Health inspection·July 23, 2025

F 0925 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few placing her on the stretcher. En route to hospital vital perform SPO2, BGL, lung sounds were clear, airway patent. [Resident#1], IV established and right hand 50 milligram of Diphenhydramine given via IV, 2 ants found on patient during transport. Vitals remain stable throughout transportation. Patient transported to [local hospital] for further observation and treatment.Record review of Resident#1's hospital records, dated 07/22/25 reflected, Resident#1 was admitted on [DATE] at 11:28 AM. Per EMS, several small ants were actively crawling around patient. Patient had noted bites around her entire body including her face and neck. Patient had noted eyelid swelling. EMS administered IV Benadryl at 15 mg. Patient's face swollen and red with some insect bites likely allergic reaction from insect bites, will start IV steroids, hydrocortisone and Benadryl cream.Visit diagnosed Insect bite, unspecified site, initial encounter (primary), Urinary tract infection without hematuria, site unspecified Dehydration and Unsatisfactory living conditions. Patient's [family member] also requested new placement to a different facility, case management assisted with placement. [Resident#1] was accepted at another SNF/NF and would be discharged on 07/23/25. Record review of the weekend MOD progress note dated 07/20/25 reflected, Writer was alerted by CNA of rash/swollen eyes. Upon entry to room, no ants present in room, on resident or bed/linen. Resident was removed from area and assessed. Linen had already been removed, bed cleaned, and resident was already showered. Scattered rash like areas noted to body and redness along with bilateral swollen eyes during assessment. Writer notified {medical doctor} made aware of clinical situation and new orders given. Family notified of orders and ER transport. Hydrocortisone cream applied to entire body and PRN pain med and Benadryl administered. EMT present and transferred resident to {local hospital} with family en route. Family provided with Administrator's contact info for any concerns. Record review of the Admin interview with CNA A reflected [CNA A] regarding the incident that took place Sunday 7/20/2025 morning. [CNA A] stated she had been in the room of the affected resident about an hour prior at 8:30 and had checked and changed resident for incontinence. Room was clean, no signs of ants in or around bed or on resident at that time. No signs of clutter in the room or open food to draw pests into the room. Record review of the PCC service Inspection Report dated 4/11/25 reflected, on 05/28/25 the following rooms where treated 106-109 and 405-408 for ants and general pest. The non-compliance was identified as past non-compliance (PNC). The IJ began on 07/20/25 and ended on 07/21/25. The facility had corrected the non-compliance before the state's investigation began. The facility took the following actions to correct the non-compliance prior to the survey: Record review of the PCC service Inspection Report dated 07/21/25 reflected the facility was treated for ants on 07/21/25 treated room [ROOM NUMBER] for ants and general pest. On 7/20/25 Treated room [ROOM NUMBER] for ants. Treated the exterior of hall 300 for ants and general pests. Record review of Resident#1 shower sheet, dated 07/20/25 reflected Resident#1 had a scattered rash on chest signed by the weekend MOD and CNA A. Record review of in-service training report dated 07/20/25, titled pest control/homelike environment /abuse prohibition conducted by ED in person and via phone reflected: Summary of in-service reflected: Our residents have the right to a safe, clean comfortable and home like environment. We must be diligent in our processes to ensure this for them. -Rooms need to be clean and free of odors. If you observe issues with cleanliness or odors, you must report it to housekeeping immediately and find the source. Facility needs to be free of pest. If you observe issues with pest control, you must report it to maintenance immediately via MS and notify ED or Maintenance-Facility must monitor food in resident rooms and ensure there aren't items drawing pest attention. If you observe issues, you must report it or correct if able.-Maintenance will adjust interventions as appropriate and as the seasons change. Including checking and treating for ants regularly.-Report to admin and DON if ants observed in residents' room, notify (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455727 If continuation sheet Page 2 of 5 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 455727 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Village Healthcare and Rehabilitation 207 E Parkerville Rd Desoto, TX 75115 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 0925 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few nurse immediately-Head to toe skin assessment to be completed by the nurse on both residents in the room.remove any ants-Remove resident and roommate from the room-check adjacent room for ants, room to be treated for ants,-Resident unable to return to room until treatment and deep cleaning completed During an observation on 07/22/25 at 8:30 am to 9:15 am revealed, the common area, dining area and rm# 301, 302, 303, 304, 305,306,307,308, 309, 310, 311 and 312 were free of ants. In an interview on 07/22/25 at 