the facility on [DATE]. Her cognitive status was moderately impaired. Her diagnoses included stroke and Parkinson's disease. Review of Resident #12's Progress Notes dated 02/06/24 at 6:09 PM written by LVN B reflected the: Resident skin is dry and warm to touch with skin tear noted on right forearm. Cleaned with normal saline and sterile strips applied. Will continue to monitor. An observation and interview on 02/14/24 at 11:45 AM with RN C and LVN D revealed they did not know Resident #12 had a skin tear. RN C said she was the nurse for the resident. RN C and LVN D walked with the surveyor to Resident #12's room. Her door was open, and she was sitting in the doorway eating a cookie. The right sleeve of Resident #12's shirt had drops of bloody drainage on it. LVN D went into the resident's room and rolled up her right sleeve. The resident had a large skin tear with 9 soiled steri-strips on it. It had a small amount of serosanguinous drainage. The area was red, swollen, and bruised. The resident said it happened when she hit her arm on the door frame. RN C and LVN D said they were not aware of the wound and would notify the WCN. Review of Resident #12's Progress Notes revealed the following: Effective Date: 02/14/24 12:03 PM Note Text: Resident with skin tear with steri-strips to right upper arm, no drainage, dried blood to steri-strips in place. Bruising to area. Steri-strips have been left open to air. Will continue to monitor every shift. Author: WCN (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676448 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 676448 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 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 0684 Effective Date: 02/15/24 08:04 AM Level of Harm - Minimal harm or potential for actual harm Note Text: Assessed resident's skin tear site with steri-strips in place. Resident stated that she felt more comfortable with having a dressing on. Order for triple antibiotic ointment with dry dressing every day and as needed. Will continue to monitor. Area cleansed and dressed. Residents Affected - Some Author: WCN Review of Resident #12's comprehensive care plan revealed a care plan for the skin tear was written on 02/14/24 following surveyor intervention. The care plan reflected: I have a skin tear to right upper arm. Facility interventions included to monitor the wound for changes. Review of Resident #12's Order Summary Report revealed an order for the skin tear was written on 02/14/24 following surveyor intervention. The order reflected: Monitor skin tear with steri-strips to right upper arm every shift for Skin/Wound support. Review of the facility incident reports, dated February 2024 reflected there were no incident reports for Resident #12's skin tear. An interview on 02/14/24 at 11:50 AM with the WCN revealed she said the wound was a skin tear. She said she saw the wound the other day, date unknown, and removed a dressing dated 02/11/24. She said she thought maybe the injury occurred on the weekend. (02/10/24 or 02/11/24). She said when she saw it, she removed the dressing so it could be left open to air. The WCN said she had been monitoring it but did not notify the physician about it and did not know when the injury occurred. She said she did not know that a progress note had been written on 02/06/24 about the injury. She said there were no physician orders for the skin tear. An interview on 02/14/24 at 12:49 PM with the DON revealed she did not know there was no monitoring, physician orders, or family notification for Resident #12's skin tear. The DON said she was notified about the injury on 02/06/24 by LVN B, but she forgot to follow-up on it. She said there should have been on-going monitoring of the skin tear and an incident report should have been created. The DON said the physician was notified on 02/06/24, but no orders were written. The DON said the family was not notified until 02/14/24. The DON said she just missed it and that monitoring of the skin tear should have occurred to make sure there were no adverse reactions. She said the family should have been notified so they would know what was going on. 2) Review of Resident #135's re-admission MDS assessment, dated 11/09/23 reflected he was an [AGE] year-old male admitted to the facility on [DATE]. His cognitive status was intact. His diagnoses included diabetes and pressure ulcers. Review of Resident #135's WCP notes, dated 02/07/24, reflected he had wounds and orders that included: Right Heel Arterial wound- Cleanse with normal saline pat dry, apply Medi honey, Calcium Alginate, cover with dry dressing daily. