Health inspection·December 3, 2025

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few administration of ABH gel and pain medication, resident assessed, Neuro check initiated, no changes noted during assessment, no complain of pain or discomfort, CNA assigned assisted to bed to provide incontinent care and transfer to W/C and taking to nurses station to close monitor and continue Neuro check, resident was taken to activities for continued supervision. Record review of Resident #1's Fall with Injury assessment dated [DATE] at 10:00 AM reflected, Incident location: Resident's room. Incident Description: Resident found on her left side of on mattress by LVN charge nurse. Resident unable to give description. Immediate Action Taken: LVN charge nurse assessed resident. Resident assisted back into bed by LVN charge nurse and CNA. Hospice in facility for visit. Injuries Observed at time of incident Injury Type: No injuries observed at time of incident. Injuries Reported Post Incident: No injuries observed post incident. Other Info: resident has hx of combative behavior, attempting to transfer self out of bed and covering face with blanket, resistant to care. People notified [Family Member A, Hospice Nurse E and Hospice MD]. Record review of Resident #1's Neurological Assessment Flow Sheet dated 10/09/25 from 10:00 AM to 9:45 PM] reflected no there were no concerns regarding Resident #1's level of consciousness, pupil response, motor functions, pain response, or vitals. Record review of Resident #1's Hospice Nurse Recertification notes documented by Hospice Nurse E for her visit with Resident #1 on 10/09/25 at 11:50 AM until 2:34 PM reflected: Integumentary [Skin] Status - New skin impairment(s) during past 60/90/180 days. Patient Wound: #1, Location: Periorbital swelling to left eye. Patient was placed in front of main nursing station by [LVN A]. Requested facility staff to transfer patient to bed so ‘I' could observe her transfer with Hoyer and complete skin exam. Spoke to patient and requested we place her in bed. When asked if she was ready to go back to bed she stated ‘no' and refused. Spoke to patient calmly to request her to allow transfer and she grabbed my lanyard and pulled it off my neck. Retrieved lantern from patients lap. Pictures taken of swelling to patients face at this time. Unable to complete skin exam until later in afternoon. Patient was transferred by Hoyer lift on 2nd shift. She was fearful but calm. She did not attempt to assault staff and verbalized her fear of being transferred by Hoyer lift. Reassured her that we would take care of her and not let her get hurt. Patient was safely transferred and skin assessment completed. Patient skin is intact. She continues to have swelling on left periorbital and temporal region as documented in wounds. Reviewed patient facial swelling with [LVN A]. He stated that patient received that previously and [Family Member] is aware. Inquired how patient received swelling and he stated he was unsure of how it happened. He stated she has been out of control, [Family Member] knows about it and she probably injured herself. 10/9 patient has periorbital swelling of unknown origin, monitor. patient has escalating aggressive behaviors. Reviewed visit with [LVN C] written order provided to [LVN C] and copy placed under DON door per her request. Reviewed today's visit with patient include behaviors observed. She stated that patient has been refusing her evening medications ‘most of the time'. Record review of Resident #1's Hospice Nurse Recertification notes written by Hospice Nurse E for her visit with Resident #1 on 10/9/2025 at 11:50 AM through 2:34 PM also included a photograph of Resident #1's face. The photograph showed that Resident #1 had a small, raised area to the left side of her face on cheekbone under her eye. The area was not bruised or discolored. The raised (swollen) area had a small white spot in the center. Record review of Resident #1's Hospice Physician Order dated 10/09/25 at 5:19 PM reflected no orders related to Resident #1's periorbital swelling to her left eye. Record review of Resident #1's Hospice Nurse Progress Note dated 10/09/25 at 9:02 PM reflected: DON [Facility Name] called to report patient had fall with injury and will be transported to [Hospital Name]. She stated patient vital signs are within normal limits. Patient has swelling to side of left face around her eye. Informed her that patient had swelling around eye at visit (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675977 If continuation sheet Page 2 of 5 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 12/03/2025 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few today and pictures were taken for documentation. The swelling was on the occipital bone on under left eye and on left temporal