Health inspection·June 15, 2023

F 0656 Resident #81 stated the facility staff supervised him when he smoked. Level of Harm - Minimal harm or potential for actual harm Interview on 06/15/23 at 10:51 AM with LVN D stated Resident #81 initially was not a smoker. She stated Resident #81 began to go out on pass with family, and the resident began to smoke. LVN D stated Resident #81 was not a regular smoker but usually smoked in the morning and evening times. Residents Affected - Few Interview on 06/15/23 at 12:48 PM with the DON revealed Resident #81 was a smoker. She stated Resident #81 was not a smoker until recently. The DON stated it had been a couple of weeks since Resident #81 started smoking. The DON stated she did not know whether a safe smoking assessment had been completed on Resident #81. The DON reviewed Resident #81 assessments and indicated his last smoking assessment revealed he was not a smoker. She stated they needed to update his safe smoking assessment. The DON stated safe smoking assessment were completed by her nursing staff. The DON stated Resident #81's care plan also needed to be updated to indicate Resident #81 was a smoker. The DON stated the MDS Coordinator was responsible for updating care plans. The DON stated the risk of not updating all clinical records was not having the most current information on all documents and staff missing a change in residents' care. Interview on 06/15/23 at 1:15 PM with the Social Worker revealed Resident #81 was a smoker. She stated Resident #81 recently started smoking. She stated Resident #81 was not an active smoker, it was something new the resident developed. She stated Resident #81 was recently added to the facility list of residents who smoke. She stated once the facility staff informed her a resident was a smoker it was her responsibility to do a new safe smoking assessment. She stated she might have overlooked Resident #81's assessment. She stated Resident #81's safe smoking assessment had not been updated. The Social Worker stated it was the MDS Coordinator's responsibility to update Resident #81's care plan. She stated the safe smoking assessment were needed to make sure residents were safe smokers and were safe to smoke with other residents. Interview on 06/15/23 at 1:37 PM with the MDS Coordinator revealed she was responsible for updating residents care plans. She stated any care/treatment a resident was receiving at the facility should be care planned. The MDS Coordinator stated she was not aware Resident #81 was a smoker. She stated she was only made aware about two months ago Resident #81's family would provide the resident with cigarettes. She stated she reviewed Resident #81's care plan today (06/15/23) and updated the resident's care plan to include he was a smoker. She stated if a resident was a smoker, it should be included in their care plan, so staff knew residents were safe while smoking and to ensure the safety of others. Review of the facility's Care Planning policy, revised June 2020, reflected: Purpose - To ensure that a comprehensive person-centered Care Plan is developed for each resident based on their individual assessed needs. Policy - The Care Plan serves as a course of action where the resident's family and/or guardian or other legally authorized representative, resident's attending Physician, and IDT work to help the resident move toward resident-specific goals that address the resident's medical, nursing, mental and psychosocial needs. Procedure .IV. The Baseline Care Plan will be updated to reflect changes in the resident's condition or needs occurring prior to the development of the comprehensive care plan. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675977 If continuation sheet Page 2 of 17 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 675977 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Village Creek Nursing & Rehabilitation 3825 Village Creek Rd Fort Worth, TX 76119 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 Review of facility's current, undated Smoking Policy reflected: Smoking Assessments will be completed in all residents that wish to smoke to ensure resident safety while smoking. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675977 If continuation sheet Page 3 of 17 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 675977 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Village Creek Nursing & Rehabilitation 3825 Village Creek Rd Fort Worth, TX 76119 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. 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 with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for one (Resident #37) of two residents reviewed for pressure ulcers in that: Residents Affected - Few 1. The facility failed to order wound supplies as per physician orders when Resident #37 was seen on 06/12/23 by the Wound Care Physician. 2. LVN D failed to update physician wound care orders in the MAR when Resident #37 was seen by the Wound Care Physician on 06/12/23. These failures placed residents at risk for deterioration of existing pressure ulcers. Findings included: Review of Resident #37's face sheet revealed Resident #37 was an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses senile degeneration of brain and Stage 3 pressure ulcer of sacral region. Review of physician's orders dated 06/12/23 revealed Resident #37's had a Stage 3 sacrum wound that measured 11 cm x 6 cm x 1 cm. The order reflected: cleanse sacrum with normal saline pat dry/apply slightly soaked gauze with Dakin solution 0.125 % (Sodium Hypochlorite), cover with dry dressing. Review of Resident #37's quarterly MDS assessment dated [DATE] revealed the resident had severe cognitive impairment, required extensive assistance of two persons for bed mobility, was totally dependent on two persons for dressing, and