Inspection·December 4, 2024

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to provide a safe, clean, comfortable, and homelike environment including but not limited to receiving treatment and supports for daily living safely for 2 (Rooms 303b, 307 b) of 6 resident rooms and all hallway handrails in the facility reviewed for cleanliness and sanitization. The facility failed to ensure that Resident Rooms # 303b, and 307 b were thoroughly cleaned and sanitized. The facility failed to ensure that the facility hallway handrails were cleaned. These deficient practices could place residents at risk of living in an unclean and unsanitary environment which could lead to a decreased quality of life. Findings included: An observation on 12/04/24 at 10:40 AM of all the facility hallway handrails revealed dark and light dirt along the brown wooden rails. An observation on 12/04/24 at 12:00 PM of room [ROOM NUMBER] b reflected the top of the 5-drawer chest had a large circular white patch of powdery substance. Interview on 12/04/24 at 12:06 PM, the resident in room [ROOM NUMBER]b (BIMS 12) stated that the facility only cleaned her room once a week. She stated housekeeping was supposed to clean her room on 12/03/24 but they had not cleaned her room. She stated they never cleaned the floors, and they did not empty her trash can. An observation on 12/04/24 at 12:07 PM of room [ROOM NUMBER] b reflected the floor around the toilet, had a white substance circling it. No interview was able to be conducted with the resident in room [ROOM NUMBER]b due to decreased cognitive status., no BIMS was able to be assessed for this resident. In an interview on 12/04/24 at 2:16 PM, the Housekeeping Supervisor stated she had been at the facility for 19 years. She stated they were to clean everything, especially the resident rooms daily. She stated they wiped the handrails down daily. She was shown pictures of the concerns observed in Rooms #303b , and 307b , as well as the hallway rails. She stated the risk the resident was that they (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 4 Event ID: 675560 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 675560 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Village Nursing and Rehabilitation Center 169 Lake Park Rd Lewisville, TX 75057 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)