Health inspection·March 14, 2025

F 0657 Level of Harm - Minimal harm or potential for actual harm resident roommate, this resident crawled out of bed and no injury or complaints of pain voiced. Intervention: place a scoop mattress on resident bed. MD notified of this incident. Record review of the facility's incident log, dated 03/13/2025, reflected [Resident #1] had a fall on 3/08/2025. Residents Affected - Few Record review of Resident #1's EMR revealed RN A failed to complete a Fall Assessment on 03/08/2025. Record review of Resident #1's EMR revealed the ADON completed a Fall Evaluation (with an effective date of 03/08/2025) five days later on 03/13/2025. Attempted to interview Resident #1 on 03/13/2025 at 1:45pm but was not successful due to her being hospitalized and diagnosed with acute metabolic encephalopathy (a change in how your brain works due to an underlying condition. It can cause confusion, memory loss and loss of consciousness) and a suspected UTI (an infection in any part of the urinary system). Attempted to interview Resident #1's FM on 03/14/2025 at 11:05 am. Unable to leave a message as the voicemail was full. During an interview with RN B on 03/14/2025 at 10:35 am, she stated you are required to document no matter if the resident was observed on the mat, or if a fall was witnessed. RN B stated the staff member that assessed the resident was the one that needed to enter documentation into the EMR and complete any assessments and reports. During an interview with the ADON on 03/14/2025 at 11:40 am, he stated Resident #1's care plan should had been updated to reflect her most recent fall. The ADON stated the incident occurred on Saturday (3/8/2025) but he did not learn of it until Monday (3/10/2025). The ADON stated himself and the DON reached out to RN A on Tuesday (3/11/2025). The ADON stated he entered a Progress Note and created an Incident Report on Wednesday (3/13/2025) because RN A had not completed these tasks. The ADON stated if a resident's care plan was not updated then the resident may have not received the most efficient care. During an interview with the ADM on 03/14/2025 at 12:10 pm, he stated staff must make notifications and enter documentation. The ADM stated the assessment and documentation should had been completed timely. The ADM stated a resident's care plan should be updated after each fall. The ADM stated if a resident's care was not updated after a fall the resident would potentially not be receiving the highest level of care. A record review of the facility's Care Planning policy, with a reviewed date of July 2020, reflected Procedures: . 9. The resident's plan of care - focus, goals, and interventions - are communicated and implemented by the members of the health care continuum accordingly. 10. The resident's plan of care is reviewed and revised on an ongoing basis, quarterly at a minimum and/or as needed with changes in condition. A record review of the facility's Fall Management System policy, with a revision/reviewed date of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675611 If continuation sheet Page 2 of 6 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 675611 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/14/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Villages of Dallas 550 E Ann Arbor Ave Dallas, TX 75216 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few January 2022, reflected Policy: It is the policy of this facility to provide an environment that remains as free of accident hazards as possible. It is also the policy of this facility to provide each resident with appropriate assessment and interventions to prevent falls and to minimize complications if a fall occurs. 3. When a resident sustains a fall, a physical assessment will be completed by a licensed nurse, with results documented in the medical record. 6. Resident's care plan will be updated. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675611 If continuation sheet Page 3 of 6 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 675611 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/14/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Villages of Dallas 550 E Ann Arbor Ave Dallas, TX 75216 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure residents' environment remained as free of accident hazards as is possible; and residents received adequate supervision and assistance devices to prevent accidents, for one 1 of 5 residents (Resident #1) reviewed for accident hazards. The facility failed to ensure Resident #1's fall mat was on the floor, next to her bed on 03/08/2025. This was evident by the photo taken on 03/08/2025 and submitted by FM B which showed Resident #1 laying on the bare floor away from her bed with her fall mat observed underneath her bed. This failure could place the resident at risk of injuries from falls and a decreased quality of care. Findings included: Record review of a facility undated face sheet for Resident #1, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1's diagnoses included: vascular dementia (a condition caused by problems with blood flow to the brain, damaging blood vessels, leading to memory, thinking, and behavioral difficulties), other lack of coordination (jerky, unsteady movements and difficulty with balance and coordination), and muscle weakness (decreased ability of muscles to contract and generate force). Record review of Resident #1's Quarterly MDS assessment dated [DATE], reflected the resident had a BIMS score of 10, which indicated moderate cognitive impairment. Resident #1's Quarterly MDS reflected she was dependent in the following areas: eating, oral hygiene, toileting hygiene, shower/bathe self, lower body dressing, putting on/taking off footwear, personal hygiene. Resident #1's MDS Section J1800 reflected that Resident #1 has had falls since admission/entry or reentry or the prior assessment with no injuries. Record review of Resident #1's undated Care Plan revealed the following: Focus: At risk for falls r/t decreased mobility, impaired cognition. Goal: Will not sustain serious injury through the review date. Interventions: Anticipate and meet needs. Be sure the call light is within reach and encourage to use it to call for assistance as needed. Keep needed items, water, etc., in reach. Focus: Has had an actual fall no injury r/t: Poor balance & Poor cognition. 01/14/25 Fall, no injury. 02/27/25 Fall, no injury. Goal: Will resume usual activities without further incident through the review date. Interventions: 1/14/25 Bed in lowest position. 2/27/25 Fall mat on floor. Continue interventions on the at-risk plan. Staff will make frequent bed checks. Record review of Resident #1's progress notes did not reveal an entry by RN A related to Resident #1 being found on the floor on 03/08/2025. Record review of Resident #1's Order Summary dated 03/13/2025, reflected [Resident #1] was to have a floor mat on both sides of her bed with the bed set at its lowest setting was ordered on 12/20/2024 and no start or end date noted. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675611 If continuation sheet Page 4 of 6 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 675611 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/14/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Villages of Dallas 550 E Ann Arbor Ave Dallas, TX 75216 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of the facility's incident log, dated 03/13/2025, reflected [Resident #1] had a fall on 3/08/2025. Record review of the facility's incident report, dated 3/13/2025, under Nursing Description reflected, Received report from the CNA of this [Resident #1] resident being on the floor, laying on her fall mat after falling out of bed. Bed in low position with floor mat in place. Record review of the photo provided by FM B showed Resident #1 lying on the hardwood floor with her fall mat underneath her bed. During an interview on 03/13/2025 at 9:01 am, FM B stated she arrived at the facility on Saturday (03/08/2025) at 9:35 am. FM B stated as she walked past Resident #1's room, she saw her lying on the floor. FM B stated Resident #1 was positioned on her right side away from her bed and her fall mat was underneath her bed. FM B stated she walked to the dining room and informed a CNA that Resident #1 was on the floor. FM B stated she then walked back to visit her own family member. During an interview with CNA A on 03/13/2025 at 1:55 pm, she stated RN A requested her help to transfer Resident #1 from the floor. CNA A stated after RN A assessed Resident #1, they placed her in bed and changed her. CNA A stated she could not remember the exact time they picked Resident #1 up off the floor, but it could not have been more than 15 minutes that she had been on the floor. CNA A stated Resident #1 wiggled herself out of the bed. CNA A stated 10 minutes later, Resident #1 had wiggled out of the bed again. CNA A stated the first time, Resident #1 was on the floormat. CNA A stated the second time Resident #1 was halfway off the fall mat. CNA A stated due to not being able to use restraints, they brought Resident #1 to the nurse's station. CNA A stated Resident #1 had a fall mat on both sides of the bed. CNA A stated when Resident #1 was not in bed, they folded the fall mats up and placed them in the corner. CNA A stated when Resident #1 was in the bed, the fall mats were placed on the floor. CNA A stated Resident #1 was unable to walk nor transfer herself. During an interview with the ADON on 03/13/2025 at 2:25 pm, he stated himself and the DON called RN A and asked her if she knew how long Resident #1 had been on the floor and RN A stated, No, but it was not a long time because she had taken the roommate's vital signs around 9:20 am and then went to chart. The ADON stated RN A said she returned to the room around 9:30 am to see if the roommate was dressed for dialysis and that was when she observed Resident #1 laying on her fall