Inspection·October 26, 2023

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Observation and interview with Resident #11 on 10/24/2023 beginning at 10:11 AM revealed that Resident #11 was on her wheelchair folding some papers on the side overbed table. It was also observed that Resident #11's call light button and call light cord were on the floor and under the bed. Resident #11 heard her roommate requesting for water. Resident #11 then tried to look for her call light and stated that she would call for assistance for her roommate. Resident #11 then stated that she could not reach her call light because the call light was on the floor and under that bed. Resident #11 added that she did not know what how the call light landed under the bed. Resident #11 said that it was hard for her to stoop down and get the call light because her back and shoulders were not that young anymore. Observation and interview with LVN O on 10/24/2023 beginning at 10:28 AM, LVN O stated that the call light should not be on the floor. LVN O added that the call light must always be by the resident at all times because the call light was a method of communication between the resident and the staff. LVN O said that this was how the residents could ask for assistance if needed. LVN O further added that without the call light, the resident won't be able to get assistance and the resident might try to get what she needed by herself and could result to fall, injury, and frustration. LVN O then picked up the call light and put the call light on top of the Resident #11's bed where the resident could reach it. Interview with CNA H on 10/25/2023 at 10:25 AM, CNA H stated that the call light should definitely be with the resident, it should always be within a place where the residents could reach it CNA H said call lights could be placed on top of the bed, coiled to the bed railing, or clipped on the bed sheet. CNA H stated, ideally, they did their rounds every two hours. CNA H added that for some residents, this was their sense of security and a form of assurance that if something happened to them, they could call for help. CNA H further added that a residents might fall while trying to get the call light that was far from them. Interview with CNA G on 10/25/2023 at 10:36 AM, CNA G stated that call lights were important for the residents because it is what they use to call when they needed assistance. CNA G said that the call lights should be in a place where the residents could reach it and press the red button. If the call light was not with the residents, they will not be able to call the staff for assistance or help and might result to fall, bumps, and skin tears. Interview with LVN B on 10/25/2023 at 11:06 AM, LVN B stated that the call light was the resident's source of help. LVN B said that the call light should always be within the reach of the resident because it was their lifeline. If the call light is not with the resident, the resident won't be able to call the staff if they needed something. If the call light was not with the resident, the resident's needs won't be addressed. LVN B added that a call light far from the reach of a resident could be viewed as a significant hazard to resident safety. Interview with ADON N on 10/26/2023 at 7:49 AM, the ADON stated that the purpose of call lights was to summon the staff for help when they needed assistance or if they were in trouble. The needed assistance could be a routine need or an emergency. The ADON added that the residents might call for a glass of water, because they wanted their door closed, because they were having pain, or because they were on the floor. The ADON further said that the call lights should always be positioned in a place where the residents could reach it. The ADON added that unreachable call lights could result to unwarranted events that could affect the residents' quality of life. The ADON concluded that the staff were expected to do their rounds and ensure that all residents have their call lights within reach. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676036 If continuation sheet Page 2 of 25 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 676036 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vista Ridge Nursing & Rehabilitation Center 700 E Vista Ridge Mall Dr Lewisville, TX 75067 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 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview with the DON on 10/26/2023 at 8:09 AM, the DON stated that residents needed their call lights to communicate to the staff know that they needed or wanted something. The DON said that the call lights should always be within reach because they are the residents' lifeline and security. The DON added that without the call lights, the residents' needs will not be addressed. The DON further added that when the call lights were not within the reach of the residents, unfavorable incidents like falls, minor hurts, or major harms could happen. Also, the residents could experience frustration, distrust, and untoward impression about the staff and the facility. The DON said that the expectation was for the staff to ensure that the call lights were within reach of the residents. The DON concluded that moving forward, she will monitor staff's by doing increased rounds to warrant adherence to the policy and to ensure the best possible care. Interview with the Administrator on 10/26/2023 at 8:23 AM, the Administrator stated that, in general, a system failure was identified and realized. The Administrator said that this oversight would be addressed to ensure quality of care and quality of life for the residents. The Administrator added that it should be in a place where the resident could reach it so that their needs could be addressed. The Administrator concluded that the expectation was that the staff would do their due diligence and check the residents more often. Record review of facility's policy Accommodation of Needs, Our facility's environment and staff behaviors are directed toward assisting the resident in maintain and/or achieving safe independent functioning, dignity, and well-being . 