Health inspection·November 15, 2025

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Cognitively Impaired).Record review of Resident #2 and Resident #1's progress notes revealed no documentation of the incident, no documentation of notification to doctor, and no documentation of notification to designated representative. On 11/13/25 the State Surveyor observed the video dated 11/5/25, on the facility monitor, the video revealed the following:At 08:03 AM, Resident #1 left the dining room with a food tray and walked back into the dining room. At 08:29 AM Resident #1 came out of the dining room again and threw a bag away and went back into the dining room. At 08:30 AM CNA-A went into the dining room and came out of the room with Resident #2 and took her down the hall. Resident #1 followed CNA-A and Resident #2 out of the dining room and down the hallway, he was holding a green piece of material in his hand. A few minutes later at 08:51 AM Resident #2 was brought back to the hallway across from the nurses' station. Resident #2 was sitting in the hall alone on a bench when Resident #1 went to the counter and stood there a few seconds and then walked over to Resident #2 turned around and kissed her on the top of her head.In a face-to-face interview with Resident #1 on 11/13/25 at 11:55 AM, he was asked about an incident between he and Resident #2, he responded I did not rape that woman. He stated he helped her change her dress and helped her put on another dress. Resident #1 did not respond to any other questions. In an attempted face to face interview with Resident #2 on 11/13/25 at 12:10 PM, she did not respond to any questions, she was dressed appropriately, and she smiled when investigator asked if she enjoyed her lunch. In a face-to-face interview with CNA-A on 11/14/25 at 6:29 AM, she stated on 11/05/25 she observed Resident #1 walking down the hallway with an adult brief and put it in the trash, she observed him return to the dining room and he closed the door. She stated that she followed Resident #1 into the dining room and observed him massaging the breast of Resident #2 on top of her blouse, she observed Resident #2's bra around her waist, she stated she patted below the waist of Resident #2 and noticed she did not have on a brief. She stated that Resident #1 and Resident #2 were the only people in the dining room. She stated that she asked Resident #1 why he had Resident #2's shirt and he stated he was taking care of her. CNA-A said that she told Resident #1 she was taking care of Resident #2. She stated after she ensured Resident #2 was dressed properly, she notified LVN-B. She stated she was asked by the Administrator to write a statement about what she saw when she entered the room. In a face-to-face interview with LVN-B on 11/14/25 at 6:42 AM she stated that on 11/05/25 she had been passing medications when CNA-A came and reported that Resident #1 was assisting Resident #2 and Resident #1 had Resident #2's undershirt and brief in his hands. She stated that she notified the Administrator immediately and completed a skin assessment on Resident #2 and did not see any injuries. She stated the resident did not exhibit any distress at the time of examination. She said she was told by the DON to wait for clarification of if Resident #1 and Resident #2 had engaged in a sexual act, before putting in a progress note and notifying the doctor and family. She stated she was supposed to wait until after the administrator finished his investigation. She stated no one ever returned to tell her the investigation was completed. In an interview on 11/14/25 at 9:55 AM with a Designated Representative, the Designated stated they had not been notified that Resident #2 that she had been sexually abused by Resident #1.In a telephone interview with the Administrator on 11/18/2025 at 2:38 PM, he stated notification was not made to the designated representative because of improper education of the nurse. He stated that the nurse was supposed to examine the residents and notify medical, the designated representative, the DON and the Administration . He stated that the residents were at risk of a lack of trust for the facility to make their loved ones safe.In a telephone interview with the DON on 11/18/25 at 2:44 PM, she stated that the LVN should have notified the designated representative once the Administrator had completed the investigation. She stated that she was not sure who made the decision not to notify (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455727 If continuation sheet Page 2 of 17 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 11/15/2025 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 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete the designated representative. She stated that the residents were at risk of ongoing abuse when the designated representative was not notified.In a telephone interview on 11/21/25 at 10:35 AM with the NP, he stated he had not been told that there was a potential sexual abuse between Resident #1 and Resident #2. He stated he had first heard there was a significant event regarding Resident #1 when he was notified that the State was in the building. He stated the staff had informed him that Resident #1 had been going in and out of other residents' rooms. He stated that Resident #1 had been very restless and was constantly going into rooms wiping down things. He stated the staff informed him that Resident #1 was not responding to direction, and he was trying to help a male resident back to bed. He denied he was ever informed of Resident #1 attempting to assist a female resident. He stated Resident #1 assisting residents placed the residents at risk of trips or falls. Record review of the facility Change of Condition policy revised 07/2015, reflected change in condition reporting 3. Licensed nurse will inform family/responsible party of change of condition and document notification. 4. All nursing actions, physician contacts and resident assessment information will be documented in the nursing progress notes. Event ID: Facility ID: 455727 If continuation sheet Page 3 of 17 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 11/15/2025 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 - Immediate jeopardy to resident health or safety Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents were free from abuse and neglect for 2 of 8 residents (Resident #1 and Resident #2) reviewed for abuse and neglect.The facility failed to ensure there was no inappropriate sexual behavior between Resident #1 and Resident #2. Resident #1 was observed in the dining room by CNA-A massaging the breast of Resident #2.An Immediate Jeopardy (IJ) was identified on 11/14/25. The IJ template was provided to the facility on [DATE] at 7:12 PM. While the IJ was removed on 11/15/25, the facility remained out of compliance at a scope of isolated with the severity level at a potential for more than minimal harm that is not immediate jeopardy, because all staff had not been trained. This failure placed other female residents at risk and or potential risk of abuse/neglect Findings Included: Record review of Resident #2's face sheet dated 11/15/25 reflected she was a [AGE] year-old female admitted into the facility 09/22/25 with a diagnosis of senile degeneration of brain (a general term for a decline in memory, thinking, and other cognitive abilities associated with aging). Record review of Resident #2's care plan dated 9/22/25 reflected ADL self-care performance deficit impaired mobility/cognition. Goal was to maintain current level of function in bed mobility, transfers, eating, dressing, grooming, toilet use and personal hygiene. Interventions were to converse with resident while providing care, explain all procedures before starting, promote dignity by ensuring privacy, staff will provide appropriate