mat. The ADON stated the incident was categorized as a fall with no injuries. During an interview with RN A on 03/14/2025 at 11:10 am, she stated she saw Resident #1 on the fall mat and immediately reached out to CNA A for assistance. RN A stated each time she went to check on Resident #1, she was back on the fall mat again. RN A stated she and CNA A assisted Resident #1 back in bed each time. RN A stated she changed Resident #1's diaper herself to make sure that was not why Resident #1 kept having the behavior. Resident #1 stated she continued to check on Resident #1 and administered her medications. RN A stated to the best of her knowledge that was what happened. RN A stated Resident #1 had not sustained any injuries. RN A stated Resident #1 was on the fall mat both times. RN A stated she assessed Resident #1 each time but failed to complete any assessments or enter any documentation into the EMR due to there being no injuries. RN A stated when she saw Resident #1 on the floor again she was confused as to why Resident #1 kept doing it. RN A stated per policy, whenever a resident was found on the floor, they would be assessed. RN A stated the nurse was required to complete all appropriate assessments that needed to be done. RN A stated she did not do any of these things because Resident #1 was on the fall mat with no injuries. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675611 If continuation sheet Page 5 of 6 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 675611 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/14/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Villages of Dallas 550 E Ann Arbor Ave Dallas, TX 75216 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview with the ADON on 03/14/2025 at 11:40 am, he stated due to Resident #1 not being in her bed and observed on her fall mat, the incident would be categorized as an unwitnessed fall. The ADON stated RN A had not charted anything. The ADON stated RN A informed him and the DON that she had not believed it was a fall because Resident #1 was on the fall mat. The ADON stated regardless, if it was a fall or not, the DON informed RN A even if she thought it was a behavior, the least she could had done was documented it as a behavior. The ADON stated the incident occurred on Saturday (3/8/2025) but he did not learn of it until Monday (3/10/2025). The ADON stated he entered a Progress Note and created an Incident Report on Wednesday (3/13/2025) because RN A had not completed these tasks. The ADON stated the Care Plan should be updated to reflect all falls to ensure residents received the most effective care. The ADON stated the Charge Nurse said she completed an assessment including a pain assessment but failed to document anything. During an interview with the ADM on 03/14/2025 at 12:10 pm, he stated Resident #1 had not sustained any injuries and was okay. The ADM stated Resident #1 used a wheelchair and was unable to get up on her own. The ADM stated they preferred fall mats to be off the floor if the resident was not in bed to prevent a tripping hazard. The ADM stated no one was perfect, and they try their best to find the best fit for each resident. The ADM stated staff should assess to ensure it was safe to transfer the resident to bed from the floor pending the nurse's discretion. The ADM stated an assessment and documentation should had been completed timely. The ADM stated he expected all staff to follow the facility's policies. A record review of the facility's Fall Management System policy, with a revision/reviewed date of January 2022, reflected Policy: It is the policy of this facility to provide an environment that remains as free of accident hazards as possible. It is also the policy of this facility to provide each resident with appropriate assessment and interventions to prevent falls and to minimize complications if a fall occurs. 3. When a resident sustains a fall, a physical assessment will be completed by a licensed nurse, with results documented in the medical record. c. A Fall Risk Evaluation will be completed post fall incident. A record review of the facility's Significant Change of Condition, Response policy, with a revision/reviewed date of December 2023, reflected It is the policy of this facility to ensure each resident receives quality of care and services to attain and maintain the highest practicable physical mental and psychosocial well-being in accordance with the interdisciplinary comprehensive assessment and plan of care. Procedure 1. If, at any time, it is recognized by any one of the team members that the condition or care needs of the resident have changed, the Licensed Nurse or Nurse Supervisor should be made aware. Examples would be the following (but not limited to): . -Change in behavior or increased problems that may cause injuries or incidents to self or others . -Fall or other related incident FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675611 If continuation sheet Page 6 of 6