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676448 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 676448 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 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 0684 Level of Harm - Minimal harm or potential for actual harm Review of Resident #135's MARs, dated February 2024, reflected on 02/11/24 Wound care not completed for the Right heel arterial wound. An interview on 02/14/24 at 2:50 PM with Resident #135 revealed he could not remember if his wound care was completed on 02/11/24. Residents Affected - Some An interview on 02/14/24 at 3:00 PM with LVN E revealed she was assigned to Resident #135 on 02/11/24. She said she was not able to perform their wound care on 02/11/24 because she got busy. She said she could have asked for help, but just did not get it done. She said wound care was important to prevent infection. An interview on 02/15/24 at 11:39 AM with the WCN revealed she was not aware that wound care was not performed on 02/11/24. The WCN said failure to perform dressing changes could lead to infection or stop wound healing. An interview on 02/15/24 at 12:41 PM with the DON revealed maybe a different nurse performed wound care even though LVN E was assigned to Resident #135. Review of the facility policy, Quality of Care - Change of Conditions, revised May 2017, reflected: 8. The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676448 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 676448 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. 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 with pressure ulcers received the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for 2 of 4 residents (Resident #135 and Resident #77) reviewed for pressure injury. Residents Affected - Few 1. LVN E failed to treat Resident #135's and Resident #77's wounds on 02/11/24. 2. The WCN failed to ensure Resident #77's head wound was not exposed to infection and contamination when she laid the resident's head on his pillow after cleaning the wound. These failures could place residents at risk for deterioration of wound. Findings included: 1. Review of Resident #77's quarterly MDS assessment, dated 02/03/24 reflected he was a [AGE] year-old male admitted to the facility on [DATE]. His cognitive status was intact. His diagnoses included wound infection, and sacral pressure ulcer. Review of Resident #77's WCP notes, dated 02/07/24, reflected he had the following wounds and orders: 1. Chest wound post-surgical - Cleanse with normal saline, pat dry apply Medi honey, gentamicin, hysept moist gauze, and secure with dry dressing. Change daily and as needed. 2. Sacrum stage 4 pressure wound - Cleanse with normal saline, dry, apply Medi honey, gentamicin, hysept moist gauze and secure with dry dressing. Change daily and as needed. 3. Right foot (lateral) DTI pressure wound - Skin prep, open to air. Change daily and as needed. 4. Posterior (back of) head stage 2 pressure wound - Apply skin prep, calcium alginate, cover with foam dressing. Change daily. Review of Resident #77's MARs, dated February 2024, reflected the resident did not receive wound care on 02/11/24. An observation and interview on 02/15/24 at 9:48 AM with Resident #77 revealed the WCN was preparing to perform wound care. The resident was lying in bed, awake and alert. The resident had a wound on the back of his head. The WCN had the resident raise his head off the pillow. The WCN removed the dressing, cleansed the area, and laid the resident's head back on the pillow. Surveyor was not able to visualize the wound. Blood was on the pillow when the WCN raised the resident's head to put on a new dressing. The WCN applied the dressing. An interview with the WCN revealed she cross-contaminated the wound when she laid the resident's head back on the pillow after cleansing the wound. An interview on 02/14/24 at 2:55 PM with Resident #77 revealed he could not remember if his wound care was completed on 02/11/24. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676448 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 676448 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 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 0686 Level of Harm - Minimal harm or potential for actual harm 2. Review of Resident #135's re-admission MDS assessment, dated 11/09/23 reflected he was an [AGE] year-old male admitted to the facility on [DATE]. His cognitive status was intact. His diagnoses included diabetes and pressure ulcers. Review of Resident #135's WCP notes, dated 02/07/24, reflected he had wounds and orders that included: Residents Affected - Few 1. Right Heel stage 4 pressure wound- Cleanse with normal saline, pat dry, apply Collagen, Hysept moist gauze, cover with gauze, secure with kerlix, change daily. 2. Coccyx Stage 4 pressure wound· Cleanse with normal saline, pat dry, apply Adaptic on bone, Wound Vac 125 mm Hg, secure with drape on MWF. 3. Upper Back Stage 3 pressure wound· Cleanse with normal saline, pat dry, apply Silver Alginate, cover with dry dressing on MWF. Review of Resident #135's MARs, dated February 2024, reflected on02/11/24 Wound care not completed for Right heel stage 4 pressure wound and the Right heel arterial wound. An interview on 02/14/24 at 2:50 PM with Resident #135 revealed he could not remember if his wound care was completed on 02/11/24. An interview on 02/14/24 at 3:00 PM with LVN E revealed she was assigned to Resident #77 and Resident #135 on 02/11/24. She said she was not able to perform their wound care on 02/11/24 because she got busy. She said she could have asked for help, but just did not get it done. She said wound care was important to prevent infection. An interview on 02/15/24 at 11:39 AM with the WCN revealed she was not aware that wound care was not performed on 02/11/24. The WCN said failure to perform dressing changes could lead to infection or stop wound healing. An interview on 02/15/24 at 12:41 PM with the DON revealed Resident #77 could have suffered contamination on his head wound when his head was laid back on the pillow. The DON said maybe a different nurse performed wound care even though LVN E was assigned to resident #77 and Resident #135. Review of the facility policy, Wound Care, dated December 2023, reflected: 10. Place one (1) gauze to cover all broken skin. Wash tissue around the wound that is usually covered by the dressing, tape, or gauze with antiseptic or soap and water. 