Health inspection·July 7, 2023

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few of the oxygen canister, approximately 5-6 inches. His nightstand sat to the left of the oxygen canister, approximately 5-6 inches. The oxygen canister sat approximately 5-6 inches from the back of the wall (at the north of the canister). No items were to the south of the canister. Oxygen tubing was connected to the canister and was coiled to the top of the canister. During an interview and observation on 7/7/23 at 2:08 p.m., revealed Resident #1 was lying in his bed. He said he had not used oxygen in months but sometimes needed it to help him breathe. The oxygen canister was still next to his bed, unsecured. Resident #1 said the oxygen canister had been right there, just like that in the room for at least 2 months. During an interview on 7/7/23 at 3:10, CNA A said CNAs did not do anything with oxygen or oxygen equipment. CNA A said oxygen tanks were to be secured during transport and at all times because of the risk of explosion. CNA A said she regularly took care of Resident #1 but had not noticed the free standing oxygen tank in his room. CNA A said if she had noticed the oxygen tank in the room not secured, she would have gotten the nurse. During an interview on 7/7/23 at 3:13 p.m., CNA B said CNAs did not do anything with oxygen or oxygen equipment. CNA B said oxygen tanks were to be secured during transport and at all times because of the risk of fire. CNA B said she regularly took care of Resident #1 but had not noticed the free standing oxygen tank in his room. CNA B said if she had noticed the oxygen tank in the room not secured, she would have gotten the nurse. During an interview and observation on 7/7/23 at 3:30 p.m., revealed RN A stood in Resident #1's room. Resident #1 was lying in his bed. He said he had not used oxygen in months but sometimes needs to help him breathe. The oxygen canister was still next to his bed, unsecured. RN A said the oxygen canister should not be free- standing in the resident's room. RN A said she had not noticed the oxygen canister in the room earlier while providing care to the Resident #1 but would remove it immediately as it was a hazard. RN A said she regularly took care of Resident #1 but could not say exactly how long the canister had been in his room. RN A said it was possible someone from therapy left it there after he (Resident #1) was transported from therapy to his room. RN A said the free-standing canister was a hazard because it could easily fall over if Resident #1 attempted to get up or if staff were to bump it unintentionally while providing care. RN A said if the canister fell it could cause injury to staff or could cause a fire. RN A removed the canister out of Resident #1's room and placed it in the oxygen supply room. There was a note on the front of the oxygen supply room that read Attention!!! Place all O2 Cylinders in a rack or secure with a chain do not leave free standing. During an interview on 7/7/23 at 3:45 p.m., OTA B said Resident #1 had not received therapy services since 6/12/23. OTA B said it was not safe to leave an oxygen canister unsecured and her technicians would know that. OTA B said oxygen was usually secured in a device that attached to the resident's wheelchair. OTA B said she did have a technician working in June 2023 that assisted with the transports to and from therapy, but currently she did not. During an interview on 7/7/23 at 3:55 p.m. the DON said the risk of a free-standing oxygen cylinder was that the cylinder could easily be knocked over which could cause a fire or explosion. The DON said staff were to perform rounds every 2 hours and she expected nursing staff to look for hazards during those rounds. The DON said she would expect to identify a free-standing oxygen tank as a safety hazard. During an interview on 7/7/23 at 4:05 p.m., the ADM said the facility performed weekly (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675966 If continuation sheet Page 2 of 3 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 675966 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Villa at Texarkana 4920 Elizabeth St Texarkana, TX 75503 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 FORM CMS-2567 (02/99) Previous Versions Obsolete administrative rounds. The ADM said she was not sure if the rounding sheet used by the administrative staff specifically listed free standing oxygen canisters as something to look for but said she would expect every staff member to know that a free-standing oxygen canister was a safety hazard. The facility policy and procedure titled, Safety and Supervision of Residents on Oxygen, dated 11/28/20, stated, To ensure sanitary, appropriate, use and storage of oxygen cylinders for the safety of all residents . (3) protected from abnormal mechanical shock, which is liable to damage the cylinder, valve, or safety device. (4) protected from tamper by unauthorized. (5) if not supported in a proper cart or stand, properly chained, or supported Event ID: Facility ID: 675966 If continuation sheet Page 3 of 3