Health inspection·December 10, 2025

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete on an egress pathway does that mean they can't be locked?Record review of LS email to surveyor reflected on 12/10/25 at 3:30 p.m. It has nothing to do with being locked or unlocked. They cannot store them in the path of egress.Record review of the facility policy Hazardous area, devices and Equipment, dated 07/2017 reflected, A hazard is defined as anything in the environment that has the potential to cause injuryor illness. Examples of environmental hazards include, but are not limited to the following: Openareas or items that should be locked when not in use;. Assessment and analysis of hazards. 2.Any element of the resident environment that has the potential to cause injury and that is accessible to a vulnerable resident is considered hazardous. Event ID: Facility ID: 675783 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 675783 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Villa at Mountain View 2918 Duncanville Rd Dallas, TX 75211 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 establish and 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 infection for 1 (Resident #1) of 5 residents reviewed for infection control. -The facility failed on 12/09/25 to ensure infection control procedures were followed when LVN F repositioned Resident #1, who was on enhanced barrier precautions, without donning appropriate PPE. -The facility failed on 12/10/25 to ensure infection control procedures were followed when CNA A and CNA B handled soiled linen and provided perineal care to Resident #1, who was on enhanced barrier precautions, without donning appropriate PPE. -The facility failed on 12/10/25 to ensure infection control procedures were followed when LVN B provided G-tube care to Resident #1, who was on enhanced barrier precautions, without donning appropriate PPE. This failure could place residents at risk of infection.Findings included:Record review of Resident #1's face sheet, dated 12/10/25 reflected he was a [AGE] year-old male who was admitted on [DATE] and diagnosed with cerebral infraction (type of stroke that occurs when a blood vessel in the brain is blocked, causing damage to brain tissue), hemiplegia following cerebral infraction right dominant side (Complete paralysis to one entire side of the body), Alzheimer's disease (the most common form of dementia, affecting memory, thinking, and behavior. It is characterized by the buildup of proteins in the brain, leading to the death of brain cells and gradual decline in cognitive function), and gastrotomy status (Refer to the condition of a patient who has undergone a gastrostomy procedure, which involves creating an opening into the stomach for feeding or drainage purposes).Record review of Resident #1's MDS, dated [DATE] reflected, his BIMS score was 03 which indicated severe cognitive impairment. Resident#1 always had urinary and bowel incontinent, Resident#1 was classified as dependent, which meant Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the residents to complete the activity for toileting hygiene, shower/bathe, lower body dressing, roll left and right, sit to lying, lying to sitting on side of bed.Record review of Resident #1's care plan, undated, reflected Resident#1 required tube feeding (PEG-TUBE) r/t GI complications. [Resident#1] goal reflected [Resident#1] will remain free of side effects or complications related to tube feeding through review date. Resident#1 Interventions did not include EBP.Record review of Resident #1's order, dated 10/15/25 reflected Enhanced Barrier Precautions r/t G-TUBE every shift Follow Facility Policy - **USE for patients with any of the following (when Contact Precautions do not otherwise apply): Wounds or indwelling medical devices, regardless of MDRO colonization status Infection or colonization with an MDRO**During an interview on 12/09/25 at 11:00 a.m., the wound care nurse stated residents who were on EBP precautions required staff to wear gown and gloves when high contact care was provided. The wound care nurse stated residents on EBP had a sign above each of their beds.During an interview and observation on 12/09/25 at 11:35 am, surveyor observed LVN F reposition Resident#1 in bed without putting on gown and gloves. Surveyor observed LVN F use hand sanitizer when she returned to the medication cart. LVN F stated a gown and gloves needed to be worn when peri care was provided to Resident#1. During an observation on 12/10/25 at 5:15 a.m., observed CNA A pick linens off the floor from Resident #1's side of the room with no gown on and carried the linens in her hand out of the room. Observed CNA A and CNA B provide peri care to Resident #1 (Surveyor stood out of view of Resident #1's private areas). Surveyor observed CNA A and CNA B not wearing PPE gown. LVN B entered the room and detached Resident #1's G-Tube from his port with no PPE gown on. LVN B walked out of the room with tubing and empty formula bottle. Observed CNA A walked out Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675783 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 675783 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Villa at Mountain View 2918 Duncanville Rd Dallas, TX 75211 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 Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete of the room with trash bags and gloves. Surveyor did not observe CNA A wash hands or use hand sanitizer after she disposed the trash. Observed CNA B, removed gloves and washed her hands before she exited the room. During an interview on 12/10/25 at 5:30 a.m., CNA A and CNA B stated residents with wounds, catheter and G-Tubes were supposed to wear gowns and gloves when direct care was provided. CNA A and CNA B stepped back in Resident #1's room and stated the enhanced barrier sign was posted above his bed. CNA A and CNA B both stated infections could be spread from resident to resident by not wearing the PPE. CNA A and CNA B stated hands should be washed before and after providing care to residents. Record review of matrix-802 and observations of resident's rooms with EBP signs above bed from 12/09/25 to 12/10/25 reflected 23 residents were on enhanced barrier precautions.During an over the phone interview at 1:20 pm, the Medical Director stated staff should wear gown and gloves when high contact care was provided to residents on EBP. The Medical Director stated staff should wash hands before and after care of residents. The Medical Director stated wearing the appropriate PPE helped to prevent the spread of MDRO's (multi-drug resistance organism) and fungal infections.During an interview on 12/10/25 at 1:00 p.m., the ADON stated he was the infection preventionist. The ADON stated residents on EBP had signs above their bed and staff put on gloves and gowns when they provided wound care, dressing, and peri care. The ADON stated the signs were posted above the bed to help identify the residents who needed EBP. The ADON stated residents on isolation precaution had signs outside the door and the facility currently does not have any residents on isolation. The ADON stated PPE bins were located inside the residents room and available.During an interview on 12/10/25 at 1:05 p.m., the DON stated when high contact care was provided gown and gloves should be worn by staff because wounds and open area could be contaminated.During an interview on 12/10/25 at 1:10 p.m., the Admin stated signs for EBP did not have to be posted outside of the door. The Admin stated staff should wear gloves and gowns when high contact was involved with those residents. Record review of Center for Clinical Standards and Quality/Quality, Safety & Oversight Group Ref: QSO-24-08-NH DATE: 03/20/24 TO: State Survey Agency Direct reflected Facilities have discretion on how to communicate to staff which residents require the use of EBP. CMS supports facilities in using creative (e.g., subtle) ways to alert staff when EBP use is necessary to help maintain a home-like environment, as long as staff are aware of which residents require the use of EBP prior to providing high-contact care activities.Record review Frequently Asked Questions (FAQs) about Enhanced Barrier Precautions in Nursing Homes | LTCFs | CDC titled Frequently Asked Questions (FAQs) about Enhanced Barrier Precautions in Nursing Homes, dated 06/28/24 reflected, .Signs are intended to signal to individuals entering the room the specific actions they should take to protect themselves and the resident. To do this effectively, the sign must contain information about the type of Precautions and the recommended PPE to be worn when caring for the resident.Record review of the facility policy, titled Enhanced barrier precautions, dated 08/22 reflected, .2. EBPs employ targeted gown and gloves use during high contact resident care activities when contract precautions do not otherwise apply.3. Examples of high contact resident care actvties requiring the use of gown and gloves for EBPs include: a)dressing .e) changing linens;.f) changing briefs or assisting toileting; g)device care or use (central line, uninary catheter, feeding tube,etc); h) wound care(any skin opening requiring a dressing). Event ID: Facility ID: 675783 If continuation sheet Page 4 of 4