Health inspection·October 1, 2025

F 0600 Level of Harm - Actual harm Residents Affected - Few behavior with patient. Depression: Patient endorses current symptoms of loss of interest and decreased concentration and denies symptoms of sad moods, fatigue, guilt, feelings of worthlessness, psychomotor agitation, psychomotor slowing and suicidal ideation/intent/plan and appetite change. Patient endorses history of sad moods. This entry was entered by NP D Resident #1Record review of Resident #1's MDS Assessment, dated 09/29/2025, Reflected the Resident #1 was a [AGE] year-old male who originally admitted to the facility on [DATE] and re admitted [DATE]. He had a BIMS score of 03, indicating severe cognitive impairment. His diagnoses included Non-Alzheimer's Dementia (cognitive decline that is not caused by Alzheimer's disease), Cerebrovascular Accident (a medical term for a condition where there's a sudden interruption of blood flow to the brain, causing damage to brain tissue), hemiplegia (a medical condition that causes paralysis or severe weakness on one side of the body). Record review of Resident #1's care plan, Date Initiated: 03/14/2024 Revised on: 09/15/2025 Reflected Potential to demonstrate physical behaviors r/t Anger, Dementia, Poor impulse control**** Resident noted to have altercation with brother in dining room and aggressive/trying to hit staff members/swinging at staff. 9/15/25- resident to resident altercation in resident's room. Interventions 9/15/25 1:1 monitoring Date Initiated: 09/15/2025 Analyze key times, places, circumstances, triggers, and what de-escalates behavior and document. Date Initiated: 09/15/2025 Assess and anticipate resident's needs: food, thirst. toileting needs, comfort level, body positioning, pain etc. Date Initiated: 03/14/2024 Document observed behavior and attempted interventions. Date Initiated: 03/14/2024 Psychiatric/Psychogeriatric consult as indicated. Date Initiated: 03/14/2024 When becomes agitated: Guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away, and approach later. Record review of Resident #1's Progress Notes reflected the following:*9/15/2025 2:34pm - Upon entering resident's room the charge nurse observed the two resident's grabbing at each other and pulling each other's shirt. Residents immediately separated and placed on 1:1 observation, [NP G], Administrator, [FM], [NP D] notified, skin assessment completed, and resident assisted out of the room and to the front lobby. This entry was written by LVN A.*9/15/2025 7:08pm SW communicated with psychiatrist. Psych visited the residents due to res-to-res allegations. One on one discontinued per psych. This entry was written by SW. Record review of Resident# 1's Psychiatric Subsequent assessment dated [DATE] reflected Seen for follow up visit. Resident seen resting in bed on 1:1. He has history of depression, anxiety, and dementia. He is being seen today due to having an altercation with another resident in which he was the aggressor. He has aphasia, so he is hard to understand. From what I understood he currently does not have a roommate and reports he was sleeping, and he was awakened due to the other resident coming into his room. He woke up startled and tried to get the other patient out of his room by swinging at him and turning over his wheelchair. He reports understanding that he cannot be aggressive with anyone in the facility. He declines being threatened by the other patient. Will discontinue 1:1 at this time. Will follow up with patient on Thursday and make changes to medications as needed Depression: Patient endorses current symptoms of decreased concentration and denies symptoms of sad moods, loss of interest, fatigue, guilt, feelings of worthlessness, psychomotor agitation, psychomotor slowing and suicidal ideation/intent/plan and appetite change. Patient endorses history of sad moods. This entry was entered by NP D Record review of the facility's incidents/accidents report from 07/01/25 to 10/01/25 reflected the incident on 09/15/2025 and there were no other incidents that involved Resident #1 or Resident #2. On 10/01/25 at 10:28 AM in an Observation and an interview with Resident #2 revealed he was sitting in a wheelchair in his room. Resident #2 said he was not in pain, the scratch to his nose had healed. He does not recall events leading to the altercation but he stated the crazy guy scratched his nose. He stated everyone (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 10/01/2025 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 0600 Level of Harm - Actual harm Residents Affected - Few was good to him, he got along with other residents and felt safe at the facility. On 10/01/2025 at 11:57AM in a telephone interview with LVN A revealed she was called to Resident#1's room by a lady who was at the facility to evaluate Resident#1 for transfer to an inpatient Physical therapy facility. LVN A stated when she got to the room Resident #2 was on the floor and Resident #1 was hitting Resident#2. She stated LVN A and the staffing coordinator separated Resident #1 from Resident #2, while CMA F assisted Resident #2 back to his chair. She stated she assessed Resident #2, he had a scratch on his nose and was bleeding. LVN A stated she treated the scratch on Resident #2 nose, then notified the MD, Administrator, DON, responsible parties, and psyche services. LVN A stated Resident #1 explained Resident#2 was in his closet taking his clothes and that was why they had an altercation. On 10/1/2025 at 2:01pm in an interview with the staffing coordinator revealed there was a vendor who was evaluating Resident #1 in his room alerted her and LVN A that Resident #1 and Resident #2 were fighting. She stated LVN A, CMA F and herself rushed to Resident #1s room. She stated she observed Resident#1 was on the chair punching Resident #2 who was on the floor next to Resident #2's wheelchair. She stated the staff separated the residents. She stated Resident#1 told the staff that Resident #2 was in his room going through Resident #1's personal belongings. She stated after the residents were separated and safe LVN A assessed the residents because Resident #2 was bleeding from his nose. She stated she was not aware of any incidents between Resident #1 and Resident #2 and was not aware if they had issues before. She stated she had been in-serviced on abuse neglect and resident to resident altercation. On 10/1/2025 at 11:15 am in an observation and interview with Resident #1 revealed he was in bed awake. Resident#1 shook his head from sided (indicating a no response) and said no when asked if anyone was in his room to take his personal belongings or if he had an altercation with another resident, he shook his head from side to side. On 10/1/2025 at 2:27PM Interview with the social worker revealed that when the altercation happened Resident#1 was in the process of transferring to an inpatient