8:43 am CNA B stated residents in the unit did not eat in their room. CNA B stated snacks were kept in a white container and were given out and staff cleaned up right after. CNA B stated the facility had issues in the past with bugs and they let the MD know. CNA B stated she had not seen ants in Resident#1 room before 07/20/25. CNA B was in serviced over the phone about pest control, resident abuse, homelike environment, and Resident#1 was transported to hospital on [DATE]. In an interview on 07/22/25 at 9:28 am the HKS stated they cleaned and disinfected common areas and resident's rooms daily. HKS stated when notified of a pest sighting, the HKS would first let the MD know. The HKS stated everything would be taken out of the resident's room and washed. The HKS stated Resident#1 room was deep cleaned and then deep cleaned again the following day. The HKS stated she viewed a small number of active and unactive ants in Resident#1 room. In an interview on 07/22/25 at 10:05 am, the MD stated it was reported to him on 07/20/25 that a Resident#1 was bitten by ants. The MD came to the facility and immediately sprayed the Resident#1 room and exterior. The MD stated pest control came out 07/20/25 and 07/21/25 and treated the interior and exterior of the facility. The MD stated the facility had minor problems in the past with residents who had spilled food in their rooms and ants followed the trail. The MD stated staff were supposed to report in MS any pest sighting. MD stated PCC technician came out twice a month to treat the facility. The MD stated the last pest control inspection was on 06/20/25. In an interview on 07/22/25 at 10:20 am the HSW stated Resident #1would be discharged to another SNF/NF. The HSW stated Resident#1's planned discharge was on 07/23/25. In an interview on 07/23/25 at 10:28 am, the HN stated that Resident#1 did not talk and was not ambulatory. The HN stated Resident#1 slept most of the day and a family member had been at her side. The HN stated Resident#1 was in the hospital for an allergic reaction to ant bites from a nursing home. Interview and observation at the local hospital on [DATE] at 10:33 am revealed Resident #1 had bites on her eyelids, face and neck. The Family member stated she visited Resident#1 on the morning of 07/20/25. Resident#1's legs were covered with a blanket and when she moved the blanket ants were crawling on her legs. The Family member stated Resident#1's eyes were swollen shut and there were ants crawling on the wall. The family member stated she went and got CNA A who assisted with Resident#1.Attempted to call LVN I on 07/22/25 at 2:24 pm and did not receive a return call before exit.In an interview on 07/22/25 at 2:30 pm weekend MOD stated LVN I called her about Resident#1 had an allergic reaction to ant bites. The weekend MOD informed the DON about the ant bites. The weekend MOD stated she did a head-to-toe assessment and documented in Resident#1 progress notes the findings. The weekend MOD stated she remember the resident having a rash on her chest and her eyes were swollen. The weekend MOD stated Resident#1 hair was wet and she did not find any ants on her. In an interview on 07/22/25 at 3:36 pm CNA A stated at 8:15 am on 07/20/25 she went into Resident#1's room to provide incontinent care and turned to feed Resident#1 and she would not eat. CNA A stated she did not see any ants in Resident#1's room at that time. CNA A stated the family member came and got her around 10 something. CNA A stated Resident#1's eyes were swollen. CNA A stated she notified LVN I and she called the MD by calling his number. CNA A stated she was in-serviced on 07/20/25 to notified LVN I so they could do a head-to-toe assessment on the resident and roommate. CNA stated Resident#1 was given a shower. CNA A stated no ants were found on the roommate side of the room. CNA A stated nearby (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455727 If continuation sheet Page 3 of 5 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 455727 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Village Healthcare and Rehabilitation 207 E Parkerville Rd Desoto, TX 75115 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 0925 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few rooms should be checked for ants and staff must make sure all food was cleaned up.In an interview on 07/22/25 at 3:40 pm CNA C stated she was not there when the incident happened with Resident#1. CNA C was in-serviced on 07/21/25 on homelike environment, pest control and resident abuse. CNA C stated she had not seen any ants. CNA C stated any sighting of pest should be reported to the MD and tell the nurse so she could do a head-to-toe assessment. Interviews on 07/22/25 from 3:45 pm to 4:10 pm revealed LVN D, CNA E, LVN F, CNA G and LVN H stated if pests were seen, first remove the residents from the room, then the MD and Admin were called, the nurse did a head-to-toe assessment, adjacent rooms were checked for pests, they removed residents' belongings, and the HK deep cleaned the rooms. In an interview on 07/22/25 at 4:12 pm the HK stated if they noticed pests to first notify the MD and then bag residents' items and complete laundry. The HK stated the room was deep cleaned twice and adjacent rooms were checked. In an interview on 07/22/25 at 10:02 am the PCC technician stated the company treated the facility