Health inspection·January 8, 2026

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 the facility's only kitchen reviewed for food safety. The facility failed to ensure that food items stored in the dry storage area were labeled with the item description (handwritten or manufacturer's label) and included the date opened, and the use by/consume by or expiration date.The facility failed to ensure that stored canned goods had uncompromised seals and were free from dents.These failures could have placed residents at risk for food-borne illness and cross contamination. Observation of the dry storage area on 01/06/2026 at 8:15 a.m. revealed the following:2 cans of jellied cranberry sauce, 14 ounces, expired 11/29/2025, the facility's written received date was 12/01/2024.2 squeezable plastic dijon mustards, 24 ounces, expired 07/09/2024, the facility's written received date was 04/2025.2 large bags of rice cereal that were not in their original containers and had no item description and no expiration or best-by date.1 package of yellow corn tortillas 85 ounces, expired 04/21/2025, the facility's written received date was 06/29/2025.1 jar of coleslaw dressing, 128 ounces, had no expiration date; the facility's written received date was 01/05/2026.1 can of dark red kidney beans 111 ounces had a dent on the bottom front seam.During an interview with the Dietary Manager on January 6, 2026, at 8:42 am it was revealed that all the kitchen staff were responsible for unloading the delivery truck and putting labels on the food. He said the label should include the received date and the date the item was opened, the date received is added to the label, so they know what items to use first. He said if staff find dented cans, they put them in his office. He said if food was expired, staff would have immediately thrown it away. When asked how staff determined the expiration date when an item had no expiration date, he said he didn't know. He added that the original box that they receive the items in has the expiration and best buy date and that's the date that should be put on the food removed from the original container. During an interview with Kitchen Aide A on January 6, 2026, at 9:33 am it was revealed that all kitchen staff were responsible for unloading the delivery truck and placing labels on the food, and that the label should include the date the food was received. Record review of the facility's Food Storage Policy, dated 07/21/2023 revealed the following statement: Label and date new food items removed from their original containers. When inspecting canned foods, look for the following signs: Badly dented cans. Review of the U.S. FDA Food Code 2022 reflected: Definitions 3. Food Receiving and Storage - When food, food products or beverages are delivered to the nursing home, facility staff must inspect these items for safe transport and quality upon receipt and ensure their proper storage, keeping track of when to discard perishable foods and covering, labeling, and dating all PHF/TCS foods stored in the refrigerator or freezer as indicated. Page 1 of 3 676464 676464 01/08/2026 Las Brisas Rehabilitation and Wellness Center 3421 W Story Rd Irving, TX 75038

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 676464 Page 2 of 3 676464 01/08/2026 Las Brisas Rehabilitation and Wellness Center 3421 W Story Rd Irving, TX 75038

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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. 676464 Page 3 of 3