was totally dependent upon two people for transfers, eating and bathing. The MDS reflected the resident had one Stage 3 pressure ulcer. Review of Resident 37's June 2023 MAR and TAR revealed there were no new wound care orders. The old orders were to cleanse the wound, apply calcium alginate and cover with dry dressing. Review of Resident #37's Wound Care Physician's notes/assessment, dated 06/06/23, revealed the resident was assessed to have a 10 cm x 6 cm x 0.5 cm (length x width x depth) Stage 3 pressure ulcer on her sacrum. The wound was assessed with slough necrosis ((non-viable tissue due to reduced blood supply), and (dead tissue, usually cream or yellow in color) and the etiology was pressure. The orders were to cleanse with normal saline apply calcium alginate daily and as needed and cover with dry dressing. Review of the Wound Care Physician's notes/assessment, dated 06/12/23, revealed the resident was assessed to have an 11 cm x 6 cm x 1 cm Stage 3 on her sacrum. The wound was assessed with slough necrosis and the etiology was pressure. The Wound Care Physician's comments revealed the wound was deteriorating due to the resident's decline. The orders were to clean the resident's sacrum with normal saline, pat dry, apply a slightly soaked gauze with Dakin's (1/4 strength) External Solution 0.125 % (Sodium Hypochlorite), and cover with dry dressing. Observation on 06/14/23 at 3:18 PM of LVN E providing Resident #37 with wound care revealed she (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675977 If continuation sheet Page 4 of 17 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 675977 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Village Creek Nursing & Rehabilitation 3825 Village Creek Rd Fort Worth, TX 76119 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few disinfected the table and left it to dry. She removed her gloves, washed her hands, and put the supplies together. She wheeled the table to Resident#37's bedside. She then washed her hands, put on gloves, and removed the old dressing on Resident #37's sacrum. Next, LVN E doffed her gloves, washed her hands, and donned new gloves. She cleansed the wound with normal saline, doffed her gloves, washed her hands, and donned new gloves. LVN E then applied calcium alginate and covered the pressure ulcer with a dry dressing. Interview on 06/14/23 at 4:41 PM with the Wound Nurse, LVN D, she stated she was the one that did the wound rounds with the Wound Care Physician on 06/12/23. LVN D stated she got all the orders, and she forgot to put new orders for Resident #37 on the MAR and order the wound supplies from the pharmacy. She stated she was aware she was supposed to document the new orders on the MAR the same day and notify the pharmacy of the new orders. LVN D stated on 06/13/23 she performed wound care on Resident #37, and she did not remember the resident's treatment was changed. On 06/14/23 LVN D was observed assisting LVN E with wound care and she did not notify her that the resident had a new order. LVN D stated she forgot about the orders until when this surveyor requested for the latest Wound Care Physician progress notes. LVN D stated she failed to notify the DON of the new orders to use Dakin solution instead of calcium alginate, and she did not order for the supplies. LVN D stated she was aware she was supposed to notify the doctor the facility was out of Dakin solution. LVN D stated failure to follow the physician orders would not promote healing of the wound, and failure to act on physician orders would make residents miss being administered the right treatment. Interview on 06/14/23 at 4:50 PM with the Wound Nurse, LVN E, she stated was not a full-time nurse, and she did not know Resident # 37 had new wound care orders. LVN E stated she followed the orders on the June 2023 MAR. LVN E stated she was aware once the physician changed the order the nurses were supposed to update the orders on the MARS and notify the DON. LVN E stated in case the new orders supplies were not available they were supposed to notify the physician and the DON, and they were supposed to document in the progress notes. Interview on 06/15/23 at 12:55 PM with the DON revealed her expectation was physician orders were supposed to be updated the same day they were received. She stated she received the same orders as the Wound Nurse from the Wound Care Physician. The DON stated she and other nurses were supposed to follow-up and ensure the new orders were updated in the MAR and faxed to the pharmacy. The DON stated she did not check whether the orders were updated the following morning on 06/13/23 on the MAR because she got busy with the surveyors. She stated she noticed the orders were missing after the surveyor asked for the doctor's progress notes. The DON stated failure of the nurses to act upon physician orders could create a problem because every change made by the doctor was necessary for the resident's treatment. The DON stated the wound care supplies were ordered on 06/15/23. Review of the facility's Pressure Injury Prevention policy, revised June 2020, reflected: .any resident who has wound will receive necessary treatment and services to promote healing, prevent infection and prevent new pressure injuries from developing. a) The attending physician will be notified to advise on appropriate treatment promptly. .f) Per the attending physician order the nursing staff will initiate treatment and utilize interventions for pressure redistribution and wound management FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675977 If continuation sheet Page 5 of 17 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 675977 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Village Creek Nursing & Rehabilitation 3825 Village Creek Rd Fort Worth, TX 76119 