Inspection·September 18, 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 observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for hall 300, 400 and room [ROOM NUMBER]. The facility failed to ensure the carpet in the hallway between room [ROOM NUMBER] and 304, was in good repair. The facility failed to ensure the carpet in the doorway to room [ROOM NUMBER] was in good repair. The facility failed to ensure the flooring in the doorway into room [ROOM NUMBER] was in good repair. The facility failed to ensure the flooring on 400 hallway was kept in good repair. These failures could place residents at risk for diminished quality of life due to the lack of a well-kept environment and equipment. Findings included: An observation on 09/16/24 at 10:30 a.m., revealed snags in the carpet near room [ROOM NUMBER], a snag in the carpet in the entry way to room [ROOM NUMBER]. An observation on 09/16/24 at 10:33 a.m., revealed worn and stained carpet in the 300 halls. The stained carpet was visible in the remaining carpeted rooms on the 300 halls. An observation on 09/16/2024 at 10:45 am, on the 400-hall revealed deep staining in several areas throughout the entire hallway. An observation on 09/17/24 at 10:00 a.m., revealed the flooring on room [ROOM NUMBER] did not reach the threshold molding and was slightly curled at the end. Interview on 09/17/24 at 9:40 a.m., with a housekeeping aide revealed that they clean the floors as best they can, they sweep and vacuum every day. She stated that they are unable to get all of the stains from the carpet. They can get some stains up, but they are unable to get the deep stains out. She stated recently started working here but they stains were here when she came to work here. Interview on 09/18/24 at 10:23 a.m., with the Maintenance Supervisor revealed he was aware of the (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 5 Event ID: 675581 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 675581 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Village at Heritage Oaks 3002 W 2nd Ave Corsicana, TX 75110 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)