region. [DON] stated she had to go and hung up. Record review of Resident #1's hospital discharge records reflected the resident was admitted to the facility on [DATE] and discharged back to the facility on [DATE]. The hospital discharge records reflected: Reason for visit: Fall (unwitnessed fall from bed onto fall mat, unknown LOC, -thinners, swelling and bruising with abrasions to L side of face, seen by hospice earlier today and swelling to face was noted at that time) . The patient was closely observed for any changes in neurological status throughout her ED stay. admission was considered given her altered mental status and injuries. Patient workup was negative, and patient be discharged back to her facility. Observation on 10/23/25 at 10:31 AM revealed Resident #1 sitting in a geri-chair in the dining area sleeping. No visible swelling or bruising observed on Resident #1's face. Interview on 10/23/25 at 11:33 AM, the Hospice DON revealed the Hospice Nurse E, who was assigned to Resident #1, no longer worked for the company. The Hospice DON stated Hospice Nurse E's documentation for Resident #1 on 10/09/25 reflected Resident #1 had swelling to her left eye, and it was reported to LVN A around 11:50 AM. She stated Hospice Nurse E's documentation indicated LVN A stated he did not know what happened to the resident. The Hospice DON stated Hospice Nurse E's documentation did not address Resident #1's fall that had occurred on 10/09/25 at 10:00 AM, which had been reported to her. She stated the only fall Hospice Nurse E had documented was the fall Resident #1 had on 10/09/25 at 9:02 PM. Interview on 10/23/25 at 12:09 PM, LVN A revealed he was the nurse assigned to Resident #1 on 10/09/25 from 6:00 AM-2:00 PM. He stated Resident #1 had an unwitnessed fall during his shift at around 10:00 AM. He stated he found Resident #1 lying on her back on the full-size mattress on the floor next to her bed. He stated Resident #1 was assessed from head to toe and no swelling or bruising was observed on resident's face. He stated he got CNA D to assist with picking Resident #1 up from the mattress to her chair. He stated he completed neuro checks throughout his shift and never noticed any swelling to the resident's face. He stated Hospice Nurse E visited Resident #1 and never mentioned anything to him regarding Resident #1 having swelling on her face. He stated the only conversation he had with Hospice Nurse E was about Resident #1's medications. Interview on 10/23/25 at 12:28 PM, Resident #1's Family Member A and B revealed they were not notified of any swelling to Resident #1's face. Family Member A and B revealed after Resident #1 was transferred to the hospital the night of 10/09/25, the following day (10/10/25) hospice was contacted and that was when they were informed that Hospice Nurse E had observed swelling on the resident's face. Family Member A stated the facility never contacted them regarding any swelling, until Resident #1 had the fall the night of 10/09/25. Observation and interview on 10/23/25 at 1:03 PM revealed Resident #1 sitting in a geri-chair in the dining room. Resident #1 stated she was doing well. Resident #1 was not a good historian and was unable to recall any injuries or falls. No injuries, swelling or bruising noted on Resident #1's face. Interview on 10/23/25 at 1:12 PM, CNA B revealed he was the CNA assigned to Resident #1 on 10/09/25 from 2:00 PM-10:00 PM. He stated when he started his shift, he was asked by Hospice Nurse E to help her transfer Resident #1 to the bed from the geri-chair. He stated he requested assistance from CNA D to assist with transferring Resident #1 via Hoyer lift. CNA B stated when Resident #1 was transferred to the bed, Hospice Nurse E pointed to the resident's face and stated there was some swelling to the left side of the resident's face. CNA B stated the swelling was not that visible, but he saw it was around the cheekbone. He stated there was no visible bruising around the area and no redness observed. CNA B stated Resident #1 did not complain of any pain, and the resident was acting her normal self. He stated he had not noticed it until Hospice Nurse E pointed it out. He stated he also did not follow-up to ensure the nurse was made aware of the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675977 If continuation sheet Page 3 of 5 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 12/03/2025 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few resident's swelling. He stated he could not recall which nurse was assigned to Resident #1 on 10/09/25. CNA B stated he thought Hospice Nurse was reporting the swelling to the charge nurse. He stated later in the night Resident #1 had an unwitnessed fall. He did not remember the exact time but stated the resident was found lying face down on the full-size