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 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on interview and record review the facility failed to use the services of a registered nurse for at least eight consecutive hours a day, seven days a week for 16 of 34 days (02/26/23, 03/04/23, 03/05/23, 04/02/23, 04/08/23, 04/09/23, 04/15/23, 04/22/23, 04/29/23, 05/20/23, 05/21/23, 05/28/23, 06/03/23, 06/04/23, 06/10/23, and 06/11/23) reviewed for nursing services. The facility failed to have RN coverage for eight consecutive hours for 7 days (Saturdays and Sundays) between 02/26/26 until 06/11/23. This failure could place residents at risk for missed resident nursing assessments, interventions, care, and treatment. Findings included: Record review of timecards for RN F, RN G and RN H for the time-period of 02/26/23 to 06/11/23 revealed there was not eight consecutive hours of RN coverage for 16 out of 34 days (02/26/23, 03/04/23, 03/05/23, 04/02/23, 04/08/23, 04/09/23, 04/15/23, 04/22/23, 04/29/23, 05/20/23, 05/21/23, 05/28/23, 06/03/23, 06/04/23, 06/10/23, and 06/11/23) reviewed for weekend RN coverage on Saturdays and Sundays. Record review of the Employee Timesheets for the time-period of 02/14/23 to 06/11/23 revealed the following for RN F and RN G: - Sunday 02/26/23, RN F timesheet: Time in 6:12 PM (Sunday) - Out 7:42 AM (Monday); 5.48 hours worked on Sunday 02/26/23. - Saturday 03/04/23, RN F timesheet: Time in 4:49 PM (Saturday) - Out 7:02 PM (Saturday); Time in 8:57 PM (Saturday) - Out 2:50 AM (Sunday); 5.43 hours worked on Saturday 03/04/23. - Sunday 03/05/23, RN F timesheet: Time in 6:00 PM (Sunday) - Out 3:04 AM (Monday); 6.00 hours worked on Sunday 03/05/23. - Sunday 04/02/23, RN G timesheet: Time in 10:00 PM (Sunday) - Out 7:15 AM (Monday); 2.00 hours worked on Sunday 04/02/23. - Saturday 04/08/23, RN G timesheet: Time in 10:00 PM (Saturday) - Out 7:06 AM (Sunday); 2.00 hours worked on Saturday 04/08/23. - Sunday 04/09/23, RN G timesheet: Time in 10:00 PM (Sunday) - Out 7:05 AM (Monday); 2.00 hours worked on Sunday 04/09/23. - Saturday 04/15/23, RN G timesheet: Time in 6:06 PM (Saturday) - Out 6:15 AM (Sunday); 5.54 hours worked on Saturday 04/15/23. - Saturday 04/22/23, RN F timesheet: Time in 2:14 PM (Saturday) - Out 7:35 PM (Saturday); 5.21 hours worked on Saturday 04/22/23. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675977 If continuation sheet Page 6 of 17 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 675977 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Village Creek Nursing & Rehabilitation 3825 Village Creek Rd Fort Worth, TX 76119 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 0727 Level of Harm - Minimal harm or potential for actual harm - Saturday 04/29/23, RN F timesheet: Time in 10:34 PM (Saturday) - Out 8:12 AM (Sunday); 1.26 hours worked on Saturday 04/29/23. - Saturday 05/20/23, RN F timesheet: Time in 10:16 PM (Saturday) - Out 8:26 AM (Sunday); 1.44 hours worked on Saturday 05/20/23. Residents Affected - Some - Sunday 05/21/23, RN F timesheet: Time in 10:39 PM (Sunday) - Out 8:00 AM (Monday); 1.21 hours worked on Sunday 05/21/23. - Sunday 05/28/23, RN F timesheet: Time in 11:11 PM (Sunday) - Out 9:37 AM (Monday); 49 minutes worked on Sunday 05/28/23. - Saturday 06/03/23, RN F timesheet: Time in 6:13 PM (Saturday) - Out 8:13 PM (Saturday); Time in 9:15 PM (Saturday) - Out 6:54 AM (Sunday); 4.45 hours worked on Saturday 06/06/23. - Sunday 06/04/23, RN F timesheet: Time in 7:41 PM (Sunday) - Out 5:52 AM (Monday); 4.19 hours worked on Sunday 06/04/23. - Saturday 06/10/23, RN F timesheet: Time in 6:15 PM (Saturday) - Out 7:27 AM (Sunday); 5.45 hours worked on Saturday 06/10/23. - Sunday 06/11/23, RN F timesheet: Time in 6:20 PM (Sunday) - Out 8:01 PM (Sunday); Time in 10:26 PM (Saturday) - Out 6:58 AM (Monday); 3.07 hours worked on Sunday 06/11/23. Interview on 06/14/23 at 4:27 AM with the Staffing Coordinator revealed she had been working at the facility since October 2022. She stated she was responsible for completing the nursing schedules. She stated the DON and ADON reviewed the nursing schedules once they were completed. She stated she was aware of the 8 hours but not aware RN coverage needed to be eight consecutive hours a day. She stated she was never informed otherwise from the ADON or the DON regarding the staffing schedules. Interview on 06/15/23 at 12:21 PM with the DON revealed the Staffing Coordinator was responsible for completing the nursing schedule. She stated the ADON and herself were responsible for overseeing the schedules and if she was not working the Administrator was responsible. The DON stated she was aware of the 8 hours RN coverage; however, she was not aware of the consecutive hours needing to be on the same day. She stated it was important to have an RN in the facility because they oversaw the LVNs and could provide resource skills and clinical guidance to other staff. Interview on 06/15/23 at 12:58 PM with the Administrator revealed the Staffing Coordinator was responsible for completing nursing schedules, and the ADON and DON were responsible for overseeing the schedules. She stated she reviewed her nurses' timecards and she did not observe any discrepancies regarding weekend RN Coverage. The Administrator stated she was aware of the 8 hours a day but was not aware the RN coverage needed to be 8 consecutive hours on the same day. The facility policy was requested; however, it was not provided prior to exit. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675977 If continuation sheet Page 7 of 17 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 675977 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Village Creek Nursing & Rehabilitation 3825 Village Creek Rd Fort Worth, TX 76119 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure all irregularities identified by the Pharmacist Consultant were reported to the attending physician and acted upon to minimize or prevent adverse consequences to the extent possible for 4 residents (Resident #78, Resident #77, Resident #45 & Resident #33) of 7 resident reviewed for drug regimen reviews, in that: 1. On 03/08/23 the Pharmacist Consultant recommended adding heart rate (pulse) to current hold parameters to Resident #78's order for Coreg (alpha and beta blocker used for hypertension) due to the medication having an effect on heart rate. The physician acknowledged the recommendation; however, the facility failed to ensure that the order was updated with hold parameters for pulse. 2. On 03/08/23 and 05/08/23 the facility's Pharmacist Consultant recommended that Resident #77 have a complete and signed informed consent on file for the use of Seroquel (antipsychotic medication). The physician acknowledged the recommendation; however, the facility failed to obtain a completed and signed informed consent from Resident #77's responsible party until 06/15/23. 3. On 03/09/23 the facility's Pharmacist Consultant recommended that Resident #45 have a complete and signed informed consent on file for the use of Nuedexta (central nervous system agent used as a mood stabilizer). The physician did not sign the recommendation and the facility failed to obtain a completed and signed informed consent from Resident #45 until 06/15/23. 4. On 04/12/23 the facility's Pharmacist Consultant recommended that Resident #33 have a complete and signed informed consent on file for the use of Seroquel (antipsychotic medication). The physician acknowledged the recommendation; however, the facility failed to obtain a completed and signed informed consent from Resident #33's responsible party until 06/15/23. These failures could place residents who require monthly drug regimen reviews and placed them at risk of receiving unnecessary medications and adverse drug consequences. Findings included: 1. Record review of Resident #78's Face Sheet revealed the resident was a [AGE] year-old female who admitted to the facility on [DATE]. Resident #78 had diagnoses that included: bipolar disorder (mood disorder), hypertension (high blood pressure), disorder of nervous system, and insomnia (sleep disorder). Record review of Resident #78's quarterly MDS assessment, dated 05/24/23, revealed Resident #78 had severe cognitive impairment with a BIMS score of 7. The MDS reflected Resident #78 exhibited behavioral symptoms that included: feeling down nearly every day, feeling tired half or more of the days, and trouble concentrating half or more of the days. The MDS also reflected Resident #78 had a diagnosis of hypertension. Record review of Resident #78's care plan, dated 06/07/23, revealed she had hypertension. The care plan interventions included the following: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675977 If continuation sheet Page 8 of 17 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 675977 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Village Creek Nursing & Rehabilitation 3825 Village Creek Rd Fort Worth, TX 76119 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 0756 -avoid taking the blood pressure reading after physical activity or emotional distress Level of Harm - Minimal harm or potential for actual harm -monitor and document any edema (swelling) Residents Affected - Some -monitor/document/report to MD as needed and signs and symptoms of malignant hypertension (severe high blood pressure), headache, visual problems, confusion . Record review of Resident #78's physician orders, dated 02/02/23, revealed orders for Coreg oral tablet 25 mg, 1 tablet PO BID for hypertension; hold if systolic blood pressure less than 100 or diastolic blood pressure less than 60. Record review of Resident #78's MAR revealed the medication, Coreg 25 mg, was being administered as ordered. There were only hold parameters for blood pressure listed in order. Record review of the Pharmacist Consultant's report, dated 03/08/23, revealed a recommendation noted to the attending physician for Resident #78: The following medications have an effect on heart rate. I recommend adding heart rate (pulse) to current hold parameters: Coreg. The recommendation was signed by Resident #78's physician and noted, Already in PCC. 2. Record review of Resident #77's Face Sheet revealed the resident was a [AGE] year-old femaile who was admitted to the facility on [DATE] and re-admitted on [DATE]. Resident #77 had diagnoses that included: other Alzheimer's disease (memory loss), psychotic disorder with delusions (mental disorder), cognitive communication deficit, and anxiety disorder. Record review of Resident #77's quarterly MDS assessment, dated 04/28/23, revealed Resident #77 had severe cognitive impairment with a BIMS score of 5. The MDS reflected the resident exhibited no behavioral symptoms, had diagnoses of psychotic disorder and anxiety disorder, and received anti-psychotic medications. Record review of Resident #77's care plan, dated 06/09/23, revealed the resident required psychotropic medications. The care plan interventions included: discussed with MD , family re[[NAME]] ongoing need for use of medication. -monitor and document for side effects and effectiveness . Record review of the Pharmacist Consultant's report, dated 03/08/23, revealed a recommendation noted to the attending physician for Resident #77: Informed consents on file for Seroquel are dose/directions specific: Dose/directions have changed therefor new consent is required. Please ensure that consent is completed on Form 3713. The recommendation was signed by Resident #77's physician, with no date of signature. Record review of Resident #77's physician orders dated 03/11/23 revealed orders for: Seroquel oral tablet 25mg (Quetiapine Fumarate) Give 