level of physical assistance with ADL's, encourage them to participate to the fullest extent possible. Record review of Resident #2's initial assessment MDS dated [DATE] reflected a BIMS score of 01 (Severe Cognitive Impairment).Record review of Resident #1's face sheet dated 11/15/25 reflected he was a [AGE] year-old male admitted into the facility 07/14/25 with a diagnoses of brain compression (a serious condition caused by increased pressure within the skull that pushes the brain against its rigid covering), and Schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly). Record review of Resident #1's care plan dated 9/3/25 reflected a focus of elopement risk and significantly intrudes on the privacy or activities, the goal was to maintain safety and would not leave the facility. Interventions/tasks were to distract resident from wandering by activities, food, conversation, television, document wandering behavior, identify pattern of wandering determine if aimless or escapist, is resident looking for something or did the wondering indicate he needed more exercise. Focus was a potential to demonstrate physical and verbal aggressive behaviors/manic episodes. Goal was to demonstrate effective coping skills and would not harm self or others. Interventions/tasks were to assess and anticipate resident's needs such as food, thirst, toileting needs, comfort and body position, pain. Communication provides physical and verbal cues to alleviate anxiety, give positive feedback, assist verbalization of source of agitation, encourage seeking out of staff members when agitated. When he becomes agitated, guide away from source of distress, engages calmly in conversation, if response is aggressive, staff to walk calmly away and approach later. Record review of Resident #1's quarterly MDS dated [DATE] reflected he had a BIMS score of 09 (Moderately Cognitive Impaired).Record review of progress notes of Resident #1 dated 11/4/25 at [1:59 PM] by LVN-B reflected, Kept going in other rooms while during shift, was found in multiple ladies' room and assisting residents to the restroom & was found after that in multiple male's room making beds. This nurse [LVN-B] discussed not going into rooms with the resident. Resident verbalized understanding. Notified NP of behaviors noted during this shift.Record review of progress note dated 11/05/25 at 3:32 AM for Resident #1 by LVN-C reflected, Res up and walking around hall and roaming in and out other patient's rooms. Res very aggressive and hard to redirect, tried to do virtual visit (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455727 If continuation sheet Page 4 of 17 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 11/15/2025 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 - Immediate jeopardy to resident health or safety Residents Affected - Few but iPad dead awaiting charging to call on call MD. [sic]Record review of progress note dated 11/05/25 at 4:23 AM for Resident #1 by LVN-C reflected, Res still agitated and aggressive. PRN orazepam was given but not effective. Res going in multiple women's rooms on unit. Hard to redirect. Res has been up all night walking and talking to self. [sic]Record review of progress note dated 11/05/25 at 4:50 AM for Resident #1 by LVN-C reflected, change in condition behavioral systems, nursing observations, evaluation, and recommendations are: Res has been up all night and going into female resident's rooms and when staff try to have him leave out room res becomes very aggressive in tone and hard to remove with verbal redirection. Res starts making demands like for food or water ect. Res was given PRN Ativan. Called spoke to on call NP. Gave order to give an additional Ativan of 0.5 mg and have NP and MD see patient once in facility. [sic]Record review of progress note dated 11/05/25 at 5:14 AM for Resident #1 by LVN-C reflected, PRN administration was: ineffective no change in behavior.Record review of Behavioral Changes and Sleep Disturbance dated 11/5/25 at 1:27 PM for Resident #1 reflected, [Resident #1] [was] a [AGE] year-old male resident at a care facility who [was] being evaluated today for behavioral changes and sleep disturbance. Staff report that the patient has been exhibiting increasingly erratic behavior over the past few days, including entering other residents' rooms without permission and refusing to leave another resident's room and became verbally aggressive with the night nurse. Staff members indicate that the patient has not slept for approximately two days, only taking brief naps during daytime hours but immediately awakening when someone enters his room. Alert but disoriented, exhibiting impulsive behaviors, poor insight and judgment. Non-compliant with facility rules and boundaries. Plans continue mental health management per psych provider, continue close supervision until stabilization of symptoms. Patient instructions, you are having trouble sleeping and have been walking into other people's rooms. Try to stay in your own room, especially at night. Use your own bathroom when needed. Completed by NPRecord review of progress note dated 11/06/25 at 5:12 AM for Resident #1 by LVN-C reflected, Early morning started going into other residents rooms. Res has not been seen by psych in last 48 hrs for follow up for behaviors at this time. Res harder to redirect and lorazepam not effective. Res not sleeping during night. [sic]Record review of NP visit with Resident #1 on 11/06/25 at 10:38 AM reflected, follow up for psychiatric issues and hypertension, patient demonstrates disorganized thinking and behavior. Constantly attempting to clean rooms and help other residents in ways that are sometimes inappropriate or dangerous.Record review on 11/13/25 of Resident #2 and Resident #1's progress notes did not reflect documentation of the sexual abuse incident, no documentation of notification to doctor, and no documentation of notification to designated representative. Record review of facility incident reports dated 10/15/25 through 11/11/25 reflected no incident report involving Resident #1 or Resident #2. On 11/13/25 the State Surveyor observed the video dated 11/5/25, on the facility monitor, the video revealed the following:At 08:03 AM, Resident #1 left the dining room with a food tray and walked back into the dining room. At 08:29 AM Resident #1 came out of the dining room again and threw a bag away and went back into the dining room. At 08:30 AM CNA-A went into the dining room and came out of the room with Resident #2 and took her down the hall. Resident #1 followed CNA-A and Resident #2 out of the dining room and down the hallway, he was holding a green piece of material in his hand. A few minutes later at 08:51 AM Resident #2 was brought back to the hallway across from the nurses' station. Resident #2 was sitting in the hall alone on a bench when Resident #1 went to the counter and stood there a few seconds and then walked over to Resident #2 turned around and kissed her on the top of her head.Record review of undated written statement of CNA-A reflected, This morning I witness [Resident #1] coming out of the dining room with a pull-up in his hand. I ask my co-worker where did he get it, he headed back (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455727 If continuation sheet Page 5 of 17 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 11/15/2025 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 - Immediate jeopardy to resident health or safety Residents Affected - Few to the dining room and shut the door that's when I went to check to see why he shut the door, as I enter the room both residents were standing by the table [Resident #1] in front of her massaging her chest with his hands holding (She had the top shirt on) her tank top. I told him to stop I patted the pt. realized her brief was off, grabbed her and started