Health inspection·October 24, 2023

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few being concerned about another family member may have been giving Resident #3 medications because she noticed Resident #3's speech being slurred after the other family member visited. The summary/findings section was not completed. The SW follow-up section was completed and dated 8/01/23 and said there was a legal guardian in place and the guardian could refuse visitation from anyone. Then it said the guardian was going to speak to the other family member about limiting visits with no concerns or guardian would prevent her from visiting at all. In the additional follow-up/notes section, it said family would notify the ADM with any ongoing concerns. There was no documentation of an investigation related to the concern of the other family member potentially giving Resident #3 medications that were not prescribed. During an entrance conference interview on 10/18/23 at 8:56 AM related to a facility reported incident dated 10/05/23, the ADM said Resident #3's Representative #1 felt another family member may be administering non-ordered medications to Resident #3, such as Seroquel. The ADM said Resident #3's Representative #1 was upset that ADM had reported the incident to the state. The ADM said she told Resident #3's Representative #1, if she was going to accuse the family member of doing something like drugging Resident #3, she had to investigate it as an accusation of abuse. The ADM said she had to report it as abuse because giving a resident medication that was not prescribed to them was abuse. During an interview on 10/19/23 at 2:51 PM, Resident #3's Representative #1 said she had talked to the facility in August 2023 when they first thought another family member might have been giving Resident #3 medications that were not ordered and the facility basically told her, since Representative #1 was the legal guardian, then she would have to be the one to tell the other family member that she could not visit and then the facility could put a sign up to not allow the other family member to visit. Representative #1 said so nothing was done by the facility about her concern in August 2023. Representative #1 said she felt the facility should have provided increased monitoring of Resident #3 during the other family member's visits to ensure she was not giving him medications that were not prescribed, but the facility said it was up to Representative #1 to prevent the other family member from visiting Resident #3. Representative #1 said she then texted the ADM on 9/22/23 and the ADM did not respond about continued concerns of the other family member could be giving Resident #3 medications that were not prescribed. Representative #1 said then on 10/04/23 she texted the ADM about wanting Resident #3 drug tested and told the ADM that she thought Resident #3 was being drugged due to Resident #3 would be more lethargic after the other family member visited. Representative #1 said Resident #3 ended up going to the hospital due to a UTI, and Representative #1 said she had him drug tested there, but it did not test for everything like Seroquel that she thought the other family member might have been giving Resident #3. Representative #1 said Resident #3 returned to the facility the same day, and then the facility tried to get a urine drug test and could not get the urine and ended up doing a blood test for Seroquel. Representative #1 said the drug test was negative, but she felt that it may have been too late to show if he had received any thing that was not ordered. Representative #1 said the other family member took Seroquel and that was why she thought the other family member may have given Resident #3 Seroquel. During an interview on 10/19/23 at 3:35 PM, the ADM said the grievance/concern report filed on 8/01/23 said Representative #1 was concerned that another family member may be giving Resident #3 medication because Representative #1 noticed Resident #3's speech being different after the other family member visited. The ADM said Representative #1 was not that concerned at that time and was just mentioning it in passing. The ADM said she told Representative #1 that as the legal guardian, she could tell the other family member that she could not visit Resident #3, but Representative #1 did not want to do that at the time. The ADM said in hindsight, she probably should have reported it, but at the time she did not feel (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675966 If continuation sheet Page 2 of 21 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 10/24/2023 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 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few it rose to the point of needing to be reported as potential abuse. The ADM said in October 2023 when Representative #1 made the allegation of suspecting the other family member was giving Resident #3 some medications that were not ordered, she said Representative #1 said she was suspicious due to the other family member seemed to be hiding something from the camera in the resident's room and Representative #1 said Resident #3 would seem more lethargic after the other family member visited. The ADM said Representative #1 was much more concerned at that time, so she reported it as abuse and investigated. During an interview on 10/19/23 at 4:22 PM, the SW and ADM said at the time of the Grievance/concern Report on 8/1/23, Resident #3's Representative #1 did not want anything done and just had a concern, and they did not feel it rose to the level of a reportable abuse. The ADM said when Resident #3's Representative #1 again brought it to their attention in October 2023 and said the other family member was also seen on camera hiding something but had not seen the other family member give him Resident #3 anything. They then felt it was reportable. The ADM said if the family felt the other family member was giving Resident #3 something then it was a type of abuse and had to be reported. The ADM said they investigated the 8/01/23 Grievance/concern report but was unable to provide documentation of the investigation or what interventions were put in place to ensure the resident was not given medications that were not prescribed by another family member. During an interview on 10/23/23 at 4:58 PM, the SW said she was responsible for filling out the Grievance/concern Report when a resident or family member came to her with a concern or grievance, but any staff could initiate the report. The SW said she filled out the top concern portion and then handed it straight to the ADM, and the ADM gets with the concerned party to discuss and come to a resolution. The SW said after the ADM completed the concern, she then gives it back to the SW and a couple of weeks after it was closed/completed, the SW logs it in the concern/grievance log book; and then the SW would follow-up with the concerned party to see if there was any other concerns and documented it in the SW follow-up report section of the concern report. She said they also would discuss the concerns in their SOC meetings every Friday. Record review of the facility's grievance policy titled Grievances/Complaints, Filing dated April 2017 revealed . any resident, family member, or appointed resident representative may file a grievance or complaint concerning care, treatment, behavior of other residents, staff members, theft of property, or any other concerns regarding his or her stay at the facility . all grievances, complaints or recommendations stemming from resident or family groups concerning issues of resident care in the facility would be considered . actions on such issues would be responded to in writing, including a rationale for the response . upon receipt of a grievance and/or complaint, the Grievance Officer will review and investigate the allegations and submit a written report of such findings to the Administrator within five working days of receiving the grievance and/or complaint . coordinate actions with the appropriate state and federal agencies . all alleged violations of neglect, abuse, and/or misappropriation of property would be reported and investigated under guidelines for reporting abuse, neglect, and misappropriation of property, as per state law . Grievance Officer, Administrator and Staff would take immediate action to prevent further potential violations of resident rights while alleged violations were being investigated . the resident, or person filing the grievance and/or complaint on behalf of the resident, would be informed (verbally and in writing) of the findings of the investigation and the actions that would be taken to correct any identified problems . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675966 If continuation sheet Page 3 of 21 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 10/24/2023 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 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to ensure each resident was free from abuse and neglect for 1 (Resident # 1) of 8 residents reviewed for abuse and neglect. The facility failed to ensure Resident #1, was free from verbal abuse when he was cursed at by CNA E during care. This failure could place residents at risk of serious harm from possible abuse and neglect. Findings included: Record review of the face sheet for Resident #1's dated 10/23/2023 revealed a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included Parkinson's Disease (brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), depression (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), and anxiety (a feeling of fear, dread, and uneasiness). Record Review of Resident #1's MDS assessment dated [DATE] revealed a BIMS score of 13, which indicated no cognitive impairment. The MDS revealed Resident #1 was understood and understood others. Resident #1 required extensive assistance with toileting and dressing. Resident #1 was frequently incontinent of bowel and bladder. Record Review of Resident #1's care plan dated 11/29/2022 revealed Resident #1 had a depression and anxiety. The intervention for the problem was to approach resident with warmth and positivity. Record Review completed of the Facility Reported Intake dated 08/04/2023 reflected it alleged that Resident #1 was verbally abused by CNA E while providing care. Record review of PIR dated 08/04/2023 reflected, per camera (observed by family, Administrator and Social Services) the aide was repeatedly telling Resident (#1) to pull his pants down for toileting, (CNA E) stated if he hit her, she would hit him back, and (CNA E) stated I don't give a fuck about your camera. Review of video revealed a date and timed stamped video of Resident #1's private room: 08/03/2023 3:51 CNA E stated in a loud harsh tone pull your pants down [Resident #1]! CNA E repeated this 6 times and then said at 16:51:32 what, you don't speak English? 16:51:55-CNA E attempted to pull residents pants down for him and resident stated I am going to hit you if you do not stop. CNA E stated, Do it and I'll hit you back. 16:52:10 Resident #1 hollered [CNA E]! You see there is a camera rolling? CNA E stated, I don't care about those fucking cameras. 16:53:55-Resident #1 stated I've never seen anyone as ugly as you. CNA E responded, you're ugly (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675966 If continuation sheet Page 4 of 21 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 10/24/2023 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 0600 shut up. Level of Harm - Minimal harm or potential for actual harm Record review of CNA E's employment record revealed she was terminated on 08/04/2023 prior to working another shift. CNA E had been educated on abuse and neglect on 07/21/2023 during an all staff Inservice. Residents Affected - Few Record review of Resident #1's social service notes dated 08/04/23 revealed no psychological harm from incident. Resident #1 was seen by counseling service monthly since incident with no harm noted. Record review of Resident #1's PIR dated 08/04/2023 revealed local police were contacted on 08/04/2023. Review of PIR revealed safe surveys (interviewing other residents taken care of by CNA E) for 10 residents. All 10 residents stated they felt safe at the facility and had not experienced abuse or neglect of any kind. Record review of staff training showed Abuse and Neglect training occurred on 08/04/2023 with 75% of staff completing the training. Attempted contact with CNA E was unsuccessful x 3 attempts 10/23/2023 at 10:15 a.m., 10/23/2023 at 4:00 p.m., and 10/24/2023 at 12:05 p.m. During an interview on 10/24/2023 at 9:30 a.m., the Administrator stated she had visited with Resident #1 several times since the incident, and he remembered the incident but was not affected by it. The Administrator stated that verbal abuse was still abuse and it was the policy of the facility that the residents live in an environment free from any type of abuse or neglect. During an interview on 10/24/2023 at 10:00 a.m., Resident #1 stated he remembered CNA E being very rude to him and cursing at him. Resident #1 stated he knew she would not get away with it because his family watched the tape from his room every day. Resident #1 stated no one had been rude to him before that incident or since that incident. Record review of the facility policy titled, Abuse and Neglect, with effective date October 2022 read in part, .It is the policy of the facility to administer care and services in an environment that is free from any type of abuse, corporal punishment, misappropriation of property, exploitation, neglect, or mistreatment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675966 If continuation sheet Page 5 of 21 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 10/24/2023 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately but not later than 2 hours after the allegation is made if the events that cause the allegation involve abuse to the state survey agency for 1 of 28 residents (Resident #3) reviewed for abuse, neglect, exploitation, and misappropriation of resident property. The facility failed to report an allegation of abuse within 2 hours after Resident #3's Representative #1 filed a Grievance/concern report on 8/01/23 about being concerned that another family member may have been giving Resident #3 medications because Resident #3's speech was slurred after the other family member visited. This deficient practice could place residents at risk for abuse, neglect, misappropriation of property, and not having their needs met. Findings included: Record review of Resident #3's face sheet dated 10/18/23 revealed Resident #3 was an [AGE] year-old male. Resident #3 was admitted to the facility initially on 3/20/23 and readmitted on [DATE] with diagnoses including Alzheimer's (progressive mental deterioration due to generalized degeneration of the brain), dementia (progressive or persistent loss of intellectual functioning with impairment of memory and thinking, and often with personality change), weakness, transient cerebral ischemic attack (brief stroke-like attack, usually resolves within minutes to hours, that could be a warning sign to a future stroke), depression (persistent sadness), anxiety (feeling of worry, nervousness, or unease), heart failure, and heart disease. Record review of Resident #3's quarterly MDS assessment dated [DATE] indicated Resident #3 was understood and usually understood others. The MDS indicated a BIMS score of 01 which indicated Resident #3 had severe cognitive impairment. Resident #3 had disorganized thinking, delusions (false belief or judgement about external reality), and he rejected care 4-6 days