1 tablet by mouth two times a day related to Psychotic disorder with delusions due to known physiological condition. Discontinued 05/23/23. Record review of Form 3713 (Consent for Antipsychotic or Neuroleptic Medication Treatment dated 03/09/23, for Resident #77 was not completed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675977 If continuation sheet Page 9 of 17 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 675977 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Village Creek Nursing & Rehabilitation 3825 Village Creek Rd Fort Worth, TX 76119 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of pharmacist consultant's report, dated 05/08/23, revealed a recommendation noted to the attending physician for Resident #77: Informed consents on file for Seroquel are dose/directions specific: Dose/directions have changed therefore new consent is required. Please ensure that consent is completed on Form 3713. The recommendation was signed by Resident #77's physician, with no date of signature. Record review of Resident #77's physician orders, dated 05/23/23, revealed orders for: Seroquel oral tablet 25mg (Quetiapine Fumarate) Give 0.5 tablet by mouth two times a day related to Psychotic disorder with delusions due to known physiological condition give 12.5 po bid. Record review of Form 3713 (Consent for Antipsychotic or Neuroleptic Medication Treatment dated 05/25/23, for Resident #77 was not completed. Record review of Resident #77's May and June MAR revealed that the medication, Seroquel 25 mg, was being administered as ordered. 3. Record review of Resident #45's Face Sheet revealed the resident was a [AGE] year-old female who admitted to the facility on [DATE] and re-admitted on [DATE]. Resident #45 had diagnoses that included: vascular dementia (memory loss caused by stroke), major depressive disorder (mood disorder), pseudobulbar affect (involuntary laughter or crying/nervous system disorder), edema (swelling/fluid retention), and congestive heart failure. Record review of Resident #45's quarterly MDS assessment, dated 05/05/23, revealed Resident #45 had severe cognitive impairment with a BIMS score of 00, exhibited no behavioral symptoms, -had a diagnosis of depression, and received anti-depressant medications. Record review of Resident #45's care plan, dated 06/05/23, revealed she had a mood problem related to pseudobulbar affect. The care plan interventions included: -administer medications as ordered -monitor and document for side effects and effectiveness -assist the resident to identify strengths, positive coping skills and reinforce these -Monitor/record mood to determine if problems seem to be related to external causes, i.e., medications, treatments, concern over diagnosis. Record review of Resident #45's physician orders, dated 01/29/23, revealed orders for: Nuedexta (Dextromethorphan-Quinidine) Capsule 20-10 mg, 1 capsule PO BID related to Pseudobulbar Affect. Record review of Resident #45's June 2023 MAR revealed that the medication, Nuedexta 20-10 mg, was being administered as ordered. Record review of pharmacist consultant's report, dated 03/09/23, revealed a recommendation noted to the attending physician for Resident #45: Resident has an order for Trazodone and Nuedexta. Please ensure informed consent has been obtained and is available in the chart. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675977 If continuation sheet Page 10 of 17 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 675977 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Village Creek Nursing & Rehabilitation 3825 Village Creek Rd Fort Worth, TX 76119 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 0756 The recommendation was not signed by Resident #45's physician. Level of Harm - Minimal harm or potential for actual harm 4. Record review of Resident #33's Face Sheet revealed the resident was a [AGE] year-old female who admitted to the facility on [DATE] and re-admitted on [DATE]. Resident #33 had diagnoses that included: dementia (memory loss), psychotic disorder with delusions (mental disorder), major depressive disorder (mood disorder), cognitive communication deficit, and epilepsy (seizure disorder). Residents Affected - Some Record review of Resident #33's quarterly MDS assessment, dated 05/25/23, revealed Resident #33 had severe cognitive impairment with a BIMS score of 00, exhibited no behavioral symptoms, -had a diagnosis of psychotic disorder, anxiety disorder and depression, and received anti-psychotic and anti-depressant medications. Record review of Resident #33's care plan, dated 06/09/23, revealed she received antipsychotic medications and was at an increased risk for adverse reactions to medications. The care plan interventions included: -administer medications as ordered -monitor and document for side effects and effectiveness -consult with pharmacy, MD to consider dosage reduction when clinically appropriate. Record review of Resident #33's physician orders, dated 04/14/23, revealed orders for: Quetiapine Fumarate (Seroquel - antipsychotic medication) 50 mg tablet, PO BID for anti-psychosis. Record review of pharmacist consultant's report, dated 04/12/23, revealed a recommendation noted to the attending physician for Resident #33: Informed consent for Seroquel is incomplete: missing resident signature. Please ensure that each section is filled out completely . The recommendation was signed by Resident #33's physician, with no date of signature. Interview on 06/12/23 at 7:02 PM with Resident #33 revealed she was well and had no concerns. Resident #33 was unable to complete a full interview due to cognitive deficits. Interview on 06/12/23 at 7:52 PM with Resident #77 revealed she was well and had no concerns. Resident #77 stated she received all her medications and denied feeling unwell or having any