walking her out to notify my nurse and pt telling me he has her, and I replied: I got her.Record review of the facility undated investigation reflected, We, [Administrator and DON], interviewed CNA-A 11/5/25 after reading her statement to get clarity on the incident between [Resident #2] and [Resident #1]. Upon speaking with her, her story was inconsistent with what was initially written as she stated she initially assumed that [Resident #1] was touching [Resident #2], by the way he was standing next to her, but was unsure if she could see that [Resident #1] was touching [Resident #2] or not as she did not observe it herself. She state that she saw [Resident #1] come out of the dining room with a brief in hand, she followed him back into the dining room and saw [Resident #1] standing next to [Resident #2], then walked [Resident #2] out of the dining room and back to her room, and notified the nurse of [Resident #1] carrying dirty brief to trash.In a face-to-face interview with CNA-A on 11/14/25 at 6:29 AM, she stated on 11/05/25 she observed Resident #1 walking down the hallway with an adult brief and put it in the trash, she observed him return to the dining room and he closed the door. She stated that she followed Resident #1 into the dining room and observed him massaging the breast of Resident #2 on top of her blouse, she observed Resident #2's bra around her waist, she stated she patted below the waist of Resident #2 and noticed she did not have on a brief. She stated that Resident #1 and Resident #2 were the only people in the dining room. She stated that she asked Resident #1 why he had Resident #2's shirt and he stated he was taking care of her. CNA-A said that she told Resident #1 she was taking care of Resident #2. She stated after she ensured Resident #2 was dressed properly, she notified LVN-B. She stated she was asked by the Administrator to write a statement about what she saw when she entered the room. In a face-to-face interview with the DON on 11/13/25 at 1:37 PM, she stated that she became aware of the alleged abuse when it was reported by LVN-B. She stated that LVN-B had conducted the assessment on Resident #2. She stated that she and the Administrator had interviewed CNA-A and CNA-A did not verbally provide the same information she had written in her statement. She stated CNA-A was asked about the discrepancy, but she did not remember the response. She stated based on the discrepancy she and the Administrator determined that nothing had happened between Resident #1 and Resident #2. She stated that Resident #1 had been sent to hospital for psych evaluation, but they sent him back with no new instructions. She stated that staff had documented it on 11/4/25 and during the early shift on 11/5/25 that Resident #1 had been going into other residents' rooms. In a face-to-face interview with LVN-B on 11/14/25 at 6:42 AM she stated that on 11/05/25 she had been passing medications when CNA-A came and reported that Resident #1 was assisting Resident #2 and Resident #1 had Resident #2's undershirt and brief in his hands. She stated that she notified the Administrator immediately and completed a skin assessment on Resident #2 and did not see any injuries. She stated Resident #2 did not exhibit any distress at the time of examination. She stated that Resident #1 was not assessed by her, she assumed that he would be assessed by the DON because the DON was talking with him and his representative about sending him to hospital for evaluation. In a face-to-face interview with the Administrator on 11/14/25 at 10:10 AM, he stated he stated that he was notified on 11/5/25 by LVN-B that CNA-A had walked into the dining room and found Resident #1 and Resident #2 in the dining room alone after Resident #1 had been seen by CNA-A putting a dirty brief in the trash. He stated he did not take any action at that time because after interviewing the CNA-A, he and the DON did not think any abuse had occurred. He stated Resident #1 and Resident #2 were still located on the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455727 If continuation sheet Page 6 of 17 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 11/15/2025 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 - Immediate jeopardy to resident health or safety Residents Affected - Few same locked unit. He stated the facility had sent Resident #1 out for assessment to two different hospitals and he was discharged back to the facility with no new orders. He denied the facility had put any extra monitoring in place to protect either of the residents. The Administrator stated the residents were at risk of the facility not creating an environment for resident safety. In a face-to-face interview with LVN-C on 11/14/25 at 5:20 PM she stated Resident #1 woke up in the middle of the night sometimes. She stated some nights he did not sleep; he would constantly want to wipe down the doorknobs and walls and sometimes he would go into other patient rooms. She stated he would only go into female patient rooms. She stated it was hard to redirect him. She denied she had seen him touch any of the women she would redirect him to leave the room sometimes he would comply and sometimes she would have to tell him several times. Last week Resident #1 came into a room while she was providing care, he walked up on her and she had to keep repeating for him to leave. She stated she stepped back from him and told him she was going to call the police, and he left the room. She stated Resident #1 had not exhibited any sexual behaviors during her shift. In a telephone interview on 11/21 /25 at 10:35 AM with the NP, he stated he had not been told that there was a potential sexual abuse between Resident #1 and Resident #2. He stated he had first heard there was a significant event regarding Resident #1 when he was notified that the State was in the building. He stated the staff had informed him that Resident #1 had been going in and out of other residents rooms. He stated that Resident #1 had been very restless and was constantly going into rooms wiping down things. He stated the staff informed him that Resident #1 was not responding to direction, and he was trying to help a male resident back to bed. He denied he was ever informed of Resident #1 attempting to assist a female resident. He stated Resident #1 assisting residents placed the residents at risk of trips or falls. Record review of facility Abuse: Prevention of and Prohibition Against revised date 10/2022 reflected, To assist the Facility's staff members in recognizing incidents of possible abuse, neglect, misappropriation of resident property, or exploitation, the following definitions are provided: 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. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Sexual abuse is non-consensual sexual contact of any type with a resident. Sexual abuse is non-consensual sexual contact of any type with a resident. If an allegation of abuse, neglect, misappropriation of resident property, or exploitation is reported, discovered or suspected, the Facility will take the following steps to protect all residents from physical and psychosocial harm during and after the investigation: Respond immediately to protect the alleged victim and integrity of the investigation; An IJ was identified on 11/14/25 and the IJ template was provided to the facility on [DATE] at 7:12 PM. The following Plan of Removal was submitted by the facility and was accepted on 11/15/2025 at 12:00 PM and indicated the following: The IJ Template was given on 11/14/23 at [7:12 PM]. The facility failed to protect Resident #2 from being sexually abused by Resident #1.The facility failed to provide supervision to prevent abuse.1. The Medical Director was notified of IJs on 11/14/25 at [7:15 PM].2. The facility's policies on abuse and neglect prevention and reporting were reviewed by the Clinical Resource, Cluster Partners, and Administrator. There were no concerns and facility will continue with current policy. 