2. The resident's individual needs and preferences . reviewed on an ongoing basis . a. providing access to assistive devices. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676036 If continuation sheet Page 3 of 25 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 676036 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vista Ridge Nursing & Rehabilitation Center 700 E Vista Ridge Mall Dr Lewisville, TX 75067 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to provide a safe, clean, comfortable, and homelike environment including but not limited to receiving treatment and supports for daily living safely for areas in the facility for 9 of 20 rooms (Room # 106, 110, 112, 114, 118, 401, 408, 405, and 418), observed for a safe, clean, comfortable, and homelike environment. The facility failed to ensure that resident rooms and handrails were cleaned and sanitized. These deficient practices could place residents at risk of infections and living in an uncomfortable environment leading to a decreased quality of life. Findings include: Observation of Room # 106 on 10/24/23 at 9:57 AM revealed a long brownish spill stain on one of the walls. The air-condition unit had dirt particles between the vents and there was an adult brief on the top of the unit. Under the bathroom sink there were grayish and brownish stains on the floor. Observation of Room # 110 on 10/24/23 at 10:03 AM revealed the room entry door floor area had dark stains in the corner and along the entrance. The bathroom entry door floor area had dark stains in the corner and along the entrance. One of the walls in the room had specks of reddish stains along the lower portion of the wall and there were black skid marks along the lower half of the wall as well. Observation of Room # 112 on 10/24/23 at 10:16 AM revealed the air-condition unit had light brownish spill stains on the top of the unit. A piece of trash was sitting in the corner of the room. The bathroom entry door floor area had thick dark dirt particles stains in the corner of the floor. Observation of Room # 114 on 10/17/23 at 10:21 AM revealed the bathroom entry door floor area had dark stains in the corner and along the entrance. An air duct/vent on the lower part of the wall had dirt particles spattered all over it and there were rust like stains on the duct/vent. Observation of room [ROOM NUMBER] on 10/24/23 at 10:26 AM revealed a rust-like stain and dirt [NAME] on the floor behind the toilet. The closet doors had splash stains near the lower portion of the doors. Observation of Room # 401 on 10/24/23 at 11:01 AM revealed the air-condition unit had dirt particles between the vents and the top of the unit had some dirt particles. The corners of the room floor had dirt build-up. The wall along the entry of the room and two small but thick brownish stains near a wall socket. The bathroom entry door floor area had dark stains in the corner and along the entrance. The bathroom floor had dark reddish stains and light black stains near a trash can. The door facing the inside of the room had splash stains, which was near a bag hanging from the door handle. There was a long reddish stain on the floor near a plastic three Drawer chest. The toilet had a brownish stain around the bottom of the toilet floor. There was a dark rust in color stains near the rear wall near a pair of flip flops. Observation of Room # 408 on 10/24/23 at 11:04 AM revealed the floor near the resident bed had dark (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676036 If continuation sheet Page 4 of 25 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 676036 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vista Ridge Nursing & Rehabilitation Center 700 E Vista Ridge Mall Dr Lewisville, TX 75067 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some red stains. The air-condition unit had light brownish spill stains on the top of the unit and between the vents had dirt particles. Observation of Room # 405 on 10/24/23 at 11:10 AM revealed the room entry door floor area had dark stains in the corner and along the entrance. There was a thick rectangular in shape red stain near the resident bed. The floor under the Air-conditioned unit had thick dirt build-up. The mini fridge in the room has brownish spills stains along the inside bottom of the unit. There was an individual size container of apple sauce in the fridge, dated 09/17/23, with no visible expiration date. Observation of Room # 418 on 10/24/23 at 11:25 AM revealed the mini fridge in the room has thick dried-up dark brownish spills stains along a crease inside bottom of the unit. Observations of the handrails on 10/24/23, 10/25/23, and 10/26/23, during various times throughout the day showed the handrails had dirt particles along the inside of the rails and splash stains along the outer rail. Interview with the Housekeeping Supervisor on 10/26/23 at 12:12 PM, he stated he had been at the facility for 4 years. He stated he trained the cleaning staff himself and he shows them how to clean the room thoroughly by demonstrating to them. He stated he cleans at least two rooms for the new hire to see how he cleaned the room. He stated they clean the room once a day to make sure the room is thoroughly cleaned . He stated they are supposed to clean the outside of the air condition unit and the maintenance