Health inspection·January 8, 2026

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 one of four (LVN A) staff members and four of six residents (Residents #22, #65, #67, & #84) reviewed for infection control procedures. LVN A failed to perform hand hygiene after direct contact with Residents #22, #65, #67, and #84 while serving meals in the dining room. This failure could place residents at risk for healthcare associated cross contamination and infections.Findings included: Record review of Resident #22's admission MDS assessment, dated 12/13/2025, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #22 had diagnoses which included: atrial fib (fast heart rate), hypertension (high blood pressure), and diabetes (high blood sugar). Resident #22 was moderately cognitively impaired and able to make decisions and required assistance of one staff for activities of daily living. Record review of Resident #65's quarterly MDS Assessment, dated 12/06/2025, revealed an [AGE] year-old female who was readmitted to the facility on [DATE]. Resident #65 had diagnoses which included: dementia (brain disease that effects memory), hypertension (increased blood pressure), and depression (mental illness). Resident #65's, severely impaired for cognition and unable to make decisions and required one staff for assistance with activities of daily living. Record review of Resident #67's annual MDS Assessment, dated 11/21/2025, revealed an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #85 had diagnosis which included: Cancer (killing of tissue), hypertension (increased blood pressure), and dementia (confusion and forgetfulness). Resident #67 was moderately impaired for cognition and required one staff for assistance with activities of daily living. Record review of Resident #84's annual MDS Assessment, dated 11/04/2025, revealed an [AGE] year-old female who admitted to the facility on [DATE]. Resident #84 had diagnosis which included: Hypertension (high blood pressure), Alzheimer's (confusion and forgetfulness), and chronic pain (pain all the time). Resident #84 was severely cognitive and unable to make decisions and required assistance of one staff for activities of daily living. Observation on 01/06/2026 beginning at 8:00 a.m., revealed LVN A had entered the main dining room, and did not use hand sanitizer. LVN A took four trays from the kitchen and placed them on a cart, used no hand sanitizer and served all four trays. LVN A served a breakfast tray to Resident #67, touched table in the dining room, touched the hand and shoulder of Resident #67 and prepared the meal tray for the resident to eat her breakfast. LVN A did not have gloves on. LVN A was observed not to wash his hands or use hand sanitizer, available in the hallway. Observation on 01/06/2026 beginning at 8:07 a.m., LVN A was observed serving and setting up Resident #84, #22, and #65's breakfast trays, unwrapped the utensils, and removed tops off of drinks, for each resident. She did not complete hand hygiene before going to the next resident. An interview on 01/06/2026 at 1:00 p.m., LVN A stated she did not complete hand hygiene after having direct contact with residents. LVN A stated she was supposed to use the hand sanitizer in between serving each tray. LVN A said she had been educated on completing hand hygiene. LVN A stated she did not sanitize her hands, because she was trying to get the breakfast trays served, so the food would not be cold. An interview with the DON on 01/08/2026 at 11:30 a.m., revealed all staff must complete hand hygiene after having contact with residents. He stated all staff were trained to wash their hands with soap and water prior to tray service, then use hand sanitizer between each tray. The DON stated if the staff did not use appropriate hygiene, they could spread germs to the residents and themselves. Record review of an in-service log dated 12/07/2025 revealed LVN A received handwashing and hand sanitizing training, to Residents Affected - Some (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676464 If continuation sheet Page 2 of 3 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 01/08/2026 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 Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete prevent the spread of infection. Record review of the Facility's Policy titled Infection Prevention and Control Policies revised May 2023 reflected: Subject: Handwashing/Hand Policy: Proper hand hygiene/hand washing technique will be accomplished at all times that handwashing is indicate. Hand Hygiene/Hand washing is the most important component for preventing the spread of infection, Maintaining clean hands is important for patients/residents/visitors/ as well as staff. 1. Hand hygiene/handwashing is done A. before patient /resident contact.After: . B. After patient/resident contact.J. Contact with environmental surfaces in the immediate vicinity of patients/residents. Event ID: Facility ID: 676464 If continuation sheet Page 3 of 3