3. The (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455727 If continuation sheet Page 7 of 17 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 11/15/2025 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 - Immediate jeopardy to resident health or safety Residents Affected - Few facility place resident #1 on 1:1 supervision. 4. Education/in-servicing was initiated on 11/14/25 with all staff on abuse and neglect to prevent abuse to residents in the facility. Education/in-servicing to be completed by the DON/ADON/Clinical Resource/Cluster DONs. Education/in-servicing on abuse and neglect included identification, prevention, reporting and what could happen should the staff member fail to follow facility policy including potential injury to a resident. Staff were instructed on examples of resident abuse/neglect and to report any and all allegations of abuse and neglect to the Abuse Coordinator. Knowledge check forms are completed with all staff on abuse and neglect training that was received. Education was given in person or via phone in written form and verbally to accommodate different learning styles of the staff for abuse/neglect. This education/in-servicing was given using developed policy and procedures based on best practice. With this education/in-servicing, staff will have definitions of the purposes and procedures and will decrease the likelihood of resident abuse or neglect occurrences. 5. All staff to receive education prior to working their next shift. All regular staff will receive the education by 11/14/2025 or prior to their next shift at the facility. PRN staff received the mandatory training notice and will receive education prior to their next shift.6. All nurses in-serviced/educated on resident's change in condition, examples of change in condition and proper documentation along with notification to Responsible Party and Medical Provider in resident's chart. This education was initiated on 11/14/25 and will be completed with all nurses prior to the start of their next shift.7. This education/in-servicing and the knowledge check forms will be completed with all staff prior to the start of their next shift. A member of management will be at the facility at each change of shift to ensure all staff complete training prior to going to work on the floor. Staff will not be allowed to work unless they have completed the training. This training will also be included in the new hire orientation and will be included for any PRN staff prior to starting work on the floor. 8. An ad hoc QA meeting regarding items in the IJ template was completed on 11/14/25. Attendees will include the Medical Director, Clinical Resource, DON, ADON, Administrator, and will include the plan of removal items and interventions.9. The DON, ADON, Cluster DONs or Clinical Resource will complete knowledge checks with 10 staff weekly on abuse and neglect. These forms will be completed with staff randomly, sampling from each shift, weekend and weekday staff, and PRN staff. The facility does not use agency / registry staff. Any concerns with staff competency will be addressed immediately through re-education and/or staff counseling. 10. The Administrator and DON will investigate and report any and all allegations of neglect or abuse through staff reporting, observations, and incident/accident reporting. Any concerns with staff knowledge or conduct will be addressed including reeducation and/or counseling. 11. Summary of IJ, corrective actions and allegations of abuse/neglect to be reviewed by QAPI Committee weekly x 4 weeks or until substantial compliance established and continue monthly for 90 days to ensure ongoing compliance. [Acting Administrator] LNFAMonitoring of the Plan of Removal from 11/15/25 included the following: 1. The facility provided a binder with the following documentation to be reviewed, reviewed facility notification to MD at [7:15 PM], record review of in-service training and education dated 11/14/25 and 11/15/25 completed by the Cluster nurses (nurses from sister facilities and regional staff. Record review of LVN, RN, ADON change in condition in-service dated 11/14/25 and 11/15/25 for all three shifts. Record review of ad hoc meeting notes dated 11/14/25 Attendees included the Medical Director by phone, Clinical Resource, DON, ADON, Administrator. Record revied of undated knowledge checks used to assess the knowledge of nursing staff. Record review of in-service dated 11/14/25 for Administrator and DON investigate and report any allegations of neglect or abuse through staff reporting, observations, and incident/accident reporting. Any concerns with staff knowledge or conduct will be (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455727 If continuation sheet Page 8 of 17 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 11/15/2025 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 - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete addressed including reeducation and/or counseling. 11/15/2025 at 12:32pm Resident #1 observation-He was in his room laying in his bed watching a women's soccer game on TV. He spoke to the surveyor and smiled. He stated that he was doing fine. Surveyor spoke to CNA-D who stated this hall is for men only. She stated that Resident #1 had been out of his room to smoke a cigarette, watch TV and had spoken to some of the men. She stated that Resident #1 had been in a good mood and there had not been any incidents since he had been on one-to-one supervision.11/15/2025 at 12:39pm Resident #2 observation she was sitting in the dining room at a table. She did not respond to surveyor when surveyor spoke to her. Resident #2 was dressed appropriately and did not make any eye contact with surveyor. Surveyor spoke to CNA-E, and she stated Resident #2 had been doing well. CNA-E stated Resident #2 does not appear to be sad. CNA-E stated Resident #2 had been eating. CNA-E stated Resident #2 normally did not talk. Interviews with CNA-A, LVN-B, LVN-C, CNA-D, CNA-E, CNA-F, LVN-G, CNA-H, CNA-I, CNA-J, LVN-K, LVN-L, CNA-M, LVN-N, CNA-O, CNA-P, Staffing Coordinator, and ADON on 11/15/25 from 12:48 PM - 2:55 PM and interviews with LVN-Q, LVN-R, CNA-S, and LVN-T on 11/15/25 from 5:30 PM - 6:25 PM revealed, they had been in-serviced/educated on who the abuse coordinator was at the facility, how and who to report abuse to if they witnessed or suspected abuse. All staff stated they received re-education of inappropriate touching between residents and who it should be reported to and the time frame should be immediate. They stated residents who exhibit aggressive or inappropriate behaviors should be placed on 1:1 supervision immediately, notify the nurse management and administrator immediately. Interviews with LVN's revealed they knew they should call the police, send the resident to the ER for examination for inappropriate touching and abuse. LVN's interviewed also stated they had been re-educated on how to determine a change in condition and that the medical provider and family should be notified. They stated a change in condition would be weight, cognition, infection or new medications and that abuse/neglect would be considered a change in condition. The Administrator was informed that the Immediate Jeopardy was removed on 11/15/2025 at 3:35 PM. The facility remained out of compliance at a scope of isolated with the severity level at a potential for more than minimal harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems that were put in place. Event ID: Facility ID: 455727 If continuation sheet Page 9 of 17 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 11/15/2025 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 24 