person is responsible for servicing the fridge. He stated they do not go into the resident's fridge because they get upset. He stated they do check for expired foods. He stated the risk to the residents' room not being thoroughly clean could result in spread of bacteria. He advised that he only had one housekeeping aide available for interview and he was out for lunch. Interview with Housekeeper F on 10/26/23 at 01:23 PM, he stated he had been at the facility for two weeks. He advised that he had been trained to clean the entire room, from top to bottom. He stated he makes sure that he cleans and wipes down everything in the room. He stated he cleaned resident rooms every day and his supervisor check the rooms. He was repeatedly asked the risk to the residents if rooms are not thoroughly cleaned, and he kept explaining how he cleaned the rooms. Interview on 10/26/23 at 01:45 AM with the Administrator, she had reviewed the emails of photos of concerns observed in residents' rooms sent to her by the surveyor. She stated she will be meeting with her Housekeeping Supervisor to address the concerns observed. She stated the facility and rooms are cleaned at least once a day. She stated she and her leadership team checks for cleanliness of room and had not observed any concerns. She stated she did not know how frequently they checked rooms but they checked for the welfare of the resident, including the cleanliness of the room. She stated the risk of the rooms and facility not being thoroughly cleaned and sanitized is an infection control concern. Review of the facility's policy on Homelike Environment (February 2021) revealed Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. 2. The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: a. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676036 If continuation sheet Page 5 of 25 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 676036 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vista Ridge Nursing & Rehabilitation Center 700 E Vista Ridge Mall Dr Lewisville, TX 75067 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 0584 clean, sanitary and orderly environment; Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676036 If continuation sheet Page 6 of 25 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 676036 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vista Ridge Nursing & Rehabilitation Center 700 E Vista Ridge Mall Dr Lewisville, TX 75067 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 0635 Provide doctor's orders for the resident's immediate care at the time the resident was admitted. 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 that residents had physician's orders for the resident's immediate care for one (Resident #11) of six residents reviewed for admission orders. Residents Affected - Few The facility failed to obtain physician orders for oxygen supplement for Resident #11 at the time of admission. This failure could place the resident at risk of not receiving necessary care and services upon admission that could result to worsen condition. Findings included: Review of Resident #11's Face Sheet dated 10/24/2023 reflected that resident was a [AGE] year-old female admitted on [DATE]. Relevant diagnoses included unspecified chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs), intermittent claudication (muscle pain due to lack of oxygen) of bilateral legs, right shoulder primary osteoarthritis (a type of arthritis that happens when the cartilage that lines your joints is worn down and your bones rub against each other), other intervertebral disc degeneration (age-related wear and tear on discs of the spine, causing pain and instability) of the lumbar region (relating to the lower part of the back), unspecified anxiety disorder, and atherosclerotic (the buildup of fats, cholesterol and other substances in and on the artery walls) heart disease of native coronary artery without angina pectoris (chest pain). Review of Resident #11's Quarterly MDS assessment dated [DATE] reflected that Resident #11 had a moderately intact cognition with a BIMS score of 12. Resident #11 required supervision in bed mobility, transfer, and eating. Resident #11 needed limited assistance in walk in room, walk in corridor, locomotion on unit, locomotion off unit, dressing, toilet use, and personal hygiene. The Quarterly MDS also indicated that the primary reason for admission was medically complex conditions such as unspecified chronic obstructive pulmonary disease, coronary artery disease, and anxiety disorder. Review of Resident #11's Comprehensive Care Plan dated 09/29/2023 reflected that Resident #11 had emphysema/COPD (chronic obstructive pulmonary disease). The interventions did not include use of oxygen supplement administration. Review of Resident #11's Physician's Order on 10/24/2023 reflected no physician's order for continuous oxygen supplement. Review of Resident #11's Physician's Order on 10/24/2023 reflected no physician's order for oxygen supplement as needed. Review of Resident #11's Physician's Order on 10/24/2023 reflected no physician's order for when to change the cannula and oxygen tubing. Review of Resident #11's Physician's Order on 10/24/2023 reflected no physician's order for who will change the cannula and oxygen tubing. Review of Resident #11's Physician's Order on 10/24/2023 reflected no physician's order to keep the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676036 If continuation sheet Page 7 of 25 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 676036 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vista Ridge Nursing & Rehabilitation Center 700 E Vista Ridge Mall Dr Lewisville, TX 75067 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 