a week. Resident #3 wandered daily. Resident #3 required extensive to total assistance of 1-2 persons for most ADLs, but he was able to self-propel himself in his wheelchair and feed himself. Resident #3 was always incontinent of bowel and bladder. Record review of Resident #3's care plan dated 4/07/23 revealed he had Alzheimer's dementia, severe impaired cognition, and he needed a special care unit due to his elopement risk. There were no interventions related to increased monitoring of Resident #3 during the other family member's visits to ensure she was not administering him medications that were not prescribed. Record review of a Concern Report dated 8/01/23 revealed Resident #3's Representative #1 reported being concerned about another family member may have been giving Resident #3 medications because she noticed Resident #3's speech being slurred after the other family member visited. The summary/findings section was not completed. The SW follow-up section was completed and dated 8/01/23 and said there was a legal guardian in place and the guardian could refuse visitation from anyone. Then it said the guardian was going to speak to the other family member about limiting visits with no concerns or guardian would prevent her from visiting at all. In the additional follow-up/notes section, it said (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675966 If continuation sheet Page 6 of 21 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 10/24/2023 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few family would notify the ADM with any ongoing concerns. There was no documentation of an investigation related to the concern of the other family member potentially giving Resident #3 medications that were not prescribed. During an entrance conference interview on 10/18/23 at 8:56 AM related to a facility reported incident dated 10/05/23, the ADM said Resident #3's Representative #1 felt another family member may be administering non-ordered medications to Resident #3, such as Seroquel. The ADM said Resident #3's Representative #1 was upset that ADM had reported the incident to the state. The ADM said she told Resident #3's Representative #1, if she was going to accuse the family member of doing something like drugging Resident #3, she had to investigate it as an accusation of abuse. The ADM said she had to report it as abuse because giving a resident medication that was not prescribed to them was abuse. During an interview on 10/19/23 at 2:51 PM, Resident #3's Representative #1 said she had talked to the facility in August 2023 when they first thought another family member might have been giving Resident #3 medications that were not ordered and the facility basically told her, since Representative #1 was the legal guardian, then she would have to be the one to tell the other family member that she could not visit and then the facility could put a sign up to not allow the other family member to visit. Representative #1 said so nothing was done by the facility about her concern in August. Representative #1 said she then texted the ADM on 9/22/23 and the ADM did not respond about continued concerns of the other family member could be giving Resident #3 medications that were not prescribed. Representative #1 said then on 10/04/23 she texted the ADM about wanting Resident #3 drug tested and told the ADM that she thought Resident #3 was being drugged due to Resident #3 would be more lethargic after the other family member visited. Representative #1 said Resident #3 ended up going to the hospital due to a UTI, and Representative #1 said she had him drugged tested there, but it did not test for everything like Seroquel that she thought the other family member might have been giving Resident #3. Representative #1 said Resident #3 returned to the facility the same day, and then the facility tried to get a urine drug test and could not get the urine and ended up doing a blood test for Seroquel. Representative #1 said she felt that it may have been too late to show if he had received any thing that was not ordered. Representative #1 said the other family member took Seroquel and that was why she thought the other family member may have given Resident #3 Seroquel. During an interview on 10/19/23 at 3:35 PM, when the ADM was asked why she reported the incident in October 2023, but did not report the grievance/concern report filed on 8/01/23 where Resident #3's Representative #1 was concerned that another family member may be giving Resident #3 medication because Representative #1 noticed Resident #3's speech being different after the other family member visited. The ADM said Representative #1 was not that concerned at that time and was just mentioning it in passing. The ADM said she told Representative #1 that as the legal guardian, she could tell the other family member that she could not visit Resident #3, but Representative #1 did not want to do that. The ADM said in hindsight, she probably should have reported it, but at the time she did not feel it rose to the point of needing to be reported as potential abuse. The ADM said in October 2023 when Representative #1 made the allegation again of suspecting the other family member was giving Resident #3 some medications that were not ordered, she said Representative #1 said she was suspicious due to the other family member seemed to be hiding something from the camera in the resident's room and Representative #1 said Resident #3 would seem more lethargic after the other family member visited. The ADM said Representative #1 was much more concerned at that time, so she reported it as abuse to the state immediately. During an interview on 10/24/23 at 11:12 PM, the ADM said at the time of the 8/01/23 Grievance/concern report, Resident #3's Representative was not that concerned, and the ADM did not feel that it (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675966 If continuation sheet Page 7 of 21 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 10/24/2023 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete rose to the point of abuse and did not feel it needed to be reported. The ADM said when Resident #3's Representative #1 reported the concern again in October 2023, there was reported suspicious activity on the video camera and Resident #3 was more lethargic per the Representative, therefore, the ADM said it had to be reported as abuse immediately. Record review of the facility's policy titled Abuse Policy dated April 5, 2016, revealed . all allegations, no matter what types of incidents reported would be investigated fully . the ADM or designee would report this allegation of abuse immediately to state agency . and to the proper local authorities . Event ID: Facility ID: 675966 If continuation sheet Page 8 of 21 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 10/24/2023 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan to meet each resident's medical, nursing, mental and psychosocial needs for 2 of 10 residents reviewed for care plans. (Resident #5, and Resident #4) 1.The facility failed to develop a comprehensive person-centered care plan including interventions for falls for Resident #5. 