mattress on the floor next to her bed. After the fall, he stated Resident #1 was transferred to the hospital. Interview on 10/23/25 at 2:13 PM, CNA D revealed she was the CNA assigned to Resident #1 on 10/09/25 from 6:00 AM-2:00 PM. She stated she could not recall the time, but LVN A asked for her assistance to help pick up Resident #1 from the floor. She stated Resident #1 had an unwitnessed fall from her bed and landed on the mattress next to her bed on the floor. She stated when they placed Resident #1 back in the bed, she noticed Resident #1 had a little bump on her cheekbone. She stated it looked like a small pimple. She stated it was not bruised, red, or swollen. She stated she did not think anything of it because it looked like a pimple. She stated throughout her shift she never noticed Resident #1's face to be swollen. She stated during the 2:00 PM-10:00 PM shift, she assisted CNA B transfer Resident #1 back to bed, and she never heard Hospice Nurse E point out any swelling to Resident #1's face. She stated if she had noticed any swelling she would have reported it to the charge nurse. Interview on 10/23/25 at 2:23 PM, LVN C revealed she was the 2:00 PM-10:00 PM nurse assigned to Resident #1 on 10/09/25. She stated during shift change, LVN A reported to her of Resident #1's fall during the morning shift. She stated no bruising or swelling to the face was reported to her. She sated LVN A told her to continue to monitor for any delayed injuries. She stated during her shift she never noticed Resident #1's face to be swollen. She stated during her shift Hospice Nurse E was still visiting Resident #1, and Hospice Nurse E never mentioned it to her. She stated she could not recall the CNA who was assigned to Resident #1, but no CNA reported to her regarding any swelling to Resident #1's face. She stated her expectations were when any change of condition or injuries were noted, staff should report it immediately. She stated the potential risk would be delay of care. Follow-up interview on 10/23/25 at 2:32 PM, LVN A revealed Hospice Nurse E never mentioned any swelling to Resident #1's face. He stated the only conversation he had with Hospice Nurse E was about the resident's medications. He stated CNA B never mentioned any swelling noted to Resident #1's face. He stated when a staff member noted an injury on a resident, he expected them to notify him immediately. He stated the potential risk would be that injury could get worse. Interview on 10/23/25 at 3:30 PM, the DON revealed Resident #1 had two unwitnessed falls in her room on 10/09/25. She stated the first fall happened around 10:00 AM, Resident #1 was assessed, and no injuries were noted. She stated throughout the day, Resident #1 was never observed with any swelling on her face. She stated Hospice Nurse E never reported any swelling to Resident #1's face. The DON stated Resident #1 had a second unwitnessed fall in her room. She stated Resident #1 was attempting to get out of her bed and fell on top of her fall mattress next to her bed. She stated after the second fall Resident #1 sustained injuries to her face; she had swelling and an abrasion to her left side of her face. She stated Resident #1 was transferred to the hospital for further treatment, and she returned the following day 10/10/25. She stated Resident #1 had no other injuries or fractures noted. The DON stated the Hospice RN and CNA B never reported any swelling to Resident #1's face. She stated when a staff noticed an injury on a resident, she expected them to notify the nurse, complete a risk management assessment, and notify the doctor. She stated the potential risk would be further injuries. The DON stated nursing staff were in-serviced on abuse prevention, customer service, change of condition/ incident/notification/PCC SBAR and falls/change of plane. Record review of the facility's Change of Condition Notification policy, revised January 2025, reflected the following: To ensure residents, family, legal representatives, and physicians are (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675977 If continuation sheet Page 4 of 5 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 12/03/2025 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 0684 Level of Harm - Minimal harm or potential for actual harm informed of changes in the resident's condition in a timely manner. The facility will promptly inform the resident, consult with the resident's Attending Physician, and notify the resident's legal representative when the resident endures a significate change in their condition caused by, but not limited to: A. An injury/accident. B. A significant change in the resident's physical, cognitive, behavioral or functional status. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675977 If continuation sheet Page 5 of 5