twice a month. PCC stated one exterior treatment would be enough to take care of the ants. PCC technician stated he came in on 07/20/25 and 07/22/25 and treated the interior and exterior of the facility for ants. The PCC technician stated no ants were found in the rooms. The PCC technician stated a lot of things could have led to an ant problem such as the weather. The PCC technician stated little showers and heavy rain caused everything on the ground to move around and food being left out could cause ants. In an interview on 07/22/25 at 4:15 pm the DON and Admin stated the Facility immediately cleared Resident #1, and her bed of ants. Resident #1 was showered and affected areas treated, housekeeping immediately deep cleaned the room, and pest control was called immediately to come and treat the room as well as adjacent rooms. Residents on the hall were checked head to toe for skin assessments, and no other signs of ants or bites were sighted. The DON stated Resident#1 roommate had a head-to-toe assessment and no bites were found on her or in her personal belongings. The DON stated Resident#1 roommate was transferred to 200 hall. Admin stated Pest control treated the exterior of the facility as well as the ant hills on the property. All staff were in-serviced on pest control, safe homelike environment, and abuse prohibition. The MD did exterior rounds of the facility and checked for entrance sights and hills and provided exterior treatment. The PCC Technician came back out the next day for a follow up treatment. Dept heads continue to round twice a day to check for signs of pests. Staff are to notify maintenance via MS and group message as well as the Admin immediately. The DON and Admin stated any pest sighted in the resident rooms will require resident to have a head-to-toe assessment immediately and room deep cleaned. During an observation on 07/22/25 at 4:45 pm the surveyor did an exterior walk through of the facility and ant hills were not noticed at that time of visit. Observed a lot of greenery and shrubbery around the facility. During an observation on 07/22/25 at 5:00 pm, resident rm# 106-109, 206, 211 and 405-408 were checked for ants. The surveyor did not observed pest at the time of visit. During an observation and interview on 07/23/25 at 11:30 am the MD and surveyor did an exterior walk through of the facility. The MD stated ant hills were treated and then knocked down the following day. The MD identified spots where ants had been knocked down and no active ants were observed at the time of the visit. Record review of the PCC service Inspection Report dated 07/21/25 reflected, On 7/20/25 Treated room [ROOM NUMBER] for ants. Treated the exterior of hall 300 for ants and general pests. On 07/21/25 treated room [ROOM NUMBER] for ants and general pest Record review of facility policy titled, safe/comfortable/homelike environment, revised 01/22 revealed: Residents are provided with a safe, clean, comfortable and homelike environment. Record review of a pest contract revealed the agreement was effective October 1, 2021, and reflected .8. Service Provider's Schedule and Availability, service provider shall be reasonably available to the Facility and shall spend sufficient time at the facility premises (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455727 If continuation sheet Page 4 of 5 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 455727 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Village Healthcare and Rehabilitation 207 E Parkerville Rd Desoto, TX 75115 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 0925 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete to fulfill service provider's duties hereunder. Record review of facility policy titled, physical Environment, revised 05/2020 reflected: POLICY:It is the policy of this facility to utilize pesticides and rodenticides in a safe and efficient manner to control pests with the least amount of contamination to the environment.Responsibilities:Facility staff will:1. Report any pest sightings and file a report using the pest observation log.2. Document problems found during inspection and the remedial actions taken.3. Advise staff on preventive measure, unsanitary conditions, etc.4. Secure services of a Pest Control company for routine and PRN services to control pests with the least amount of contamination to the environment.Pest Identification:The following guidelines for pest identification:1. When pests are sighted, determine why the infestation is occurring and advise department on preventive measures.2. Use pesticides only after all other channels of control are exhausted.3. Use pesticides only as a preventive measure and in conjunction with proper mechanical controls.4. Report insect or pest sightings to the housekeeping/maintenance supervisor immediately. Include the following information:a. Type of problemb. Locationc. Person reporting and time reported.Pest Prevention:The following are guidelines for pest prevention:1. All storage and food preparation areas are to be kept clean. This includes walls, floors, shelving, cabinet tops, sinks, equipment, etc.2. Keep grounds free of trash and brush.3. Keep the dumpster area clean.4. Food stored in resident rooms will be in covered containers.5. Clean up food spills.6. Screen foundation areas with mesh. Event ID: Facility ID: 455727 If continuation sheet Page 5 of 5