11. Apply treatments as indicated. 12. Dress wound. [NAME] dressing with initials, time, and date. Be certain all clean items are on clean field. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676448 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 676448 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 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 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 safety in the facility's only kitchen. Residents Affected - Few The facility failed to ensure that food items past their expiration date were discarded. This failure could place residents at risk for food borne illness. Findings included: Observation and interview with the Dietician on 02/13/24 at 10:30 a.m. while conducting a tour of the facility refrigerated storage area with Dietician, a 16-ounce container of Beef Bullion paste that had a date reading 11/07/23, no other date was observed on the container. The container was found to have been opened on an unknown date. Dietician explained that the date on the container was the date that the facility had received the Beef Bullion paste and that most pre-packaged containers were expected to be ok for consumption for 90 days after they have been opened. The Dietician immediately discarded the container in front of the investigator. In an interview on 02/15/24 at 2:12 PM with the Dietician she revealed that it was possible if the Beef Bullion paste was past its expiration date and had gone bad it could have exposed vulnerable residents to food borne illnesses and could possibly cause harm if residents if they became ill. In an interview on 02/15/24 at 3:12 PM with the DON she revealed that it was important to make sure that any foods that were past their expiration date in the kitchen should be discarded and never served to residents as it could expose residents to illness. Review of the facility's policy Frozen and Refrigerated Foods Storage, revised November 2017, reflected, 9. Items stored in the refrigerator must be dated upon receipts, unless they contain a manufacturer use by, sell by, best by date, or a date delivered . The Food and Drug Administration Food Code dated 2017 reflected, 3-305.11 Food Storage. (A) .food shall be protected from contamination by storing the food: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination .(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 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking . Date marking is the mechanism by which the Food Code requires active managerial control of the temperature and time combinations for cold holding. Industry must implement a system of identifying the date or day by which the food must be consumed, sold, or discarded. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676448 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 676448 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to establish and maintain an infection 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 1 (Resident #3) of 8 residents reviewed for infection. Residents Affected - Few 1. The facility failed to ensure CNA A performed hand hygiene during incontinence care for Resident #3. This failure could cause residents to suffer from infection. Findings included: 1. Review of Resident #3's Face Sheet dated 02/6/24, reflected she was a [AGE] year-old female admitted on [DATE]. Her diagnoses included dementia. An observation and interview on 02/14/24 at 2:26 PM revealed CNA A was preparing to perform incontinence care for Resident #3. CNA A washed his hands and put on gloves. The resident was in bed lying on her back. CNA A folded down the front of the brief and cleaned the peri-area. The resident was assisted to reposition to her right side. The resident was incontinent of stool. CNA A cleaned the stool off the resident's buttocks. CNA A did not remove his gloves or perform hand hygiene. CNA A grabbed cream and applied it to the resident's buttocks and grabbed a clean brief. CNA A was asked about hand hygiene. He said he did not change his gloves or perform hand hygiene because he got nervous. He said he had been trained to perform hand hygiene and change his gloves. CNA A said hand hygiene was important to prevent infection. An interview on 02/15/24 at 12:54 PM with the DON revealed staff were supposed to perform hand hygiene and glove changes when performing incontinence care. The DON said if hand hygiene and glove changes were not performed then contamination could occur. Record review of facility's policy, Infection Control Guidelines for All Nursing Procedures, dated November 2023, reflected: 3. Employees must wash their hands for twenty (20) seconds or longer using antimicrobial or nonantimicrobial soap and water under the following conditions: a. Before and after direct contact with residents; b. When hands are visibly dirty or soiled with blood or other body fluids; c. After contact with blood, body fluids, secretions, mucous membranes, or non-intact skin; d. After removing gloves . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676448 If continuation sheet Page 9 of 9