issues. Interview on 06/13/23 at 9:40 AM with Resident #78 revealed she had no concerns. Resident #78 stated she received all her medications and denied feeling unwell or having any issues related to medications she received. Resident #78 stated that her blood pressure was checked daily but was unsure if her heart rate was being monitored. Interview on 06/15/23 at 10:35 AM with Resident #45 revealed she could not recall if she signed consent forms for her medications. She denied having any issues with the medications she was currently taking. Interview on 06/15/23 at 11:15 AM with Resident #33's responsible party was unsuccessful due to no response to phone call. Interview on 06/15/23 at 12:59 PM with the DON revealed that once the Pharmacy Consultant made any (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675977 If continuation sheet Page 11 of 17 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 675977 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Village Creek Nursing & Rehabilitation 3825 Village Creek Rd Fort Worth, TX 76119 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some recommendations or reported irregularities with medications, the ADON was responsible for following up with the physician. The DON stated it was then her responsibility to oversee and ensure that everything was acted on. The DON stated the ADON was currently on leave. The DON stated it was her responsibility to ensure consents were being signed. The DON stated the pharmacist's recommendation for heart rate parameters to be added to Resident #78's order for the medication, Coreg, was not updated due to an oversight. She stated the risk of not updating the order could be administering the medication with the resident's heart rate being outside of the recommended parameters, which could result in the resident's heart rate being too low or too high, passing out, or heart stopping. The DON also stated that it was the ADON's responsibility to ensure that all consent forms for psychotropic medications were completed and signed by the resident or responsible parties. The DON stated she was unaware that Resident #77's, Resident #33's and Resident #45's consent forms were not being completed. The DON stated consent forms were necessary to prevent administering medications against a resident's will, and not obtaining one could be a violation of the resident's rights. Interview on 06/15/23 at 1:28 PM with the Nurse Practitioner revealed she had worked for the facility since April 2023 and tended to all residents. The Nurse Practitioner stated she acknowledged at that time, that the pharmacy recommended Resident #78's order for the medication Coreg include parameters for the heart rate and that it was signed by the attending physician. She denied being at the facility at the time the recommendation was made and could not comment on why the order had not been updated in the resident's chart. The Nurse Practitioner stated that the medication, Coreg, was known to affect the heart rate and her concern would be more for a low heart rate. She stated an irregularly low heart rate would be considered below 60. She stated the risk to Resident #78 if given a medication that could potentially lower the heart rate if her heart rate was already too low could be light headedness and increased risk of falls. Interview on 06/15/23 at 1:46 PM with MA B revealed he had worked at the facility since 2018. He stated when administering medications, he referred to the orders on the MAR, which informed him of the correct resident, medication, time, dose, and route. MA B stated the MAR also had special notes for certain medications, like hold parameters. He opened Resident #78's MAR to check for special notes on all hypertension medications, including Coreg, and found that there were only hold parameters listed for the blood pressure. He stated there were no hold parameters listed for heart rate. He stated that based on his experience, when taking the blood pressure readings, he would know to also check the heart rate (pulse) even without parameters listed in the orders. MA B stated a heart rate (pulse) reading below 60 would prompt him to hold medications and report it to the charge nurse. He stated that he could not comment on what other medication aides would know to do. Record review of the facility's Drug Regimen Review policy, revised June 2020, reflected: Purpose: The intent is that the facility maintains the resident's highest practical level of physical, mental, and psychosocial well-being and prevents or minimizes adverse consequences related to medication therapy to the extent possible, by providing oversight by a licensed pharmacist, attending physician, medical director, and the DON. Policy: I. The pharmacist will review each resident's medication regimen at least once a month to identify irregularities and to identify clinically significant risks and/or actual potential adverse consequences which may result from or be associated with medications. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675977 If continuation sheet Page 12 of 17 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 675977 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Village Creek Nursing & Rehabilitation 3825 Village Creek Rd Fort Worth, TX 76119 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some II. The pharmacist will report any irregularities to the attending physician and the facility's medical director and director of nursing, and these reports must be acted upon Procedure: . IV. The attending physician will respond to any irregularities reported by the pharmacist by reviewing the irregularities and documenting in the resident's medical record that the irregularity has been reviewed, and what, if any, action has been taken to address it. a. If no action has been taken, the attending physician must document his/her rationale. b. Documentation by the attending physician must occur within 30 days of issuance of the pharmacist's report, unless the irregularity is an emergent issue requiring immediate action. V. The medical director and DON will also review the pharmacist's report if any irregularities are identified. a. The DON is responsible for following up with the attending physician, as indicated. Record review of the facility's Resident Census and Conditions of Residents Form 672, dated 06/12/23, reflected 17 residents received antipsychotic medications and 40 residents receiving antidepressant medications. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675977 If continuation sheet Page 13 of 17 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 675977 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Village Creek Nursing & Rehabilitation 3825 Village Creek Rd Fort Worth, TX 76119 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 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen. Residents Affected - Some The facility failed to ensure food items and clean dishes were kept away from airborne contaminants and an unsanitary environment. These failures could place all residents, who receive food from the kitchen, at risk for food contamination and food-borne illness. Findings included: Observation of the kitchen on 06/12/23 at 6:30 PM revealed the ceiling just above the food preparation area was splattered with an unknown brown substance, with some spots shiny and sticky-like. The ceiling just above where the pots and pans were stored had an unknown yellowish, hard, and textured substance in multiple spots. In the same area, one vent on the ceiling was observed with rust and fluttering lint. Interview on 06/12/23 at 6:45 PM with [NAME] A revealed all kitchen staff were trained and in-serviced on kitchen sanitation several times per month and as needed. She stated it was the responsibility of all kitchen staff to maintain the cleanliness of the kitchen. She stated general cleaning of the kitchen such as sweeping, mopping, washing dishes and wiping down the counters and equipment was done daily. She stated that deep cleaning was done weekly. [NAME] A did not know who was responsible for cleaning the ceiling and stated that she had never done so. Interview on 06/13/23 at 10:00 AM, the Dietary Manger stated she had a cleaning schedule implemented for all shifts to follow; however, she no longer required the staff to sign off on a form because she could see that the tasks were being completed. The Dietary Manager stated there was a daily, weekly, and monthly cleaning schedule, but she expected thorough cleaning daily. She stated all kitchen staff were trained and in-serviced on kitchen sanitation at least monthly. She stated the maintenance staff were responsible for cleaning the vents and ceiling. The Dietary Manager stated she was aware of the debris on the ceiling but was unsure how it got there or what it was. She stated the dirty ceiling did not look sanitary but that it did not risk any harm to the residents because, although it was above a food preparation area, the substance would not drip or fall into the food. The Dietary Manager stated that if any dust or debris fell onto the pots and pans, the staff would see it and know to wash before use. Interview and observation on 06/15/23 at 11:30 AM with the Maintenance Director revealed that the ceiling had been cleaned and all vents were cleaned and replaced with new covers. The Maintenance Director stated he had worked at the facility for about a year and a half, and he was unaware that it was his department's responsibility to keep the kitchen ceiling clean. However, he stated it was his responsibility to clean the vents and replace the filters very 60 days. Interview on 06/15/23 at 2:45 PM with the Administrator revealed her expectation was for the kitchen to be clean and sanitary. She stated it was the kitchen staff's responsibility to ensure that the entire kitchen, including the ceiling, was cleaned. However, she stated that in the past there were (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675977 If continuation sheet Page 14 of 17 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 675977 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Village Creek Nursing & Rehabilitation 3825 Village Creek Rd Fort Worth, TX 76119 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some older staff in the kitchen who were unable to reach higher surfaces, so the task of cleaning the ceiling had been given to the maintenance staff. The Administrator stated there might have been a miscommunication between the newer staff about whose responsibility it was to keep the ceiling clean. She stated the Maintenance Director had agreed to do weekly checks moving forward. The Administrator agreed with the Dietary Manager and stated the debris and substances splattered on the ceiling was not an actual risk to the residents, other than creating an unsanitary environment, because the substances were stuck and not falling onto the food. Record review on 06/13/23 at 10:30 AM of the facility's current, undated Monthly Cleaning Schedule revealed the task of cleaning the ceiling. The entire document was blank, with no staff initials or signatures to indicate that the tasks were completed. A signed cleaning schedule was requested from the Dietary Manager, and she was unable to provide one. Record review of the facility's policy titled Cleaning Schedule, revised December 2022, reflected: Purpose: To establish guidelines for maintaining a routine cleaning schedule. Policy: The nutrition services staff will maintain a sanitary environment in the nutrition services department by complying with the routine cleaning schedule developed by the nutrition services