Inspection·September 16, 2025

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete authority completed quarterly assessment. The MDS Coordinator stated she was not working at the facility when the care plan meeting was held on 03/04/2025 and the previous MDS Coordinator was no longer employed at the facility. She stated she was not aware of the request for a positioning wedge. She stated if a request for services required follow up, the MDS Coordinator was responsible for that. During an interview on 09/16/2025 at 3:45 PM, the DON stated each morning staff met and discussed care plans and interventions to put in place. She stated resident #1 had been at the facility for a long time and received ongoing PASRR services. She stated she was unaware a positioning wedge was recommended for Resident #1 on 03/04/2025. She printed Resident #1's PCSP which reflected the recommendation for a repositioning wedge. She stated page 7 of the PCSP did not reflect any changes to his care plan. She stated if new needs were identified, they would be documented there. She stated Resident #1 had his last PCSP meeting on 08/25/2025 and it reflected a repositioning wedge was not needed. During an interview on 09/16/2025 at 3:55 PM, the Administrator stated after an IDT meeting, staff members discussed any items that needed follow up and he followed up with the MDS Coordinator to ensure the PCSP was complete. The Administrator stated he was not told Resident #1 needed a positioning wedge or the facility would have already purchased one. He stated it was important for the facility to provide recommended services to ensure the resident's needs were met.During a telephone interview on 09/19/2025 at 4:30 PM, the Habilitation Coordinator stated the repositioning wedge was recommended during the 03/04/2025 interdisciplinary team meeting, because Resident #1 leaned to one side, and she had approved it. She stated the nursing facility emailed her about the visit from a state surveyor requesting information about Resident #1. She stated the facility requested an interdisciplinary team meeting and she scheduled a meeting on October 1st to evaluate Resident #1's needs. Record review of the facility's policy Resident Assessment: PASRR, reviewed 05/2021, reflected It is the policy of this facility to ensure that each resident is properly screened using the PASRR specified by the state. (A) That, because of the physical and mental condition of the individual, the individual requires the level of services provided by a nursing facility; and (B) If the individual requires such a level of services, whether the individual requires specialized services for the intellectual disability. Event ID: Facility ID: 675560 If continuation sheet Page 2 of 4 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 09/16/2025 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)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (Resident #2) of five residents observed for infection control. The facility failed to ensure that LVN B washed her hands or used hand sanitizer while administering medication to Resident #2 on 09/16/2025. This failure could place the residents at risk of cross-contamination and the development of infections.Findings include:Review of Resident #2's Face Sheet, dated 09/16/2025, reflected the resident was a [AGE] year-old female admitted on [DATE]. Resident #2 had diagnoses which included hypertension (elevated blood pressure) and cellulitis (skin infection) of the right lower limb. Review of Resident #2's Quarterly MDS Assessment, dated 08/30/2025, reflected moderately impaired cognition with a BIMS score of 08. Section I (Active Diagnoses) reflected Resident #2 was treated for cellulitis and Section N (Medications) indicated the resident was administered antibiotics. Review of Resident #2's Comprehensive Care Plan, dated 08/28/2025, reflected Resident #2 had cellulitis of the lower right leg related to trauma. Interventions included Give antibiotics for infection and mild analgesics to relieve discomfort as prescribed by Physician. During an observation and interview on 09/16/2025 at 9:22 AM, LVN B was observed administering medication to Resident #2. The medication cart was parked outside Resident #2's door. LVN B opened the laptop on the medication cart to view the resident's orders and removed the medications to administer. The pills were placed in a medicine cup on top of the medication cart. LVN B put on clean gloves to open a capsule and poured the contents into a medicine cup. She crushed the other pills as ordered and removed her gloves. LVN B was not observed performing hand hygiene before putting on gloves or after removing the gloves. LVN B opened the pudding container on top of the cart and used a clean plastic spoon to remove the pudding and mixed it with the crushed medication. LVN B took the cup of medication to the resident's room and placed it on the bedside table. She used the bed controller to raise the head of the resident's bed and administered the medication. Resident #2 requested medication for pain. LVN B returned to the medication cart and viewed the resident's orders. LVN B was not observed to have performed hand hygiene upon exiting the resident's room. She removed pain medication from the locked box in the medication cart and documented it in the narcotic log. LVN B opened the top of the pudding container and used a clean plastic spoon to add pudding to the medicine cup. LVN B administered pain medication to Resident #2. LVN B washed her hands in the resident's restroom before leaving the room. LVN B stated she should have used hand sanitizer or washed her hands each time she entered and exited the resident's room. She stated she should have used hand sanitizer between the glove change. LVN B stated it was important to prevent cross contamination when caring for the residents. During an interview on 09/16/2025 at 4:50 PM, the DON stated the expectation was for staff to wash their hands or use hand sanitizer when removing gloves or in between touching surfaces that could be dirty. She stated it was important for staff to sanitize when going in and out of a resident's room. She stated it was important to prevent the spread of germs, and the facility had begun in-service training for staff. During an interview on 09/16/2025 at 4:55 PM, the Administrator stated it was important for staff to wash or sanitize their hands before going in or leaving a resident's room. He stated that anytime a staff member removed their gloves, it was important to sanitize. He stated it was important to prevent the spread of infection. Review of the facility's policy Hand Hygiene: Infection Control, revised 10/2022, reflected Hand hygiene is one of the most effective measures to prevent the spread of infection. Studies show that effective hand decontamination can significantly reduce Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675560 If continuation sheet Page 3 of 4 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 09/16/2025 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)

F 0880 Level of Harm - Minimal harm or potential for actual harm the rate of healthcare associate infection. Use and alcohol based hand rub or alternatively soap and water for the following situations . Before and after direct contact with residents; Before preparing or handling medications. After contact with objects in the immediate vicinity of the resident; After removing gloves. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675560 If continuation sheet Page 4 of 4