hours after the allegation was made, if the events that caused the allegation involve abuse to the administrator of the facility and to other officials including to the State Survey Agency in accordance with State law through established procedures for 2 of 8 residents (Resident #1 and Resident #2) reviewed for abuse and neglect.The facility did not make a report to local law enforcement or State Survey Agency (HHS) of an allegation on 11/05/25 when Resident #1 was found in the dining room massaging the breast of Resident #2 after he had taken off her adult brief. This failure could place residents at risk harm to include sexual abuse and could lead to diminished quality of life and psychosocial harm.Record review of Resident #2's face sheet dated 11/15/25 reflected she was a [AGE] year-old female admitted into the facility 09/22/25 with a diagnosis of senile degeneration of brain (a general term for a decline in memory, thinking, and other cognitive abilities associated with aging). Record review of Resident #2's care plan dated 9/22/25 reflected ADL self-care performance deficit impaired mobility/cognition. Goal was to maintain current level of function in bed mobility, transfers, eating, dressing, grooming, toilet use and personal hygiene. Interventions were to converse with resident while providing care, explain all procedures before starting, promote dignity by ensuring privacy, staff will provide appropriate level of physical assistance with ADL's, encourage them to participate to the fullest extent possible. Record review of Resident #2's initial assessment MDS dated [DATE] reflected a BIMS score of 01 (Severe Cognitive Impairment).Record review of Resident #1's face sheet dated 11/15/25 reflected he was a [AGE] year-old male admitted into the facility 07/14/25 with a diagnoses of brain compression (a serious condition caused by increased pressure within the skull that pushes the brain against its rigid covering), and Schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly). Record review of Resident #1's care plan dated 9/3/25 reflected a focus of elopement risk and significantly intrudes on the privacy or activities, the goal was to maintain safety and would not leave the facility. Interventions/tasks were to distract resident from wandering by activities, food, conversation, television, document wandering behavior, identify pattern of wandering determine if aimless or escapist, is resident looking for something or did the wondering indicate he needed more exercise. Focus was a potential to demonstrate physical and verbal aggressive behaviors/manic episodes. Goal was to demonstrate effective coping skills and would not harm self or others. Interventions/tasks were to assess and anticipate resident's needs such as food, thirst, toileting needs, comfort and body position, pain. Communication provides physical and verbal cues to alleviate anxiety, give positive feedback, assist verbalization of source of agitation, encourage seeking out of staff members when agitated. When he becomes agitated, guide away from source of distress, engages calmly in conversation, if response is aggressive, staff to walk calmly away and approach later. Record review of Resident #1's quarterly MDS dated [DATE] reflected he had a BIMS score of 09 (Moderately Cognitively Impaired).Record review on 11/13/25 of Resident #2 and Resident #1's progress notes did not reflect documentation of the sexual incident, no documentation of notification to doctor, and no documentation of notification to designated representative. On 11/13/25 the State Surveyor observed the video dated 11/5/25 , on the facility monitor, the video revealed the following:At 08:03 AM, Resident #1 left the dining room with a food tray and walked back into the dining room. At 08:29 AM Resident #1 came out of the dining room again and threw a bag away and went back into (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455727 If continuation sheet Page 10 of 17 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 11/15/2025 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the dining room. At 08:30 AM CNA-A went into the dining room and came out of the room with Resident #2 and took her down the hall. Resident #1 followed CNA-A and Resident #2 out of the dining room and down the hallway, he was holding a green piece of material in his hand. A few minutes later at 08:51 AM Resident #2 was brought back to the hallway across from the nurses station. Resident #2 was sitting in the hall alone on a bench when Resident #1 went to the counter and stood there a few seconds and then walked over to Resident #2 turned around and kissed her on the top of her head.Record review of undated written statement of CNA-A reflected, This morning I witness [Resident #1] coming out of the dining room with a pull-up in his hand. I ask my co-worker where did he get it, he headed back to the dining room and shut the door that's when I went to check to see why he shut the door, as I enter the room both residents were standing by the table [Resident #1] in front of her massaging her chest with his hands holding (She had the top shirt on) her tank top. I told him to stop I patted the pt. realized her brief was off, grabbed her and started walking her out to notify my nurse and pt telling me he has her and I replied: I got her. [sic]Record review of the facility undated investigation reflected, We, [Administrator and DON, interviewed CNA-A 11/5/25 after reading her statement to get clarity on the incident between [Resident #2] and [Resident #1]. Upon speaking with her, her story was inconsistent with what was initially written as she stated she initially assumed that [Resident #1] was touching [Resident #2], by the way he was standing next to her, but was unsure if she could see that [Resident #1] was touching [Resident #2] or not as she did not observe it herself. She state that she saw [Resident #1] come out of the dining room with a brief in hand, she followed him back into the dining room and saw [Resident #1] standing next to [Resident #2], then walked [Resident #2] out of the dining room and back to her room, and notified the nurse of [Resident #1] carrying dirty brief to trash. [sic]In a face-to-face interview with CNA-A on 11/14/25 at 6:29 AM, she stated on 11/05/25 she observed Resident #1 walking down the hallway with an adult brief and put it in the trash, she observed him return to the dining room and he closed the door. She stated that she followed Resident #1 into the dining room and observed him massaging the breast of Resident #2 on top of her blouse, she observed Resident #2's bra around her waist, she stated she patted below the waist of Resident #2 and noticed she did not have on a brief. She stated that Resident #1 and Resident #2 were the only people in the dining room. She stated that she asked Resident #1 why he had Resident #2's shirt and he stated he was taking care of her. CNA-A said that she told Resident #1 she was taking care of Resident #2. She stated after she ensured Resident #2 was dressed properly, she notified LVN-B. She stated she was asked by the Administrator to write a statement about what she saw when she entered the room. In a face-to-face interview with LVN-B on 11/14/25 at 6:42 AM she stated that on 11/05/25 she had been passing medications when CNA-A came and reported that Resident #1 was assisting Resident #2 and Resident #1 had Resident #2's undershirt and brief in his hands. She stated that she notified the Administrator immediately and completed a skin assessment on Resident #2 and did not see any injuries. She stated the resident did not exhibit any distress at the time of examination. In a face-to-face interview with the Administrator on 11/14/25 at 10:10 AM, he stated that he was notified by LVN-B that CNA-A had walked into the dining room and found Resident #1 and Resident #2 in the dining room alone. He stated he conducted a soft investigation, he stated there was no difference between a soft investigation and a regular investigation. He stated that he would do the same thing for both investigations, skin assessments, safe surveys, and in-services. He stated that the investigation depended on the situation. He stated in this soft investigation he did not identify anything that was reportable. The Administrator was asked, Was Resident #1 asked to help staff with ADL care? The Administrator denied that Resident #1 was asked to help with other residents' ADL (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455727 If continuation sheet Page 11 of 17 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 11/15/2025 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete care. The Administrator was asked, If nothing happed between Resident #1 and Resident #2, how did Resident #2 end up without a brief, Resident #1 with a dirty brief to put in the trash, and they were the only two people in the room? He stated he could not assume that anything had happened between the residents because there were no witnesses. The Administrator stated the residents were at risk of the facility not creating an environment for resident safety. Record review of facility Abuse and Neglect Policy revised 10.2022 reflected, Facility staff with knowledge of an actual or potential violation of this policy must report the violation to his or her supervisor or the Facility administrator immediately. The Facility will assist staff in identifying abuse, neglect, and exploitation of residents, and misappropriation of resident property. 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. Allegations of abuse, neglect, misappropriation of resident property, or exploitation will be reported outside the Facility and to the appropriate State or Federal agencies in the applicable timeframes, as per this policy and applicable regulations.Record review of Long-Term Care Regulation Provider Letter dated 08/29/24 reflected, 2.1 Incidents that a NF Must Report to HHSC A NF must report to CII the following types of incidents, in accordance with applicable state and federal requirements: Abuse1 Event ID: Facility ID: 455727 If continuation sheet Page 12 of 17 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 11/15/2025 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 0610 Respond appropriately to all alleged violations. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to have evidence that all allegations of abuse, neglect, exploitation, or mistreatment, were thoroughly investigated for 2 of 18 residents (Resident #1, Resident #2) reviewed for abuse and neglect.The facility failed to thoroughly investigate inappropriate sexual behavior between Resident #1 and Resident #2. Resident #1 was observed in the dining room by CNA-A massaging the breast of Resident #2.An Immediate Jeopardy (IJ) was identified on 11/14/25. The IJ template was provided to the facility on [DATE] at 7:12 PM. While the IJ was removed on 11/15/25, the facility remained out of compliance at a scope of isolated with the severity level at a potential for more than minimal harm that is not immediate jeopardy, because all staff had not been trained. This failure could place residents at risk for abuse/neglect and could lead to a diminished quality of life and psychosocial harm. Findings included: Record review of Resident #2's face sheet dated 11/15/25 reflected she was a [AGE] year-old female admitted into the facility 09/22/25 with a diagnosis of senile degeneration of brain (a general term for a decline in memory, thinking, and other cognitive abilities associated with aging). Record review of Resident #2's care plan dated 9/22/25 reflected ADL self-care performance deficit impaired mobility/cognition. Goal was to maintain current level of function in bed mobility, transfers, eating, dressing, grooming, toilet use and personal hygiene. Interventions were to converse with resident while providing care, explain all procedures before starting, promote dignity by ensuring privacy, staff will provide appropriate level of physical assistance with ADL's, encourage them to participate to the fullest extent possible. Record review of Resident #2's initial assessment MDS dated [DATE] reflected a BIMS score of 01 (Severe Cognitively Impairment).Record review of Resident #1's face sheet dated 11/15/25 reflected he was a [AGE] year-old male admitted into the facility 07/14/25 with a diagnoses of brain compression (a serious condition caused by increased pressure within the skull that pushes the brain against its rigid covering), and Schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly). Record review of Resident #1's care plan dated 9/3/25 reflected a focus of elopement risk and significantly intrudes on the privacy or activities, the goal was to maintain safety and would not leave the facility. Interventions/tasks were to distract resident from wandering by activities, food, conversation, television, document wandering behavior, identify pattern of wandering determine if aimless or escapist, is resident looking for something or did the wondering indicate he needed more exercise. Focus was a potential to demonstrate physical and verbal aggressive behaviors/manic episodes. Goal was to demonstrate effective coping skills and would not harm self or others. Interventions/tasks were to assess and anticipate resident's needs such as food, thirst, toileting needs, comfort and body position, pain. Communication provides physical and verbal cues to alleviate anxiety, give positive feedback, assist verbalization of source of agitation, encourage seeking out of staff members when agitated. When he becomes agitated, guide away from source of distress, engages calmly in conversation, if response is aggressive, staff to walk calmly away and approach later. Record review of Resident #1's quarterly MDS dated [DATE] reflected he had a BIMS score of 09 (Moderately Cognitively Impaired).On 11/13/25 the State Surveyor observed the video dated 11/05/25, on the facility monitor, the video revealed the following:At 08:03 AM, Resident #1 left the dining room with a food tray and walked back into the dining room. At 08:29 AM Resident #1 came out of the dining room again and threw a bag away and went back into the dining room. At 08:30 AM CNA-A went into the dining room and came out of the room with Resident #2 and took her down the hall. Resident #1 followed CNA-A and Resident #2 out of the dining room and down the hallway, he was holding a green piece of material in his hand. A few minutes later at 08:51 AM Resident #2 was Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455727 If continuation sheet Page 13 of 17 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 11/15/2025 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 0610 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few brought back to the hallway across from the nurses station. Resident #2 was sitting in the hall alone on a bench when Resident #1 went to the counter and stood there a few seconds and then walked over to Resident #2 turned around and kissed her on the top of her head.Record review of undated written statement of CNA-A reflected, This morning I witness [Resident #1] coming out of the dining room with a pull-up in his hand. I ask my co-worker where did he get it, he headed back to the dining room and shut the door that's when I went to check to see why he shut the door, as I enter the room both residents were standing by the table [Resident #1] in front of her massaging her chest with his hands holding (She had the top shirt on) her tank top. I told him to stop I patted the pt. realized her brief was off, grabbed her and started walking her out to notify my nurse and pt telling me he has her