2.The facility failed to develop a comprehensive person-centered care plan including interventions for pain and opioid use for Resident #4 These failures could place residents at risk of not having individual needs met, a decreased quality of life, and cause residents not to receive needed services. Findings include: 1. Record review of a face sheet dated 10/23/2023 revealed Resident #5 was an 85- year-old male and was admitted on [DATE] with diagnoses including atrial fibrillation (an irregular and often very rapid heart rhythm), hypertension (elevated blood pressure), and weakness Record review of the most recent MDS assessment dated [DATE] indicated Resident #5 was understood and understood others. The MDS indicated a BIMS score of 13 showing that Resident #5's cognition was intact. Resident #5 was noted to have a fall with no injury. Record review of the incident report dated 08/19/2023 at 7:30 p.m., indicated Resident #5 had a fall in his bathroom resulting in an ER visit for syncopal (blood pressure drops rapidly) episode. Record review of Resident # 5's care plan last updated 08/25/2023 by the Care Plan Coordinator indicated, no fall on 08/19/2023 and no intervention for fall were developed. During an interview on 10/23/2023 at 2:20 p.m., the Care Plan Coordinator stated Resident #5's fall from 08/19/2023 should have been care planned with the intervention of sending him to the ER for testing and a diagnosis of syncope. The Care Plan Coordinator stated each fall with intervention should be care planned in attempt to decrease repeat falls for the same reasons. 2. Record review of a face sheet dated 10/23/2023 revealed Resident #4 was a 77- year-old female and was admitted on [DATE] with diagnoses including atrial fibrillation (an irregular and often very rapid heart rhythm), hemiplegia (Muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles), and aphasia (loss of ability to understand or express speech, caused by brain damage). Record review of the most recent MDS assessment dated [DATE] indicated Resident #4 was usually understood and usually understood others. The MDS indicated a BIMS score of 13 showing that Resident #4's cognition was intact. Resident #4 was noted to have unclear speech. Resident #4 had frequent pain that limited ADL function from day to day. Resident #4 ranked her pain a 10 on a scale of 1-10. Resident #4 received opioids daily. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675966 If continuation sheet Page 9 of 21 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 10/24/2023 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 0656 Level of Harm - Minimal harm or potential for actual harm Record review of the physician orders for Resident #4 indicated she had an order for Tramadol 50mg one tab every 6 hours as needed for pain with a start date of 11/29/2022. Record review of the July 2023 and August 2023 MARs for Resident #4 indicated she received Tramadol 50mg daily from 07/29/2023 to 08/04/2023. Residents Affected - Few During an interview on 10/23/2023 at 10:00 a.m., Resident #4 indicated through unclear speech that she had pain daily in her right shoulder, arm, and hand. Resident #4 stated it hurt bad bad all the time. Resident #4 stated pain pill make it ok. Record review of Resident # 4's comprehensive care plan last updated on 08/11/2022 revealed no care plan was developed for pain and no care plan was developed for opioid use. During an interview on 10/23/2023 at 2:20 p.m., the Care Plan Coordinator stated Resident #4's pain and opioid use should have been care planned. The Care Plan Coordinator stated it was her job to make sure all areas of the MDS were care planned that affected the residents. The Care Plan Coordinator stated not care planning those areas could affect the type of care the resident received. During an interview on 10/24/2023 at 11:50 a.m., the Administrator stated she expected all care plans to be updated to reflect the most accurate information possible for each resident. The Administrator stated the care plan should be used to guide the care of each resident and failure to update the care plan could result in a disruption of care. Review of a facility policy titled Care Plans dated 11/2020 revealed the resident care plan was used to plan and assign care for all disciplines. The resident care plan must be kept current at all times. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675966 If continuation sheet Page 10 of 21 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 10/24/2023 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. 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 ensure residents who were unable to carry out activities of daily living received the necessary services to maintain personal hygiene for 2 of 12 residents reviewed for ADLs (Residents # 2 and Resident # 6) Residents Affected - Few 1.The facility did not provide incontinent care for Resident #2 for 6-8 hours for 2 days 2. The facility did not provide scheduled showers for Resident #6. These failures could place residents at risk of not receiving services/care and decreased quality of life. Findings Include: 1.Record review of an undated face sheet indicated Resident #2 was a [AGE] year-old male and admitted on [DATE] and readmitted on [DATE] with diagnoses including dementia (the loss of cognitive functioning thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities), Alzheimer's disease (a progressive disease beginning with mild memory loss and possibly leading to loss of the ability to carry on a conversation and respond to the environment) and repeated falls. Record review of the MDS assessment dated [DATE] indicated Resident #2 was sometimes understood but understood others. A BIMS score of 99 indicated Resident #2 was severely cognitively impaired. The MDS indicated Resident #2 required extensive assist of 2 staff for bed mobility and transfer and he was dependent for toileting. Resident #2 was coded as always being incontinent of bowel and bladder. Record review of the care plan dated 09/11/2023 had no care plan for incontinence. Record review of a facility grievance filed by Resident #2's family on 09/15/2023 indicated Resident #2 had a camera in his room that showed no one entered the room from 10 p.m. to 5:00 a.m. on 09/14/2023 to 09/15/2023. Resolution was noted to in-service staff on providing care by entering the room and physically checking for incontinence. During an interview on 10/23/2023 at 9:20 a.m., LVN N stated she told the CNAs not to disturb Resident #2 on 09/14/2023 night if he was sleeping. LVN N stated he had been combative earlier in the night and had to be given Ativan 0.5mg to decrease his agitation. LVN N stated she felt if he was woken, he would start being combative again. LVN N stated she understood the importance of incontinent care for skin integrity but felt Resident #2 needed to rest. LVN N stated he was cleaned at 9:30 p.m. on 9/14/2023 and again at 5:00 a.m. on 9/15/2023. During an interview on 10/23/2023 at 10:00 a.m., CNA I stated she had not provided incontinent care for Resident #2 on 09/14/2023 to 09/15/2023 from 10:00 p.m. until 5 a.m. at the instruction of LVN N. During an interview on 10/23/2023 at 11:00 a.m., CNA F stated she had done incontinent care for Resident #2 many times because other aides do not like to work with him. CNA F stated he took extra time and a calm slow approach. CNA F stated people had to understand his disease to understand that he (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675966 If continuation sheet Page 11 of 21 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 10/24/2023 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few cannot help what he was doing or saying. CNA F stated she worked during the day and had come into the facility and found Resident #2 extremely wet, soaked through the sheets on several (4-5) occasions. During an interview on 10/24/2023 at 10:30 a.m., Resident #2's family stated the incident on 09/15/2023 was only one grievance made by the family about the resident not getting incontinent care throughout the night. Resident #2's family stated they had reported Resident #2 not getting care throughout the night several times. Resident #2's family was unable to provide dates and times for these occurrences. Resident #2's family stated the facility was supposed to check the resident every 2 hours but twice a night would have been acceptable. Resident #2's family stated this was all discussed during a care the care plan meeting the day after Resident #2 readmitted . During an interview on 10/24/2023 at 11:45 a.m., the Administrator said she had received concerns from the family that Resident #2 would go hours without anyone coming into his room. The Administrator stated they had in serviced the staff multiple times about providing care to difficult residents and she expected for all residents to get the care they need. The Administrator stated it was unacceptable to not provide incontinent care for an entire shift. The Administrator stated most residents were provided with at least 2 episodes of incontinent care throughout the night. 