0635 oxygen cannula and tubing in a bag when not in use. Level of Harm - Minimal harm or potential for actual harm Review of Resident #11's Physician's Order on 10/24/2023 reflected no physician's order for when to change the humidifier. Residents Affected - Few Review of Resident #11's Physician's Order on 10/24/2023 reflected no physician's order to wash filters from oxygen concentrator. Review of Resident #11's Physician's Order on 10/24/2023 reflected no physician's order for what to assess like redness to nares (openings of the nose where the prongs of the cannula are inserted). Review of Resident #11's admission Orders on 10/24/2023 reflected no order for oxygen supplement. Observation and interview with Resident #11 on 10/24/2023 beginning at 10:11 AM revealed that Resident #11 was on her wheelchair folding some papers on the side overbed table. It was also observed that Resident #11's had an oxygen concentrator at the side of the bed. The oxygen concentrator was off. Resident #11 confirmed that she used oxygen at night. Interview with LVN O on 10/24/2023 at 10:28 AM, LVN O stated that the Resident #11 had been using oxygen supplement since she was transferred to hall 200. LVN O confirmed that Resident # 11 only used her oxygen supplement at night and breathing treatments during the day. Observation and interview with LVN O on 10/25/2023 beginning at 10:40 AM, LVN O reiterated that the Resident #11 had been using oxygen supplement since she was transferred to hall 200. LVN O confirmed again that Resident # 11 only used her oxygen supplement at night and breathing treatments during the day. LVN O added that Resident #11 used oxygen because of her COPD (chronic obstructive pulmonary disease). When asked to see the order for oxygen supplement, LVN O started to search her computer and then stated that she could not find the order for oxygen. LVN O acknowledged that the order for oxygen supplement for Resident #11 was not on the eMAR (electronic medication administration record). LVN O said that it was important to have a physician's order to know what to do, what to assess, and what was the treatment plan. LVN O added that this would put the resident at risk of not having the medications, treatments, and services they needed. LVN O also verbalized that she was responsible in transcribing and checking the orders when the Resident #11 was transferred to hall 200. Interview with LVN B on 10/25/2023 at 11:06 AM, LVN B stated that it was important to have a physician's orders because those orders serve as the guide on what care or treatment the resident needed. LVN B said that without the orders, the resident's medical issues will not be addressed, and this could cause regression and decline in health. Review of Resident #11's new Physician's Order on 10/25/2023 after advising LVN O that Resident #11 did not have Physician Order for oxygen supplement reflected O2 @ 2 L/Min via NC PRN to maintain O2 sats > 90%, dated 10/25/2023 at 11:28 AM. Review of Resident #11's new Physician's Order on 10/25/2023 after advising LVN O That Resident #11 did not have Physician Order for oxygen supplement reflected Change o2 tubing/water every week on Sunday and PRN (as needed), dated 10/25/2023 at 11:28 AM. Review of Resident #11's new Physician's Order on 10/25/2023 after advising LVN O That Resident #11 did not have Physician Order for oxygen supplement reflected Check o2 filter for placement and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676036 If continuation sheet Page 8 of 25 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 676036 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vista Ridge Nursing & Rehabilitation Center 700 E Vista Ridge Mall Dr Lewisville, TX 75067 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 0635 cleanliness every week on Sunday and PRN, dated 10/25/2023 at 11:28 AM. Level of Harm - Minimal harm or potential for actual harm Interview with ADON N on 10/26/2023 at 7:49 AM, ADON N stated that every resident must have physician orders because the staff needed guidance from the doctor of what to do with regards to the care needed. One of the purposes of physician orders was to boost patient safety by lowering or eliminating medication errors. ADON N continued that physician orders were to communicate the medical care that the resident was to receive while in the facility. ADON N said that there should be orders for medications, treatments, wound care, diet, therapy, and preventive measures. ADON N concluded that the staff would not forget to thoroughly check that the orders were transcribed on the residents eMAR. Residents Affected - Few Interview with the DON on 10/26/2023 at 8:09 AM, the DON stated that there should be physician orders on everything being done to the resident. The DON said that physician orders serve as proof of the services rendered by the facility to the resident. She added that these orders communicate the medical care the resident is to have. The DON further added that without those orders, the staff will not know the needed care and the needed treatment. The DON explained that without a physician order, it would be detrimental for the residents because this situation could lead to unfavorable medical issues or exacerbation of the present illness. The DON said that the charge nurse was the one responsible in transcribing the physician orders upon admission. The DON said that the expectation was for the staff to ensure that physician orders are entered in the system during admission. The DON concluded that moving forward, she would monitor staff's adherence to the policy to ensure the best possible care. Interview with the Administrator on 10/26/2023 at 8:23 AM, the Administrator stated that, in general, a system failure was identified and realized. The Administrator said that this oversight would be addressed to ensure quality of care and quality of life for the residents. The Administrator concluded that the expectation is that the staff would do their due diligence and check the residents more often. Record review of facility' policy admission Notes, revealed preliminary resident information shall be documented upon a resident's admission to the facility . When a resident is admitted to the nursing unit, the admitting nurse must document . the admitting diagnosis . physician's order received and verified. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676036 If continuation sheet Page 9 of 25 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 676036 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vista Ridge Nursing & Rehabilitation Center 700 E Vista Ridge Mall Dr Lewisville, TX 75067 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 observation, interviews, and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for a resident for 4 (Resident,#7, #11, #22, and #82) of 12 residents reviewed for Care Plans. The facility failed to ensure Resident #11, and Resident #22 were care planned for oxygen administration. The facility failed to accurately assess Resident #7's diagnosis of malnutrition by not including the resident's physician orders for weekly weigh-ins as an intervention on the care plan. The facility failed to accurately assess Resident #82's communication concerns and did not include the resident's physician orders for speech therapy as an intervention on the care plan. These failures could place residents at risk for not receiving care and services to meet their needs, diminished function of health, and regressions in their overall health. Findings include: Review of Resident #11's Face Sheet dated 10/24/2023 reflected that resident was a [AGE] year-old female admitted on [DATE]. Relevant diagnoses included unspecified chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs), intermittent claudication (muscle pain due to lack of oxygen) of bilateral legs, right shoulder primary osteoarthritis (a type of arthritis that happens when the cartilage that lines your joints is worn down and your bones rub against each other), other intervertebral disc degeneration (age-related wear and tear on discs of the spine, causing pain and instability) of the lumbar region (relating to the lower part of the back), unspecified anxiety disorder, and atherosclerotic (the buildup of fats, cholesterol and other substances in and on the artery walls) heart disease of native coronary artery without angina pectoris (chest pain). Review of Resident #11's Quarterly MDS assessment dated [DATE] reflected that Resident #11 had a moderately intact cognition with a BIMS score of 12. Resident #11 required supervision in bed mobility, transfer, and eating. Resident #11 needed limited assistance in walk in room, walk in corridor, locomotion on unit, locomotion off unit, dressing, toilet use, and personal hygiene. The Quarterly MDS also indicated that the primary reason for admission was medically complex conditions such as unspecified chronic obstructive pulmonary disease, coronary artery disease, and anxiety disorder. Review of Resident #11's Comprehensive Care Plan dated 09/29/2023 reflected that Resident #11 had emphysema (a lung disease that damages the air sacs in the lungs causing shortness of breath)/COPD (chronic obstructive pulmonary disease). The interventions did not include, specifically, the use of oxygen supplement administration. Review of Resident #22's Face Sheet dated 10/24/2023 reflected that resident was an [AGE] year-old male admitted on [DATE]. Relevant diagnoses included unspecified cerebral infarction (disrupted (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676036 If continuation sheet Page 10 of 25 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 676036 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vista Ridge Nursing & Rehabilitation Center 700 E Vista Ridge Mall Dr Lewisville, TX 75067 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 blood flow to the brain), unspecified neuromuscular (combination of the nervous system and muscles) dysfunction of bladder, unspecified cough, unspecified dysphagia (swallowing difficulties), and benign prostatic hyperplasia (a condition in men in which the prostate gland is enlarged and not cancerous) with lower urinary tract symptoms. Review of Resident #22's Quarterly MDS assessment dated [DATE] reflected that Resident #22 had an intact cognition with a BIMS score of 13. Resident #22 required supervision in eating. Resident #11 needed limited assistance for bed mobility, transfer, walk in room, walk in corridor, locomotion on unit, locomotion off unit, dressing, toilet use, and personal hygiene. The Quarterly MDS Assessment also indicated that the primary reason for admission was medically complex conditions such as unspecified cerebral infarction, anemia, coronary artery disease, hypertension, and neurogenic bladder. The Quarterly MDS Assessment also implied that Resident #22 used an oxygen supplement while a resident of the facility and within the last 14 days. Review of Resident 22's Physician order dated 04/23/2023 reflected, O2 @ 2L via NC (oxygen at 2 liters via nasal cannula) continuous. Review of Resident #22's Comprehensive Care Plan dated 10/17/2023 reflected that Resident #22 had pulmonary disease/URI (upper respiratory infection - an infection of the nose, sinuses, or throat)/Bronchitis. One of the interventions was provide O2 as ordered: 2LPM via NC PRN (2 liters per minute via nasal cannula as needed). The interventions did not include