and I replied: I got her. [sic]Record review of the facility undated investigation reflected, We, [Administrator and DON, interviewed CNA-A 11/5/25 after reading her statement to get clarity on the incident between [Resident #2] and [Resident #1]. Upon speaking with her, her story was inconsistent with what was initially written as she stated she initially assumed that [Resident #1] was touching [Resident #2], by the way he was standing next to her, but was unsure if she could see that [Resident #1] was touching [Resident #2] or not as she did not observe it herself. She state that she saw [Resident #1] come out of the dining room with a brief in hand, she followed him back into the dining room and saw [Resident #1] standing next to [Resident #2], then walked out of the dining room and back to her room and notified the nurse of [Resident #1] carrying dirty brief to trash. [sic]In a face-to-face interview with the DON on 11/13/25 at 1:37 PM, she stated that she became aware of the alleged abuse when it was reported by LVN-B. She stated that LVN-B had conducted the assessment on Resident #2. She stated that she and the Administrator had interviewed CAN-A and CAN-A did not verbally provide the same information she had written in her statement. She stated CAN-A was asked about the discrepancy, but she did not remember the response. She stated based on the discrepancy she and the Administrator determined that nothing had happened between Resident #1 and Resident #2. She stated that Resident #1 had been sent to hospital for psych evaluation, but they sent him back with no new instructions. She stated that staff had documented it on 11/4/25 and during the early shift on 11/5/25 that Resident #1 had been going into other residents rooms. In a face-to-face interview with LVN-B on 11/14/25 at 6:42 AM she stated that on 11/05/25 she had been passing medications when CAN-A came and reported that Resident #1 was assisting Resident #2 and Resident #1 had Resident #2's undershirt and brief in his hands. She stated that she notified the Administrator immediately and completed a skin assessment on Resident #2 and did not see any injuries. She stated the resident did not exhibit any distress at the time of examination. In a face-to-face interview with the Administrator on 11/14/25 at 10:10 AM, he stated he stated that he was notified by LVN-B that CNA-A had walked into the dining room and found Resident #1 and Resident #2 in the dining room alone. He stated he conducted a soft investigation, he stated there was no difference between a soft investigation and a regular investigation. He stated that he would do the same thing for both investigations skin assessments, safe surveys, and in-services. He stated that the investigation depended on the situation. He stated in this soft investigation he did not identify anything that was reportable. The Administrator was asked, Was Resident #1 asked to help staff with ADL care? The Administrator denied that Resident #1 was asked to help with other residents ADL care. The Administrator was asked, If nothing happed between Resident #1 and Resident #2, how did Resident #2 end up without a brief, Resident #1 with a dirty brief to put in the trash, and they were the only two people in the room? He stated he could not assume that anything had happened between the residents because there were no witnesses. The Administrator stated the residents were at risk of the facility not creating an environment for resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455727 If continuation sheet Page 14 of 17 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 11/15/2025 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 0610 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few safety. In a telephone interview on 11/21/25 at 10:35 AM with the NP, he stated he had not been told that there was a potential sexual abuse between Resident #1 and Resident #2. He stated he had first heard there was a significant event regarding Resident #1 when he was notified that the State was in the building. He stated the staff had informed him that Resident #1 had been going in and out of other residents rooms. He stated that Resident #1 had been very restless and was constantly going into rooms wiping down things. He stated the staff informed him that Resident #1 was not responding to direction, and he was trying to help a male resident back to bed. He denied he was ever informed of Resident #1 attempting to assist a female resident. He stated Resident #1 assisting residents placed the residents at risk of trips or falls. A. Record review of facility Abuse and Neglect Policy revised 10.2022 reflected, Investigation 1. All identified events are reported to the Administrator immediately.2. After receiving the allegation, and during and after the investigation, the Administrator will ensure that all residents are protected from physical and psychosocial harm (See, Protection, below).3. A licensed nurse will immediately examine the resident upon receiving reports of alleged physical or sexual abuse. The findings of the examination shall be recorded in the resident's medical record. 4. All allegations of abuse, neglect, misappropriation of resident property, and exploitation will be promptly and thoroughly investigated by the Administrator or his/her designee. Upon receiving a report or allegation of a potential violation of this policy involving the taking, keeping, using, or distributing photos or video recordings, the Administrator or his or her designee will analyze the allegations and determine whether the conduct at issue implicates resident privacy or security as protected by the Health Insurance Portability and Accountability Act ( HIPAA). Any such actual or potential violation will be managed as per the Facility's HIPAA policies and procedures.5. The investigation will include the following: An interview with the person(s) reporting the incident; An interview with the resident(s); Interviews with any witnesses to the incident, including the alleged perpetrator, as appropriate; A review of the resident's medical record; An interview with staff members (on all shifts) who may have information regarding the alleged incident; Interviews with other residents to whom the accused employee provides care or services or who may have information regarding the alleged incident; An interview with staff members (on all shifts) having contact with the accused employee; and A review of all circumstances surrounding the incident. 6. To the extent there is evidence that could be used in a criminal investigation, staff will immediately notify the Administrator or his/her designee. Staff are not to tamper with or destroy any such evidence at any time. 7. At the conclusion of the investigation, the Facility will attempt to determine if abuse, neglect, misappropriation of resident property, or exploitation has occurred.8. The investigation, and the results of the investigation, will be documented. 9. All phases of the investigation will be kept confidential in accordance with the Facility's policies governing the confidentiality of medical records and privilege of quality assurance/ quality improvement programs. B. Protection 1. If an allegation of abuse, neglect, misappropriation of resident property, or exploitation is reported, discovered or suspected, the Facility will take the following steps to protect all residents from physical and psychosocial harm during and after the investigation: Respond immediately to protect the alleged victim and integrity of the investigation; Examine the alleged victim for any sign of injury, including a physical examination or psychosocial assessment if needed; Increase supervision of the alleged victim and residents; Make room or staffing changes, if necessary, to protect the resident(s) from the alleged perpetrator; Protect the involved persons from retaliation; and Provide emotional support and counseling to the resident during and after the investigation, as needed. 