Health inspection·August 2, 2023

F 0689 Level of Harm - Minimal harm or potential for actual harm During an observation of Resident #1's bedroom on 8/01/23 at 2:23 PM revealed approximately 6 to 7 feet of television cable cord laying on the floor approximately 8 inches from the wall at the widest point from the outer bathroom wall area and then going behind the personal refrigerator on the opposite side of the resident's bed. The television cable cord had a raised loop in it and curled where some areas were raised off the floor. Residents Affected - Few During an observation and interview on 8/02/23 at 9:35 AM, CNA A said she had worked at the facility for two years and had worked primarily in the memory care unit for two months. CNA A said Resident #1 was constantly walking in the memory care unit and would go in and out of all the rooms in the memory care unit. With surveyor intervention, CNA A entered Resident #1's room. CNA A said the television cord had probably been there for as long as she had been working in the unit. CNA A said there used to be a long dresser in the open area where the television cable cord was laying in the floor, but they moved the dresser and the extra bed out of the room a little while ago. CNA A said the extra bed and dresser were moved out of Resident #1's room, because they needed them somewhere else. CNA A said she had not noticed the television cable cord in the floor, because Resident #1 was seldomly in her room on CNA A's shift. CNA A said it should have been reported and secured, because it was a trip hazard for the resident. During an observation and interview on 8/02/23 at beginning at 1:20 PM, LVN B said she had worked at the facility since December of 2022 and usually worked in the memory care unit. With surveyor intervention, LVN B entered Resident #1's room. LVN B said CNA A had told her about the television cable cord this morning after surveyor had interviewed CNA A. LVN B said she then notified the Maintenance Supervisor, and he came and secured the cord along the wall. LVN B said she had not previously noticed the television cable cord in Resident #1's floor until CNA A reported it to her on 8/02/23. LVN B said she seldomly goes into Resident #1's room, because Resident #1 was always ambulating all other the memory care unit and seldom in her room. LVN B said the extra bed and dresser had probably been gone about a month. LVN B said the television cable cord in Resident #1's floor could have caused the resident to fall. During an interview on 8/02/23 at 1:28 PM, the Maintenance Supervisor said Resident #1's television cable cord should not have been in the floor, and it should have been secured. The Maintenance Supervisor said he was not notified until 8/02/23 about the cable cord needing secured. The Maintenance Supervisor said there was a maintenance logbook at each nurses' station and the staff should be writing any maintenance issues in the logbook. The Maintenance Supervisor said the logbooks were checked frequently and repairs were made timely. The Maintenance Supervisor said no one had reported the cable cord being in the floor in the logbook for the memory care unit. The Maintenance Supervisor said he secured the television cable cord as soon as he was notified. The Maintenance Supervisor said the maintenance department staff made weekly rounds throughout the facility and looked for needed repairs. The Maintenance Supervisor said he did not know when the last time the memory care unit rooms were checked due to, he had been off work. During an interview on 8/02/23 beginning at 3:25 PM, the DON said Resident #1 was very active and continuously walked throughout the memory care unit. The DON said Resident #1 had a fall in April 2023 from getting her feet tangled in the bed remote cord. The DON said they rearranged the resident's furniture and in-serviced staff on being mindful of cords to ensure there were no tripping hazards in the residents' rooms. The DON said she was not aware of the television cable cord being in the floor and it could have caused a resident to trip and fall. The DON said she would be re-educating her staff to be checking the residents' rooms for trip hazards. (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 08/02/2023 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 During an interview on 8/02/23 at 3:39 PM, the Administrator said Resident #1 was ambulatory and walked throughout the memory care unit. The Administrator said Resident #1 had a fall in April 2023, Resident #1 must have somehow knocked the bed remote cord in the floor and somehow got her feet tangled in it. The Administrator said they in-serviced staff to make rounds and be mindful of tripping hazards and to keep areas safe at all times. The Administrator said she was unaware of the television cable cord being in Resident #1's floor and it should have been secured. Record review of an In-service Training Report dated 4/24/23 with the topic of Fall prevention to all staff, indicated When making rounds in resident rooms, always be mindful of any tripping hazards. If you observed any bed cords, oxygen cords or tubing, or any other items that may cause a resident to fall, remove or relocate the item immediately. Keep walkways free of clutter, furniture, or any other tripping hazards. We always want to be proactive and try to prevent a fall before it happens. It is ALL of our job to work together and keep our residents safe. Record review of the facility's policy titled Quality of Life-Homelike Environment, with a revised date of May 2017, indicated . residents were provided with a safe, clean, comfortable, and homelike environment . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675966 If continuation sheet Page 3 of 3