a care plan for continuous oxygen. Interview with LVN O on 10/24/2023 at 10:28 AM, LVN O stated that the Resident #11 had been using oxygen supplement since she was transferred to hall 200. LVN O confirmed that Resident # 11 only used her oxygen supplement at night and breathing treatments during the day. Observation on 10/24/2023 at 10:45 AM revealed that Resident #22 was on his bed, sleeping. It was also observed that Resident #22 had an oxygen supplement at 2 liters per minute via nasal cannula. Observation and interview with LVN O on 10/25/2023 beginning at 10:40 AM, LVN O reiterated that the Resident #11 had been using oxygen supplement since she was transferred to hall 200. LVN O confirmed again that Resident # 11 only used her oxygen supplement at night and breathing treatments during the day. LVN O added that Resident #11 used oxygen because of her COPD (chronic obstructive pulmonary disease). When asked to see the care plan for oxygen supplement, LVN O started to search her computer and then stated that she could find the care plan for oxygen. LVN O acknowledged that the care plan for oxygen supplement for Resident #11 was not on the electronic health record eMAR. LVN O said that care plans were done and implemented to make sure that each resident will have an individualized care that would define the meaning of patient-centered care. LVN O said that without the care plan, the current health status of the resident would not be addressed. If the medical issues were not addressed, the resident will not attain the quality of care appropriate for them. Record review of Resident #7's Face Sheet dated 10/25/23 indicated she was an 82 -year-old female admitted on [DATE]. Relevant diagnoses included Protein - Calorie Malnutrition, and Muscle Weakness. Record review of Resident #7's Minimum Data Set (MDS) on dated 09/27/23 indicated she had a Brief Interview for Mental Status (BIMS) score of 14 (cognitively intact). Active Diagnosis indicated Malnutrition. Record review of Resident #7's Active Physician Orders dated 10/25/23 indicated the resident had an (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676036 If continuation sheet Page 11 of 25 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 676036 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vista Ridge Nursing & Rehabilitation Center 700 E Vista Ridge Mall Dr Lewisville, TX 75067 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 active order effective 09/22/23 indicating the following: Level of Harm - Minimal harm or potential for actual harm Weight Upon Admission/readmission and Q WK x 4 WK (every week times four weeks) Record review of Resident #7's Care Plan on 10/06/2023 indicated the following: Residents Affected - Few Focus: #7 is on a consistent carbohydrate diet, regular texture. Goal: The resident will maintain adequate nutritional status as evidenced by no signs or symptoms of malnutrition. Interventions: o Administer medications as ordered. Monitor/Document for side effects and effectiveness. Develop an activity program that includes exercise, mobility. Offer activities of choice to help divert attention from food. Monitor/record/report to MD PRN an s/sx of malnutrition. Emaciation (Cachexia), muscle wasting, significant weight loss: 3Lbs in 1 week, > 5% in one month, > 7.5% in 3 months, 10% in 6 months. Provide, serve diet as ordered. RD to evaluate and make diet change recommendations PRN. Record review of Resident #82's Face Sheet dated 10/25/23 indicated she was a 73 -year-old female admitted on [DATE]. Relevant diagnoses included adult failure to thrive, and Dysphasia (difficulty swallowing) Record review of Resident #82's Minimum Data Set (MDS) on dated 08/24/23 indicated she had a Brief Interview for Mental Status (BIMS) score of 07 (severe cognitive impairment) Record Review of Resident #82's Physician orders dated 08/22/23 indicated the resident was to receive Speech therapy four times a week for 30 minutes. Record review of Resident #82's Care Plan, revised on 08/30/2023 indicated the following: Focus: #82 had a communication problem Goal: The resident will be able to make basic needs known Interventions: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676036 If continuation sheet Page 12 of 25 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 676036 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vista Ridge Nursing & Rehabilitation Center 700 E Vista Ridge Mall Dr Lewisville, TX 75067 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 Anticipate and meet needs. Level of Harm - Minimal harm or potential for actual harm Be conscious of resident position when involved in activities, dining room to promote proper communication with others. Residents Affected - Few Speak on adult level, speaking clearly and slower than normal. Interview with the Director of Rehabilitation (DOR) on 10/24/23 at 02:00 PM revealed Resident # 82 was scheduled for Physical, Occupational, and Speech Therapy, and she had completed Physical and Occupational Therapy; however, the Resident was still receiving Speech Therapy four times a week . She stated that the Speech Therapy should be care planned and she stated that they have meetings every morning to discuss residents receiving therapy and the Social Worker should have placed it on the Care Plan to ensure that the resident did not miss out on required care. She stated she and the Speech Therapist should check Care plans to ensure therapy is care planned. She stated she was new to the Director role and still learning her role, but she will ensure that this is corrected moving forward. Interview with LVN B on 10/25/2023 at 11:06 AM, LVN B stated that every relevant medical issue of a resident must be care planned. LVN