2. Record review of a face sheet dated 10/19/2023, indicated Resident #6 was an [AGE] year-old male admitted on [DATE] with the diagnoses of candidiasis of the skin (infection of the skin and nails caused by the candida fungus. Candida infections often occur in areas exposed to moisture for long periods of time), anxiety (feeling of fear, dread, and uneasiness), and cerebral infarction (occurs because of disrupted blood flow to the brain due to problems with the blood vessels that supply it). Record review of the MDS assessment dated [DATE] indicated, Resident #6 had a BIMS of 13, which indicated no cognitive impairment. Resident #6 was coded as being understood and understanding others. Resident #6 required dependent assist with toileting and bathing. No refusal or rejection of care was noted on the MDS assessment. Record review of the comprehensive care plan dated 08/22/2023 for Resident #6 indicated no refusal or rejection of care. Record review of Completed ADL Documentation from August 2023 reflected Resident #6 was scheduled to have baths on 08/01/2023, 08/03/2023, 08/05/2023, 08/08/2023, 08/10/2023, 08/12/2023, 08/15/2023, 08/17/2023, 08/19/2023, 08/22/2023, 08/24/2023, 08/26/2023, and 08/29/2023. Resident #6 had recorded baths on 08/01/2023 only. Resident #6 received 1 out of 13 bathes scheduled for August 2023. Record review of Completed ADL Documentation from September 2023 reflected Resident #6 was scheduled to have baths on 09/02/2023, 09/05/2023, 09/07/2023, 09/09/2023, 09/12/2023, 09/14/2023, 09/16/2023, 09/19/2023, 09/21/2023, 09/23/2023, 09/26/2023, 09/28/2023, and 09/30/2023. Resident #6 had recorded baths on 09/03/2023, 09/14/2023, 09/19/2023, 09/22/2023, and 09/29/2023. Resident #6 received 5 of the 13 bathes scheduled for September 2023. During an observation and interview on 10/19/2023 at 9:20 a.m., Resident #6 had severely dry skin. He was wearing a navy-colored sweatshirt and it was covered in dead skin. Resident #6 had a rash to his face and smelled strongly of ammonia from urine. Resident #6 stated they had gotten better about bathing him, but they still were not bathing him as often as he needed. Resident #6 stated he itched horribly and it made him want to claw his skin off He stated his crotch itched the most because he (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675966 If continuation sheet Page 12 of 21 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 10/24/2023 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few sat in wet diapers all day. Resident #6 stated he had jock itch more than once since he came to the facility. Resident #6 said he needed a bath and some lotion, and he would be very content. Resident #6 stated he last received a bath 10/16/2023. During an interview on 10/23/2023 at 1:10 p.m., CNA G stated Resident #6 was supposed to get a shower every Monday, Wednesday, and Friday. CNA G stated she attempted to give wash downs with a wipe when the facility was short staffed. CNA G stated Resident #6 was changed to a 2-10 bath in September after he made a complaint about not getting a bath. CNA G stated Resident #6's family member visits him during the day sometimes and when his family was here, he asked for his bath to be done later. During an interview on 10/23/2023 at 11:30 a.m., the DON stated the CNAs performed showers on the residents, but any of the nursing staff could and should perform showers when needed. The DON stated she expected the CNAs to provide baths to the residents three days per week at minimum. The DON stated she was aware the facility had a few days when the hot water was not working and a bath or two may had been missed on those days. During an interview on 10/24/2023 at 11:45 a.m., the Administrator stated it was the job of the nursing department to ensure all residents were bathed and personal hygiene was maintained. The administrator stated it was the facility's job to accommodate the residents schedule when giving care. ADL policy was requested on 10/24/2023 from corporate nurse at 10:00 a.m. and 11:30 a.m. and was not received prior to exit. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675966 If continuation sheet Page 13 of 21 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 10/24/2023 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 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure adequate supervision was provided to prevent accidents for 1 of 1 resident reviewed for accidents and supervision. (Resident #2) The facility failed to provide appropriate supervision for Resident #2 to prevent falls with and without injury. This failure places residents at risk for serious injury related to falls. Findings included: 1. Record review of an undated face sheet indicated Resident #2 was a [AGE] year-old male and admitted on [DATE] and readmitted on [DATE] with diagnoses including dementia (the loss of cognitive functioning thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities), Alzheimer's disease (a progressive disease beginning with mild memory loss and possibly leading to loss of the ability to carry on a conversation and respond to the environment) and repeated falls. Record review of the MDS dated [DATE] indicated Resident #2 was sometimes understood but understood others. A BIMS score of 99 indicated Resident #2 was severely cognitively impaired. The MDS indicated Resident #2 required extensive assist of 2 staff for bed mobility and transfer and he was dependent for toileting. Resident #2 was coded as always being incontinent of bowel and bladder. Resident #2 had 2 or more falls with no injury coded. Record review of incident reports for Resident #2 revealed the following: 09/07/2023- Resident #2 had a fall in his room on the secured unit at 7:15 a.m., all meds were on hold-intervention was urinalysis. 09/08/2023- Resident #2 had a fall in his room on the secured unit at 12:30 a.m., aides heard a big bang and found resident on the floor in room with a broken lamp on the floor beside him.- intervention turn and reposition bars added to bed. 09/13/2023- Resident #2 had a fall in his room on the secured unit at 2:11 a.m., nurse was out of unit on 200 hall, CNA H was on break in her car, CNA I was providing care to another resident when she heard a thud. Intervention CNAs working the unit at night could not leave the building for breaks. 09/30/2023-Resident #2 had a fall on the floor in unit at 3:35 p.m., fall mats in place- No intervention further intervention. 10/05/2023- Resident #2 had a fall in his new room on 400 hall at 8:30 p.m., slipped off bed onto floor. No Intervention further intervention. 10/07/2023- Resident #2 brought to nurses' station so staff could watch him. Resident #2 was noted (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675966 If continuation sheet Page 14 of 21 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 10/24/2023 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 to be on the floor by a nurse from another station that was passing by at 7:30 a.m.- Intervention was high back wheelchair. Level of Harm - Actual harm Residents Affected - Few 10/10/2023-Resident #2 was found on the floor in room- Intervention- Inservice staff about working with agitated, impulsive residents and how to provide incontinent care to them. 10/13/2023-Resident #2 fell in his room and was found on the fall mat. No intervention. 