Health inspection·September 13, 2023

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 3. Review of Resident #36's quarterly MDS assessment, dated 08/24/2023, reflected she was a [AGE] year-old female admitted to the facility on [DATE], with the following diagnosis: Gout, and neuralgia. Resident #31 was severely impaired for decision making. Resident #36 is unable to answer any questions. Review of the Resident #36's plan of care dated 08/15/2023 with updates reflected goals and approaches to include wheelchair mobility. An observation on 09/11/23 at 12:15 p.m., revealed Resident #36's right and left arm rest was cracked with jagged edges on the wheelchair with the interior padding exposed. The arm pads were not appropriately cleaned. 4. Review of Resident #38's admission MDS assessment, dated 07/06/2023, reflected she was an [AGE] year-old female admitted to the facility on [DATE], with the following diagnoses: Cerebral infraction (stroke), lack of coordination, and Alzheimer. Resident #38 was severely impaired for decision making. Resident # 38 was unable to answer any questions. Review of the Resident #38's plan of care dated 07/06/2023 reflected goals and approaches to include wheelchair mobility. An observation and interview on 09/11/2023 at 12:20 p.m., revealed Resident #38's right side arm rest was missing and left side arm rest on the wheelchair was cracked with jagged edges, and the interior padding was exposed. The arm pads were not appropriately cleaned. Interview on 09/13/23 at 11:00 a.m. with CNA B revealed when a resident has something wrong with their wheelchair, she would report it to the nurse. CNA B stated she did not know anything about a maintenance log at the nurse's station and she was unaware of any wheelchairs that required maintenance to the arm rest. Interview on 09/13/23 at 12:00 p.m. with LVN A revealed if the resident had a problem with a wheelchair, she would inform the therapy department. The therapy department would order the part that was needed and fix the wheelchair. LVN A stated maintenance was not involved. LVN A was not aware of any wheelchairs requiring new arm rest., she did state there was maintenance logbook at the nurses station, and book was for the staff to let the maintenance know of areas in the facility that require repair, like a broken toilet. Interview on 09/13/23 at 12:20 p.m. with the Director of Rehab revealed the therapy staff would assist in repairing wheelchairs. The Director of Rehab stated if the staff informed us and the parts are ordered we can repair them. The Director of rehab stated the maintenance department use to help, but we have been assisting. The Director of Rehab stated she was unaware of any wheelchairs that need new arm rest. Interview on 09/13/23 at 1:00 p.m. with the interim Administrator and the DON revealed the process was supposed to be the staff wrote in the maintenance log at the nurse's station concerning the problems, such as wheelchairs that require new arm rest. The Maintenance man would check the book daily order the parts, if needed, and repair the wheelchair. The Administrator was supposed to oversee this process. The DON stated there had not been anyone in the maintenance position for three months and she was unaware there were any wheelchairs that required new arm rest. The interim Administrator and the DON both said they would perform a sweep and get the wheelchairs repaired right away because (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676464 If continuation sheet Page 2 of 6 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 676464 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Las Brisas Rehabilitation and Wellness Center 3421 W Story Rd Irving, TX 75038 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 0584 this could affect their resident's mobility. Level of Harm - Minimal harm or potential for actual harm Record review of the maintenance log reflected no documentation concerning broken or missing wheelchair arm rest. Residents Affected - Some Review of the facility policy and procedure Wheelchair safety: Use and Maintenance revised dated May 5th 2023 reflected, The Facility promotes patient, resident and staff safety through the appropriate use and maintenance of wheelchairs 4. Wheelchair Maintenance and Servicing. A. Wheelchairs will be inspected and receive preventive maintenance as needed. B. Resident, patients, and staff remove equipment from service that is defective or requires maintenance or repair. C. Common replacement items include arm, leg, and footrests, cushions, seats, back supports, front and rear wheel assemblies, and brakes. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676464 If continuation sheet Page 3 of 6 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 676464 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Las Brisas Rehabilitation and Wellness Center 3421 W Story Rd Irving, TX 75038 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 designated to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for three (Residents #24, #127, and #128) of five residents reviewed for infection control. Residents Affected - Some RN C failed to disinfect the glucometer machine (an instrument for measuring the concentration of glucose in the blood) in between resident use, for Residents #127, and #24. LVN D failed to disinfect the glucometer machine (an instrument for measuring the concentration of glucose in the blood) after resident use, for Resident #128. This failure could place residents at-risk of cross contamination which could result in infections or illness. Findings included: Resident #128 Review on 09/11/23 of Resident #128's EHR revealed the resident was a [AGE] year-old female that was admitted to the facility on [DATE] with diagnoses including: Diabetes (elevated blood sugar) and cerebral infarction (stroke). Review of Resident #128's new admission MDS dated [DATE], revealed was severely impaired cognition for decision making, her functional status indicated he needed one person assist only with her ADLs. Record review of Resident #128's physician orders dated 08/30/23 reflected Novolog FlexPen U-100 Insulin per sliding scale following a fasting blood check four times a day for diabetes mellites type two (elevated blood sugar), acuchecks (an instrument for measuring the concentration of glucose in the blood) four times a day. Resident #127 Review on 09/11/23 of Resident #127's EHR revealed the resident was a [AGE] year-old female that was admitted to the facility on [DATE] with diagnoses including: Diabetes (elevated blood sugar), and cardiovascular accident (stroke) . Review of Resident #127's 5-day MDS, dated [DATE] revealed a BIMs score of 12, indicating she was mildly impaired cognition for decision making, her functional status indicated he needed assist of one staff with her activities of daily living. Record review of Resident #127's physician orders dated 09/06/23 reflected insulin glargine 100 units/ml give 6 units two times a day, insulin lispro 100 units/ml per sliding scale three times a day before meals, and metformin 500mg two times a day for diabetes mellites type two (elevated blood sugar), acuchecks (an instrument for measuring the concentration of glucose in the blood) three times a day before meals. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676464 If continuation sheet Page 4 of 6 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 676464 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Las Brisas Rehabilitation and Wellness Center 3421 W Story Rd Irving, TX 75038 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 Resident #24 Level of Harm - Minimal harm or potential for actual harm Review on 09/11/23 of Resident #24's EHR revealed the resident was a [AGE] year-old female that was admitted to the facility on [DATE] with diagnoses including: Diabetes (elevated blood sugar), and cardio obstructive pulmonary dieses (short of breath) . Residents Affected - Some Review of Resident #24's quarterly MDS, dated [DATE] revealed a BIMs score of 15, indicating she was cognitively intact for decision making, her functional status indicated he needed assist of two staff with her activities of daily living. Record review of Resident #24's physician orders dated 09/12/23 reflected insulin aspart 100 units/ml give per sliding scale three times a day, Lantus solution U-100 Insulin give 30 units two time a day, for diabetes mellites type two (elevated blood sugar), acuchecks (an instrument for measuring the concentration of glucose in the blood) three times a day before meals. Observation on 09/11/23 at 11:41 a.m. revealed LVN D performed a blood sugar test on Resident #128. LVN D sanitized the glucometer machine (an instrument for measuring the concentration of glucose in the blood) without using the appropriate sanitizing wipes, using an alcohol swab instead before and after testing Resident #128's blood. Interview on 09/11/23 at 11:50 a.m., LVN D stated reusable equipment, like blood glucometers, should be sanitized with wipes purple top that she had on her medication cart between each resident use to prevent transmitting an infection from one resident to another. She stated she was supposed to cleanse the blood glucometer in-between each usage, as she had been instructed, but she did not know why she had not done it this time. LVN D stated that if the equipment that was used on the residents was not cleaned correctly it could cross contaminate causing a spread of infection. Observation on 09/12/23 at 11:15 a.m. revealed RN C performed a blood sugar test on Resident #127. LVN C sanitized the glucometer machine (an instrument for measuring the concentration of glucose in the blood) without using the appropriate sanitizing wipes, using an alcohol swab instead before and after testing Resident #127's blood. Observation on 09/12/23 at 11:22 a.m. revealed RN C performed a blood sugar test on Resident #24. LVN C sanitized the glucometer machine (an instrument for measuring the concentration of glucose in the blood) without using the appropriate sanitizing wipes, using an alcohol swab instead before and after testing Resident #24's blood. While in the room RN C dropped the glucometer on the floor after checking the blood sugar. RN C exited the room wiped the glucometer off with an alcohol swab and place back in the drawer of the medication cart. Interview on 09/12/23 at 11:a.m. with RN C revealed she was an agency nurse that worked at the hospital fulltime, and she filled in extra at nursing facilities. RN C stated she had done very few glucometers checks at the hospital and when she had she always cleaned with the sanitizing wipes purple top that the hospital had, I was not aware that the nursing facility had sanitizing wipes. RN C opened the bottom drawer, and the sanitizing wipes purple top were on the cart. The RN closed the drawer and did not use the purple top wipes. Interview on 09/13/23 at 8:30 a.m. with the DON she stated that her expectation was that staff would sanitize all reusable equipment between each resident use. She stated that not doing so placed residents at risk of cross contamination of infections from one resident to another. She stated there (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676464 If continuation sheet Page 5 of 6 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 676464 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Las Brisas Rehabilitation and Wellness Center 3421 W Story Rd Irving, TX 75038 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm was plenty of supplies for the nursing staff to have the sanitization wipes that are EPA-registered disinfectant, on all the medication carts. The DON stated there had recently been conducted an in-service for the staff on infection control and cleaning equipment, even the agency nurses have been in-serviced. The DON stated alcohol swabs are less than the recommended base of alcohol and they will not clean the glucometers appropriately for all the bacteria that cause infections. Residents Affected - Some Review of the in-service records dated 08/01/23 reflected in service training topic Glucometer Acuchecks [brand name of the glucometer] disinfection LVNs D name was on the list RN Cs was not further review reflected follow-up activity with competencies review there was a competency test for LVN C presented follow-up competencies reports. Review of facility's Infection prevention and control policies and procedures, revised May 15 2023, reflected the following: cleaning and disinfection procedures 2. Alcohol is not approved for disinfecting items which are potentially contaminated with blood . 3. Blood glucose meters and point of care testing devices are at high risk of becoming contaminated with bloodborne pathogens such as HBV, HCV, and HIV. Transmission of these viruses from individual to individual has been documented due to contaminated blood glucose devices. According to the CDC, cleaning, and disinfection of meters between resident uses can prevent transmission of these viruses through indirect contact. 5. Use an EPA disinfectant wipe which is labeled effective against TB or HBV, HCV and HIV to remove any visible contaminants, soil or other debris. 6. Use a second EPA disinfectant wipe to disinfect the device surfaces, ensuring adequate contact time. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676464 If continuation sheet Page 6 of 6