B said that a care plan served as a guidance on how to measure the effectiveness of the care being done. LVN B added that a care plan was a place where all the goals and interventions should be located so that the staff would know what to do. LVN further added that without the care plan, the residents would not acquire the appropriate level of care needed for their current medical issues. Interview with ADON N on 10/26/2023 at 7:49 AM, ADON N stated that every resident must have a care plan because a care plan served as a guidance for the staff to know the goals and interventions for each medical issue. ADON N said that without a care plan, the resident would not have the care needed and their current health status would not be addressed. ADON N continued that care plan was to communicate the needed interventions for medications, treatments, wound care, diet, therapy, and preventive measures. ADON N concluded that the staff should not miss to care plan the relevant medical issues of the residents so that all the staff involved in the care of the resident would be in sync. Interview with DON on 10/26/2023 at 8:09 AM, the DON stated that care planning was a team approach. The DON added that without a care plan, the current health issues would not be addressed and managed accordingly. The DON further stated that the care plan should be accurate and up to date. It should be done upon admission, quarterly and when there is a change of condition on the part of the residents. The DON said that it is not acceptable that a resident does not have a care plan because the resident will not be taken care of accordingly. The DON said that the expectation is for the staff to ensure that every assessed medical problem were care planned. The DON concluded that moving forward, she will monitor staff's adherence to the policy to ensure the best possible care. Interview with the Administrator on 10/26/2023 at 8:23 AM, the Administrator stated that, in general, a system failure was identified and realized. The Administrator said that this oversight would be addressed to ensure quality of care and quality of life for the residents. The Administrator concluded that the expectation is that the staff would do their due diligence and check the residents more often. Observation and interview with MDS Nurse W at 9:00 AM on 10/26/2026, MDS Nurse W stated that care plan were made during admission, quarterly, and when there was a change of condition. MDS Nurse W said that she would know what to care plan by checking the admission notes and attending the care plan (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676036 If continuation sheet Page 13 of 25 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 676036 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vista Ridge Nursing & Rehabilitation Center 700 E Vista Ridge Mall Dr Lewisville, TX 75067 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 meeting. MDS Nurse W added that she also checked the progress note to see if the resident had a significant change, needed antibiotics, and if the resident just came back from the hospital. MDS Nurse W further added that care plan was very important because this served as a roadmap for the staff to know the interventions needed by the resident presently. MDS Nurse W was advised that Resident #11 did not have a care plan for oxygen supplement. MDS Nurse W checked the computer and acknowledged that there was no care plan for Resident #11's oxygen supplement. MDS Nurse W was advised that Resident #22 did not have a care plan for continuous oxygen. MDS Nurse W checked her computer and acknowledged that Resident #22 did not have a care plan for continuous oxygen. MDS Nurse W said that without the care plan, the needs of the residents would not be met. Interview with MDS Nurse M on 10/26/2023 at 9:20 AM, MDS Nurse M stated that MDS nurses met with department heads to make sure that every aspect of the residents' issues or medical problems were care planned. MDS Nurse M said that the oversights were already corrected. MDS Nurse M concluded that this would be an opportunity to also check the care plans of the other residents. Interview with the Speech Pathologist (SP) on 10/26/23 at 09:54 AM, she had been here for a year. She stated she provided Speech therapy for Resident# 82 four times a week for 30 minutes, which she had been receiving since her admittance. She stated she provided feedback to the Director of Rehabilitation (DOR) and the DOR would address it during the weekly department head meetings. She stated the Social Worker was assigned to input all updates in the Care plans. She stated she did not review care plans but would start doing so to ensure that the information was being updated in Care Plan. She stated the resident's speech therapy should had been care planned. She stated the risk of the resident not having the speech therapy care planned could result in the resident missing out on receiving care. Interview with the Social Worker (SW) on 10/26/23 at 10:30 AM, she stated she had been the social worker for the past year. The SW stated she participated in the Care plan meetings, and she scheduled care plans with the families, but she did not update the physical care plans in Point Click Care (PCC). She stated that the MDS nurse inputs all the updates in the care plans viewed and it is usually done the same day. She stated the risk of the resident not having the items care planned could result in the residents experiencing lack of care and other health concerns. Interview with the Regional Clinical Reimbursement (RCR) on 10/26/23 at 10:50 AM, she stated she had only been with the organization for a few weeks. She stated that in her past facilities, if the resident