10/16/2023- Resident #2 fell at 7:36 a.m. at the nurse's station. No witness. Laceration to eye requiring sutures. Noted on the floor by a nurse from another hall.- Sent to ER. 10/16/2023- Resident #2 fell at 11:45 a.m., at the nurse's station while 3 nurses sat at the station. Resident landed on his right arm. 10/17/2023- Resident #2 fell in room at 6:27 a.m., slipped off bed onto right knee and scooted on buttock across room. Intervention was frequent monitoring. No documentation of frequent monitoring was located. 10/20/2023- Resident #2 found sitting on floor in room. Resident had a skin tear to his right hand and complained of pain. Xray done and a fracture of indeterminate age was found to his ulnar bone. During on observation on 10/18/2023 at 2:00 p.m., Resident #2 was up in his wheelchair in his room alone. Resident #2's room was noted to have fall mats on the floor on the right side of bed and foam wrapped around the transfer bar on his bed. Resident #2 remained in room alone for 15 minutes until CNA came to assist him to bed. Resident #2 was noted to have a large area of bruising to his left eye deep purple in color. Resident #2 had a laceration to his brow bone on the left side. During an interview on 10/19/2023 at 10:02 a.m., CNA H stated she was working with Resident #2 on the night of 09/13/2023 when he fell. CNA H stated she went on her lunch break and when out to her car to talk on her cell phone. CNA H stated Resident #2 was up in his wheelchair in his room when she left CNA I alone on the unit while she went to break. CNA H explained the nurse for the secured unit was also the nurse for the 200 hall at night time and they stayed out on 200 hall unless they needed them to come back there for something. CNA H stated the nurse came outside and beat on her car hood and signaled for her to come back in the facility. CNA H stated the nurse informed her Resident #2 had fallen and she needed to come in from her break to assist the other aide in getting him up off the floor. CNA H stated Resident #2 had fallen over in the wheelchair because it was on its side when she arrived at the room. CNA H stated Resident #2 was not injured from the fall. CNA H stated the next day there was an in-service that said the staff on night shift had to stay in the building during break. CNA H stated with the nurse on 200 hall there was no way to keep an eye on all the residents if you are assisting another resident and no one else is on the hall. During and observation on 10/19/2023 at 11:35 a.m., Resident #2 was sitting in a wheelchair at the nurse's station. No nurses or CNAs were noted to be at the station at the time. Resident #2 was unattended outside of nursesnurse's station for 10 minutes prior to the nurse returning to the nurses station. During an interview on 10/19/2023 at 2:15 p.m., CNA I stated she recalled Resident #2 falling on 09/13/2023 because she was on the unit alone and she had opened the unit door and hollered for the nurse to come check on him. CNA I stated she was giving care to another resident when she heard (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675966 If continuation sheet Page 15 of 21 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 10/24/2023 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 - Actual harm Residents Affected - Few Resident #2 fall. CNA I stated she had to finish the care she was doing before she could go see what occurred in Resident #2's room. CNA I stated Resident #2 has tipped his wheelchair over and was lying on his side on the floor. CNA I stated he had not appeared to be injured but she went and got the nurse to check him to make sure. CNA I stated there was no way to watch all the residents when they were caring for any resident that took 2 people to care for or if one of them was on break. CNA I stated they did their best and they had not had too many instances where they were left alone and something happened. During an interview on 10/22/2023 at 10:00 a.m., LVN J stated she was the nurse that found Resident #2 on the floor in the 400 hallway on 10/07/2023. LVN J stated she was told by other nurses that Resident #2's family wanted him to be looked after more closely and the staff was to put him at the nurse's station when they got him up. LVN J said it was right after 7:00 a.m., when she was walking toward the nurse's station, she saw him down on the floor. She stated his wheelchair was few feet behind him and it appeared he had gotten up and took a few steps and fell. LVN J stated the CNAs were getting people ready for breakfast and his nurse was in a resident's room. There was no one at the nurse's station to keep an eye on him at that time of day. LVN J stated Resident #2 had to have constant eyes on him unless he was asleep. During an interview on 10/22/2023 at 11:00 a.m., CNA F stated she had assisted Resident #2 many times with getting out of bed and bathing. CNA F stated on 10/16/2023 around 7:15 a.m., she was working on 300 because an aide called in and when she rounded the corner at the nurse's station, she found Resident #2 on the floor lying in a large puddle of blood. CNA F stated she looked for his nurse briefly and could not find her, so she notified the nurse working the 300 hall. CNA F stated LVN K came and assessed the resident and sent him to the hospital. CNA F stated Resident #2 did not need to be left at the nurse's station when no one was around to watch the resident. CNA F stated he was safer in his room if he was unattended because he had padded furniture and fall mats there. During an observation on 10/22/2023 at 11:30 a.m., Resident #2 was sitting at the nurse's station in a wheelchair. Resident #2 had a splint/cast noted to his right arm at this time. No staff was at the nurse's station or in sight of Resident #2 for 20 minutes. The 300-hall nurse and 400- hall nurse that share the nurse's station were checking blood sugars on the hall and the 1 CNA was on break and 1 was providing care to another resident during this time. During an interview on 10/22/2023 at 1:10 p.m., LVN K stated she was the nurse that sent Resident #2 out on 10/16/2023 at 7:40 a.m. LVN K stated she was not the nurse assigned to care for and monitor Resident #2 on 10/16/2023. LVN K stated she was familiar with Resident #2 because he had several falls prior to 10/16/2023 and his family was very vocal at the facility. LVN K stated she could not locate his nurse (RN L) after assessing him, so she continued with the process and sent him to the ER to be evaluated. LVN K stated she was unaware of the reason Resident #2 was left at the nurse's station unattended and his nurse was not in the building to ask who was supposed to be monitoring him. LVN K stated he returned around 2 hours later with some sutures to his eyebrow. LVN K stated later on 10/16/2023 at around 11:00 a.m., Resident #2 was at the nurses' station when he returned from the ER, and he fell again at the nurse's station. LVN K stated she and two other nurses were sitting at the nurses' station with their heads down and did not see what happened that made him fall. Record review of the timesheet for RN L for 10/16/2023, showed she was clocked out from 7:12 a.m. to 7:42 a.m. During an interview on 10/22/2023 at 1:25 p.m., RN L stated she was assigned to the care of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675966 If continuation sheet Page 16 of 21 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 10/24/2023 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 - Actual harm Residents Affected - Few Resident #2 as his charge nurse on 10/16/2023. RN L stated she was not available during his first fall at 7:15 or 7:30 a.m., but she was sitting across from him at the nurse's station