2. If the allegation of abuse, neglect, misappropriation of resident property, or exploitation involves another (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455727 If continuation sheet Page 15 of 17 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 11/15/2025 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 0610 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few 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.An IJ was identified on 11/14/25 and the IJ template was provided to the facility on [DATE] at 7:12 PM. The following Plan of Removal was submitted by the facility and was accepted on 11/15/2025 at 12:00 PM and indicated the following: The IJ Template was given on 11/14/23 at [7:05 PM]. The facility failed to protect Resident #2 from being sexually abused by Resident #1. The facility failed to provide supervision to prevent abuse.1. The facility place resident #1on 1:1 supervision. 2. The Medical Director was notified of IJs on 11/14/25 at [7:15 PM].3. Administrator suspended on 11/14/25 pending the outcome of the investigation. 4. The facility's policies on abuse and neglect prevention and reporting were reviewed by the Clinical Resource, Cluster Partners, and Cluster Administrator. There were no concerns and facility will continue with current policy. 5. Education/in-servicing was initiated on 11/14/25 with all staff on abuse and neglect to prevent abuse to residents in the facility. Education/in-servicing to be completed by the DON/ADON/Clinical Resource/Cluster DONs. Education/in-servicing on abuse and neglect included identification, prevention, reporting and what could happen should the staff member fail to follow facility policy including potential injury to a resident. Staff were instructed on examples of resident abuse/neglect and to report all allegations of abuse and neglect to the Abuse Coordinator. Knowledge check forms are completed with all staff on abuse and neglect training that was received. Education was given in person or via phone in written form and verbally to accommodate different learning styles of the staff for abuse/neglect. This education/in-servicing was given using developed policy and procedures based on best practice. With this education/in-servicing, staff will have definitions of the purposes and procedures and will decrease the likelihood of resident abuse or neglect occurrences. 6. All staff to receive education prior to working their next shift. PRN staff received the mandatory training notice and will receive education prior to their next shift.7. This education/in-servicing and the knowledge check forms will be completed with all staff prior to the start of their next shift. A member of management will be at the facility at each change of shift to ensure all staff complete training prior to going to work on the floor. Staff will not be allowed to work unless they have completed the training. This training will also be included in the new hire orientation and will be included for any PRN staff prior to starting work on the floor. 8. An ad hoc QA meeting regarding items in the IJ template was completed on 11/14/25. Attendees will include the Medical Director, Clinical Resource, DON, ADON, Cluster Administrator, and will include the plan of removal items and interventions.9. The DON, ADON, Cluster DONs or Clinical Resource will complete knowledge checks with 10 staff weekly on abuse and neglect. These forms will be completed with staff randomly, sampling from each shift, weekend and weekday staff, and PRN staff. Any concerns with staff competency will be addressed immediately through re-education and/or staff counseling. 10. The Administrator and DON will investigate and report all allegations of neglect or abuse through staff reporting, observations, and incident/accident reporting. Any concerns with staff knowledge or conduct will be addressed including reeducation and/or counseling. 11. Summary of IJ, corrective actions and allegations of abuse/neglect to be reviewed by QAPI Committee weekly x 4 weeks or until substantial compliance established and continue monthly for 90 days to ensure ongoing compliance. [Acting Administrator] LNFA Monitoring of the Plan of Removal from 11/15/25 included the following:The facility provided a binder with the following documentation to be reviewed, reviewed facility notification to MD at [7:15 PM], observed facility Administrator was no longer in the facility, an acting (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455727 If continuation sheet Page 16 of 17 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 11/15/2025 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 0610 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Administrator continued to meet with surveyor, record review of in-service training and education dated 11/14/25 and 11/15/25 completed by the Cluster nurses (nurses from sister facilities and regional staff. Record review of LVN, RN, ADON change in condition in-service dated 11/14/25 and 11/15/25 for all three shifts. Record review of ad hoc meeting notes dated 11/14/25 Attendees included the Medical Director by phone, Clinical Resource, DON, ADON, Administrator. Record revied of undated knowledge checks used to assess the knowledge of nursing staff. Record review of in-service dated 11/14/25 for Administrator and DON to investigate and report any allegations of neglect or abuse through staff reporting, observations, and incident/accident reporting. Any concerns with staff knowledge or conduct will be addressed including reeducation and/or counseling. 11/15/2025 at 12:32pm Resident #1 observation-He was in his room laying in his bed watching a women's soccer game on TV. He spoke to the surveyor and smiled. He stated that he was doing fine. Surveyor spoke to CNA-D who stated this hall is for men only. She stated that Resident #1 had been out of his room to smoke a cigarette, watch TV and had spoken to some of the men. She stated that Resident #1 had been in a good mood and there had not been any incidents since he had been on one-to-one supervision.Interviews with CNA-A, LVN-B, LVN-C, CNA-D, CNA-E, CNA-F, LVN-G, CNA-H, CNA-I, CNA-J, LVN-K, LVN-L, CNA-M, LVN-N, CNA-O, CNA-P, Staffing Coordinator, and ADON on 11/15/25 from 12:48 PM - 2:55 PM and interviews with LVN-Q, LVN-R, CNA-S, and LVN-T on 11/15/25 from 5:30 PM - 6:25 PM revealed, they had been in-serviced/educated on who the abuse coordinator was at the facility, how and who to report abuse to if they witnessed or suspected abuse. All staff stated they received re-education of inappropriate touching between residents and who it should be reported to and the time frame should be immediate. They stated residents who exhibit aggressive or inappropriate behaviors should be placed on 1:1 supervision immediately, notify the nurse management and administrator immediately. Interviews with LVN's revealed they knew they should call the police, send the resident to the ER for examination for inappropriate touching and abuse. LVN's interviewed also stated they had been re-educated on how to determine a change in condition and that the medical provider and family should be notified. They stated a change in condition would be weight, cognition, infection or new medications and that abuse/neglect would be considered a change in condition. The Administrator was informed that the Immediate Jeopardy was removed on 11/15/2025 at 3:35 PM. The facility remained out of compliance at a scope of isolated with the severity level at a potential for more than minimal harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems that were put in place. Event ID: Facility ID: 455727 If continuation sheet Page 17 of 17