manager. Procedures: I. The nutrition services manager will develop a cleaning schedule that includes the frequency of which equipment and areas are to be cleaned. a. The cleaning schedule is posted weekly. b. The cleaning schedule includes tasks assigned to specific positions within the nutrition services department. c. Nutrition services staff will initial next to the assigned task once it is completed. II. The nutrition services manager monitors the cleaning schedule to ensure compliance. Record review of the Federal Drug Administration Food Code dated 2017 section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils revealed (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) Nonfood-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675977 If continuation sheet Page 15 of 17 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 675977 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Village Creek Nursing & Rehabilitation 3825 Village Creek Rd Fort Worth, TX 76119 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 maintain an infection prevention and control program designated to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 3 (Resident #24, Resident #83, and Resident#69) of 5 residents reviewed for infection control. Residents Affected - Some The facility failed to ensure MA C disinfected the blood pressure cuff in between blood pressure checks for Residents #24, #83, and #69. This failure could place residents at-risk of cross contamination which could result in infections or illness. Findings included: Review of Resident# 24's quarterly MDS assessment, dated 05/25/23, revealed the resident was [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included elevated blood pressure, muscle weakness, and cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it). Resident #24 had severe cognitive impairment with a BIMS score of 5. Review of Resident #24's June 2023 physician orders revealed an order for Nifedipine 30 mg one tablet daily. Review of Resident #83's Comprehensive MDS assessment, dated 05/06/23, revealed the resident was [AGE] year-old female admitted to the facility on [DATE] with diagnoses including elevated blood pressure, hyperlipidemia (an abnormal high concentration of fats or lipids in the blood), and muscle weakness. Resident#83 was unable to complete the interview for cognition assessment. Resident #83 had moderate cognitive impairment with a BIMS score of 8. Review of Resident #83's June 2023 Physician Orders revealed an order for Nifedipine 60 mg one tablet by mouth, two times a day. Review of Resident #69's Quarterly MDS assessment, dated 04/21/23, reflected the resident was a [AGE] year-old female who admitted to the facility on [DATE]. The resident had diagnoses including elevated blood pressure, anxiety, and muscle weakness. Resident#69 had moderate cognitive impairment with a BIMS score of 12. Review of Resident #69's [NAME] 2023 physician orders revealed orders for Metoprolol tablet 25 mg give 1 tablet by mouth one time a day, Amlodipine tablet 10 mg 1 tablet by mouth daily, and Lisinopril tablet 2.5 mg give 1 tablet by mouth daily. Observation on 06/14/23 at 7:39 AM revealed MA C performing morning medication pass, during which time MA C checked Resident #24's blood pressure. MA C did not sanitize the blood pressure cuff after using it on Resident #24. MA C put the blood pressure cuff on top of the medication cart after use. Observation on 06/14/23 at 7:47 AM revealed MA C continued to perform morning medication pass, during which time she checked the blood pressure on Resident #83. MA C used the same blood pressure cuff (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675977 If continuation sheet Page 16 of 17 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 675977 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Village Creek Nursing & Rehabilitation 3825 Village Creek Rd Fort Worth, TX 76119 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 right after using it on Resident#24. MA C did not disinfect the blood pressure cuff before or after using it on Resident #83. She left the blood pressure cuff on top of the medication cart. Observation on 06/14/23 at 7:54 AM revealed MA C continued to perform morning medication pass, during which time she checked Resident #69's blood pressure. MA C used the same blood pressure cuff right after using it on Resident#83. MA C did not disinfect the blood pressure cuff before or after using it on Resident #69. Interview on 06/14/23 at 8:01 AM, MA C stated reusable equipment, like blood pressure cuffs, should be disinfected with wipes between each resident use (before and after use on each resident) to prevent transmitting of infection from one resident to another. MA C stated she forgot to wipe the cuff this time because she did not have the wipes in the cart. MA C stated she had done training on infection control and cleaning of reusable equipment. Interview on 06/14/23 at 2:19 PM with the DON revealed her expectation was that staff would disinfect all reusable equipment between each resident use. The DON stated failure to disinfect the blood pressure placed residents at risk of cross contamination from one resident to another. The DON stated she was responsible for training staff on infection control. The DON stated she had trained her staff on infection control on 06/08/23 and MA C was among those that attended the training. Record review of facility's Cleaning and Disinfecting resident Care Items and equipment, policy, revised May 2017, reflected: .non-critical items are those that come in contact with intact skin but not mucous membranes bed pans, blood pressure cuffs .Reusable items are cleaned and disinfected or sterilized between residents FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675977 If continuation sheet Page 17 of 17