when he fell for the second time that day just a few hours later. RN L stated Resident #2 moved quickly when he decided to get up. RN L stated she and the other nurse behind the nurse's station had their heads down and she did not know he had fallen until she heard him hit the floor. During an interview on 10/23/2023 at 10:00 a.m., Resident #2's family stated they attempted to hire a sitter to come in at night and sit with Resident #2 until he became tired and was ready to go to bed in attempt to decrease his agitation and decrease his falls. Resident #2's family stated the approach of some of the staff to a man with dementia was what caused him to become upset and restless. Resident #2's family stated he did not do well with lots of noise or people grabbing him by the clothes to do care. Resident #2's family stated she made all this clear to the facility when he had an episode of being combative and injured his hand. Resident #2's family stated after a week and a half of the sitter coming into the building and helping Resident #2, the Administrator stated she could no longer come be the sitter for Resident #2 because she was employed by the facility prn. Resident #2's family stated the Administrator refused to provide extra supervision for Resident #2 stating this is not a facility that provides 24 hours a day sitters. During an interview on 10/23/2023 at 11:45 a.m., the Administrator stated she did tell the family she could not use the CNA as the sitter for Resident #2 because in the facility handbook it stated no gifts could be received for care given for residents of the facility. The Administrator stated it was the facilities responsibility to come up with interventions for falls and to continue to update the interventions when they do not work to prevent accidents and injuries. The Administrator stated it was ultimately the facilities responsibility to provide adequate supervision to keep all the residents safe. Record review of a policy dated July 2017 titled Safety and Supervision of Residents revealed that the facility strived to make resident safety and supervision and assistance to prevent accidents facility wide priorities. The individualized, resident-centered approach to safety .1. Our individualized resident-centered approach to safety addresses safety and accident hazards for individual residents.4. Implementing interventions to reduce accident risks and hazards shall include the following .communicating specific interventions to all relevant staff; assigning responsibility for carrying out interventions; providing training, as necessary; ensuring the interventions are implemented; and documenting interventions. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675966 If continuation sheet Page 17 of 21 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 10/24/2023 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 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 and sanitary environment and to help prevent the development and transmission of communicable diseases and infections for 1of 1 memory care unit reviewed for infection control and 6 of 24 residents observed during hydration pass. (Resident #6, Resident #7, Resident #8, Resident #9, Resident #10, and Resident #11) Residents Affected - Some The facility failed to ensure the ice scoop for the memory care unit was sanitarily stored while not in use. The facility failed to ensure CNA A did not use a contaminated ice scoop to fill the memory care unit residents' cups with ice. The facility failed to ensure HA C did not cross-contaminate each resident's cup while using an ice scoop to fill Resident #6, 7, 8, 9, 10, and 11's cups during hydration pass. The facility failed to ensure HA C stored the ice scoop sanitarily while not in use during hydration pass. These failures could place residents at risk for cross-contamination and the spread of infection. Findings included: 1. Record review of Resident #6's face sheet dated 10/23/23 indicated Resident #6 was an [AGE] year-old male and admitted to the facility on [DATE] with diagnoses including myopathy (muscle disease), depression (persistent sadness), anxiety (feeling of worry, nervousness, or unease), weakness, hypertension (high blood pressure), cerebral infarction (disruption of blood flow to part of the brain that results in part of the brain dying, also called a stroke), lack of coordination, and repeated falls. Record review of Resident #6's quarterly MDS assessment dated [DATE] indicated Resident #6 was understood and understood others. The MDS indicated a BIMS score of 13 which indicated Resident #6 had no cognitive impairment. 2. Record review of Resident #7's face sheet dated 10/23/23 indicated Resident #7 was a [AGE] year-old female and admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including dementia (progressive or persistent loss of intellectual functioning with impairment or memory and thinking and often with personality changes), neutropenia (abnormally low white blood cells, leading to increased susceptibility to infection), diabetes (high sugar level in the blood), hypertension, heart failure, weakness, and lack of coordination. Record review of Resident #7's annual MDS assessment dated [DATE] indicated Resident #7 was understood and understood others. The MDS indicated a BIMS score of 15 which indicated Resident #7 had no cognitive impairment. Record review of Resident #7's care plan dated 9/15/23 indicated Resident #7 had neutropenia and was at risk for infection with interventions to keep the environment clean and people with infection (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675966 If continuation sheet Page 18 of 21 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 10/24/2023 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 0880 away. Level of Harm - Minimal harm or potential for actual harm 3. Record review of Resident #8's face sheet dated 10/23/23 indicated Resident #8 was a [AGE] year-old female and admitted on [DATE] with diagnoses including weakness, abnormalities of gait, dementia, and malnutrition (lack of proper nutrition). Residents Affected - Some Record review of Resident #8's quarterly MDS assessment dated [DATE] indicated Resident #8 was understood and usually understood others. The MDS indicated a BIMS score of 09 which indicated Resident #8 had moderate cognitive impairment. 4. Record review of Resident #9's face sheet dated 10/23/23 indicated Resident #9 was a [AGE] year-old male and admitted to the facility on [DATE] with diagnoses including muscle wasting, weakness, abnormality of gait, malnutrition, Wernicke's encephalopathy (life threatening illness caused by a thiamine deficiency), hypertension, liver failure, alcohol abuse, and altered mental status. Record review of Resident #9's annual MDS assessment dated [DATE] indicated Resident #9 was understood and understood others. The MDS indicated a BIMS score of 09 which indicated Resident #9 had moderate cognitive impairment. 5. Record review of Resident #10's face sheet dated 10/23/23 indicated Resident #10 was a [AGE] year-old female and admitted to the facility initially on 2/20/23 and readmitted on [DATE] with diagnoses including cerebral infarction, muscle wasting, aphasia (language disorder that affects a person's ability to communicate), right sided weakness after cerebral infarction, diabetes, hypertension, and kidney disease. Record review of Resident #10's quarterly MDS assessment dated [DATE] indicated Resident #10 was usually understood and usually understood others. The MDS indicated a BIMS score of 13 which indicated Resident #10 had no cognitive impairment. 