rehabilitation. She stated that Resident#1 and Resident #2 were roommates for a longtime and they got along very well. She stated that one day Resident #2 said that he no longer wanted to be roommates with Resident #1.She stated that there was no incident between the two of them. She stated that after the altercation she did one on one supervision with Resident #1 until he was cleared by psych. She stated that Resident #2 told her that he thought he had left some of his belongings in Resident#1s room, and that was the reason he had gone to Resident#1 room when the altercation happened. She stated that Resident#1 and Resident#2 have had no issues with other residents. She stated that she had been in-serviced on abuse prohibition and Resident to resident altercation. She stated that if two residents had an altercation, she would separate them notify the nurse to do an assessment, notify the DON and administrator. She stated that it the facility policy that after an altercation to have residents one on one supervision until they are evaluated by psyche services. On 10/1/2025 at 2:38pm in an interview with the DON revealed that the administrator and LVN A notified her of the altercation between Resident#1 and Resident#2. She stated that when the altercation happened Resident#2 was in Resident#1 closet taking his clothes out. The DON stated that LVN A, the staffing coordinator and CMA F separated the residents and the two residents were place on one-on-one supervision until they were evaluated by psych services. She stated that LVN A completed head to toe assessment, and Resident#2 had a scratch to his nose. The DON stated that the MD and responsible parties for both residents were notified. She stated that NP F evaluated Resident#1 and Resident#2 the discontinued the one-on-one supervision. She stated that the residents were separated by moving them to different sides of the hall to limit access to each other. She stated that the staff was in-serviced on Resident-to-Resident altercations and to observe and keep Resident#1 and Resident#2 from close (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 10/01/2025 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 0600 Level of Harm - Actual harm Residents Affected - Few proximity without isolating them. The DON stated that Resident#1 and Resident#2 were roommates, and they got along very well. She stated that one day Resident#1 refused to share something with Resident#2, then Resident #2 said he no longer wanted to share a room with Resident#1, so the facility moved Resident#2 to a different room. The DON stated that after moving rooms the residents still got along, they sat close together. The DON stated that the staff had been in-serviced on abuse and neglect and Resident to resident altercation and de-escalation. DON stated that Resident#1 and Resident#2s care plans were updated. On 10/1/2025 at 2:45pm in an interview with the Administrator revealed that he was notified by LVN A that Resident#1 and Resident#2 had an altercation and Resident#2 had a scratch on his nose that was bleeding. He began an investigation that revealed that Resident#2 went into Resident# 1 room and that was when the altercation happened. He stated that the two residents had been roommates before, and Resident #2 requested to be moved to another room. The administrator stated that after the altercation Resident#1 and Resident#2 were placed one on one supervision until both residents were seen by psyche services that evening and the one-on-one supervision was discontinued. He stated that the staff was in-serviced on abuse prohibition and Resident to Resident de-escalation and altercation. The facility notified the doctor and responsible parties for both Resident#1 and Resident#2. He stated that after the altercation the residents were separated to different sides of the hall to make sure they did not have access to each other. He stated that the next day Resident#1 was transferred to an in-patient rehabilitation for physical therapy, and when he returned the two residents remain of different halls and there have been no incidents between the two residents. He stated that Resident#1 and Resident#2 had no known previous incident with each other. Resident#1 had an incident sometime back, but he was the victim not the aggressor. He stated that both Resident#1 and Resident#2 have not had aggression towards other residents. He stated that the facility conducted safe surveys and there were no identified issues. On 10/1/2025 at 2:56pm in an interview with NP F revealed that she was notified by the facility that Resident#1 and Resident #2 had an altercation. She stated that both residents were on psych services, and she had been seeing them for a while and neither Resident#1 nor Resident#2 presented aggressive behavior previously. She stated that she evaluated Resident#1 and Resident#2 the same day in the evening. She stated that after evaluating Resident#1 and Resident#2 she determined that the incident happened because Resident#1 went to Resident#2 room to get what Resident#1 thought was his personal belongings, because that was his old room. She stated that Resident#1 was asleep and woke up suddenly to find Resident#2 going through his personal belongings, and he reacted aggressively partly due brain injury post stroke. She stated that after evaluating Resident#1 and Resident#2 she discontinued the one-on-one supervision because there was no evidence of danger to themselves, to each other, or to other residents. She stated that she was satisfied with the interventions that the facility took after the altercation including separating the Residents to opposite side of the hall to minimize access to each other. Record review of the facility's policy, Revised Revision/Review Date(s):4.2019; 1.2021; 1.2022; 10.2022 and titled Abuse: Prevention of and Prohibition Against reflected:1.Abuse is willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. This includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Physical Abuse includes but is not limited to hitting, slapping, pinching, and kicking. It also includes controlling behavior through corporal (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 10/01/2025 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 0600 Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete punishment.2.If the allegation of abuse, neglect, misappropriation of resident property, or exploitation involves another resident, the Facility will: Separate the residents so they do not interact with each other until circumstances of the reported incident can be determined. If a room change is appropriate, advise the residents and/or resident representatives of reason for the change in writing. Continue to assess, monitor, and intervene as necessary to maximize resident health and safety. Event ID: Facility ID: 455727 If continuation sheet Page 5 of 5