6. Record review of Resident #11's face sheet dated 10/23/23 indicated Resident #11 was an [AGE] year-old female and admitted to the facility on [DATE] with diagnoses including hypertension, muscle wasting, abnormality of gait, malnutrition, depression, anxiety, and Parkinson's (progressive disease of the nervous system marked by tremors and imprecise movements). Record review of Resident #11's annual MDS assessment dated [DATE] indicated Resident #11 was understood and understood others. The MDS indicated a BIMS score of 15 which indicated Resident #11 had no cognitive impairment. During an observation on 10/18/23 beginning at 11:40 AM, observed an ice chest in the memory care dining room and the ice scoop with water droplets on it was sitting in a side table drawer unbagged and sitting on top of a magazine with the drawer open. During an observation on 10/19/23 beginning at 11:20 AM, observed in the Memory Care unit, CNA A fill approximately 10 cups with ice using the ice scoop from the side table drawer that was sitting on top of a magazine and the ice scoop was not in a bag. CNA A then replaced the ice scoop back into the side table drawer on top of the magazine and the ice scoop was not placed in a bag. CNA A then came back at 11:25 AM and removed the unbagged ice scoop from the side table drawer and resumed filling approximately 10 more cups with ice and placed the ice scoop back into the drawer on top of the magazine unbagged when she was finished. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675966 If continuation sheet Page 19 of 21 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 10/24/2023 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an observation on 10/19/23 beginning at 11:33 AM, observed HA C go into Resident #7's room and brought the resident's cup out to the ice chest cart, removed the lid, and filled the cup with ice while touching the ice scoop to the top of the cup, and then placed the ice scoop on a flat area of the cart, and returned cup to the resident. HA C then went into Resident #8's room and brought her water cup out to the ice chest cart, and placed three scoops of ice into cup, and touched the top of the cup each time. HA C then went to Resident #6's room and brought his water cup to ice chest cart, and placed three scoops of ice into his cup, and touched the top of the cup each time. HA C then went into Resident #9's room and brought a small cooler bag to the ice chest cart and filled it with ice and touched the inside of the cooler bag with the ice scoop, and then laid the ice scoop on the flat area of the cart. HA C then went to Resident #10's room and brought her cup to the ice chest cart and filled the cup with ice and put ½ the scoop into the cup and touched the inside of cup with the ice scoop. HA C then went and got Resident #11's cup and brought her cup to the ice chest cart and filled her cup with ice and put ½ the scoop into the cup and touched the inside of cup with the ice scoop. HA C placed the scoop on the flat area of the ice chest cart after filling each resident's cup and small ice bag, until she was at the end of the hall and then HA C placed the ice scoop in the covered scoop holder on the 2nd shelf of the ice chest cart. During an interview on 10/19/23 at 11:42 AM, HA C said she had worked at the facility for almost a month. HA C said the ice chest, ice scoop, and the ice chest cart were cleaned twice daily. HA C said she did touch the tops and inside of the residents' cups and just did not think about it until surveyor asked her about it. HA C said it would be cross-contamination and could transfer germs to other residents and make them sick. During an interview on 10/19/23 at 11:46 AM, CNA B said she had worked at the facility for 2 years. CNA B said she worked on the 400 Hall and now primarily works on the 100 Hall. CNA B said the ice scoop should be stored in a bag. CNA B said if it was not stored in a bag and laid on top of a magazine in a drawer then it would need to be cleaned and sanitized, preferably run through the dishwasher in the kitchen. CNA B said it would be cross-contamination and could make residents sick. During an interview on 10/19/23 at 1:46 PM, ADON D said she was not aware the ice scoop was being stored in the side table drawer by the ice chest in the memory care dining room and it was not in a bag. ADON D said the ice scoop should be stored in a plastic bag when not in use. ADON D said when she realized the scoop was not being stored sanitarily, she sent it to the kitchen to be washed in the dishwasher. ADON D said she then made sure it was placed in a plastic bag when it was returned to the memory care unit. ADON D said the ice scoop being laid in the drawer on top of the magazine without a plastic bag, contaminated the ice scoop with who knows what germs or what else was in there. ADON D said using a contaminated ice scoop to scoop ice from the ice chest and fill the memory care unit residents' drink cups, was an infection control issue and could potentially make residents sick. During an interview on 10/23/23 at 12:30 PM, CNA A said she had worked at the facility for a couple of weeks. CNA A said she usually worked the 6a-2p shift. CNA A said every morning she took the ice chest for the memory care unit to the kitchen and the kitchen staff washed it inside & out and they run the ice scoop through the dishwasher, and she said she wiped the ice chest cart down with disinfectant wipes. CNA A said the ice scoop should be stored in a plastic bag, so it does not become contaminated, and it keeps it clean. CNA A said on 10/19/23, she saw the ice scoop was in the drawer of the side table by the ice chest and it was not in a bag, and she used it anyway. CNA A said, I knew better; I have had been a CNA for 35 years. CNA A said she should have taken the scoop to the kitchen and had it cleaned and not used it to scoop ice with. CNA A said the drawer was nasty and anything could be on the ice scoop, and it could make residents sick. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675966 If continuation sheet Page 20 of 21 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 10/24/2023 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 10/24/23 at 10:30 AM, the DON said it was absolutely not appropriate to store or use an ice scoop that had been in a drawer on top of a magazine without being in a bag to fill ice cups for the residents. The DON said the ice scoop was contaminated and should have been taken to the kitchen to be cleaned/sanitized. The DON said it was not appropriate for HA C to touch the ice scoop to the tops or inside the residents' cups or touch the inside of a resident's ice bag or sit the ice scoop on top of the ice chest cart when not in use. The DON said HA C's actions contaminated the ice scoop and the ice and resulted in cross-contamination between the residents. The DON said it was an infection control issue. During an interview on 10/24/23 at 11:12 AM, the ADM said the ice scoops should be stored in a bag or in an appropriate holder to keep clean. The ADM said if the ice scoops become contaminated then they should be sanitized prior to using. The ADM said storing the ice scoop in the drawer of the side table on top of a magazine unbagged was not sanitary and was an infection control issue. The ADM said the hydration aide touching the ice scoop to or inside each residents' cup while filling cups with ice, could spread infection, and was disgusting. Record review of the facility's policy titled Ice Machines and Ice Chests dated January 2023 revealed . ice storage/distribution containers would be used and maintained to assure a safe and sanitary supply of ice . ice storage chests/containers, and ice could become contaminated by unsanitary manipulation by employees, residents, and visitors . improper storage or handling of ice . keep the ice scoop/bin in a covered container when not in use . clean and sanitize the tray and ice scoop daily . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675966 If continuation sheet Page 21 of 21