had physician orders, there was no need to care plan the intervention. She was advised that the facility care plan for assessments stated Review the resident's admission assessment and/or preliminary care plan to assess for any special situations regarding the resident's care. The RCR stated she had not had the chance to review the facility's policy, but based on the facility's policy on Resident Examination and Assessment for Resident #7 and #82 did not include all appropriate interventions. She stated the risk of not having the care plan not being accurate could result in missed care. Record Review of facility policy on Care Planning-Interdisciplinary Team, Revised undated, revealed The interdisciplinary team is responsible for the development of resident care plans. Comprehensive, person-centered care plans are based on resident assessments and developed by an interdisciplinary team. Review of the facility policy, Resident Assessments, undated, reflected: .3. A comprehensive assessment includes: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676036 If continuation sheet Page 14 of 25 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 676036 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vista Ridge Nursing & Rehabilitation Center 700 E Vista Ridge Mall Dr Lewisville, TX 75067 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 a. completion of the Minimum Data Set (MDS) . 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: 676036 If continuation sheet Page 15 of 25 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 676036 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vista Ridge Nursing & Rehabilitation Center 700 E Vista Ridge Mall Dr Lewisville, TX 75067 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 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that resident maintained acceptable parameters of nutritional status, such as usual body weight or desirable body weight range for 1 of 6 residents (Resident #7) reviewed for assisted nutrition and hydration. Residents Affected - Few The facility failed to assess Residents #7's weight on a weekly basis per physician orders, and the resident experienced more than a 5% weight loss in a month. This failure could place resident at risk of experiencing a decline in health due to malnutrition. Findings included: Record review of Resident #7's Face Sheet dated 10/25/23 indicated she was an 82 -year-old female admitted on [DATE]. Relevant diagnoses included Protein - Calorie Malnutrition, and Muscle Weakness. Record review of Resident #7's Minimum Data Set (MDS) on dated 09/27/23 indicated she had a Brief Interview for Mental Status (BIMS) score of 14 (cognitively intact). Record review of Resident #7's Active Physician Orders dated 10/25/23 indicated the resident had an active order effective 09/22/23 indicating the following: Weight Upon Admission/readmission and Q WK x 4 WK Record review of Resident #7's Weight Summary from 09/22/23 to 10/25/23 on the facility's system of record indicated the resident experienced a 5.5% weight loss within a month from 152.12 lbs on 09/22/23 to 144.5 lbs on 10/08/23 (loss of 7.62 lbs). Weight assessements were missed on 09/29/23 and 10/06/23. Interview on 10/26/23 at 08:55 AM with CNA C, she said she had been at the facility over 2 years. She stated that the facility used to have an extra CNA designated to gather resident weights, but they have not had anyone assigned for over four weeks. She stated the risk of not tracking the resident's weight could result in them getting sicker. Interview with Administrator, Director of Nursing, Assistant Director of Nursing, Regional Director of Operation, Regional Clinical Reimbursement (RCR) on 10/25/23 at 2:00 PM and they were advised of Resident #7's active orders for weekly weigh-ins and the 5.5% weight loss within a month, with records only showing two weigh-ins. The DON stated that facility had a designated CNA responsible for obtaining the resident's weights, but they later determined that she was failing to do it consistently and had terminated her sometime in July 2023. She stated currently, the hall nurses are responsible for ensuring weekly weigh-ins are completed and recorded. The Administrator stated that they were aware that this is a concern and would create a Quality Assurance and Performance Improvement (QAPI) plan to address it. The DON stated that currently all hall nurses were required to complete all weigh-ins. The DON stated the risk of not tracking residents with excessive weight loss weigh, could result in a decline in health. Interview on 10/26/23 at 09:12 AM with LVN A, she stated she had been at the facility for over 13 years on an as needed basis. She stated she was unsure who was assigned to weigh the residents, but she was sure that it is being done. She could not explain how she knew residents were being weighed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676036 If continuation sheet Page 16 of 25 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 676036 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vista Ridge Nursing & Rehabilitation Center 700 E Vista Ridge Mall Dr Lewisville, TX 75067 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 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few weekly. She stated that resident weights were taken on specific days by an assigned person. She stated that she thought that hall nurses should be completing weekly weigh-ins on weekends. She stated the risk of not tracking the resident's weight could result in the resident getting sicker. Interview with ADON N on 10/26/23 at 09:48 AM, he stated he had been the ADON at the facility for the past 12 years. ADON N stated the facility had a dedicated CNA weighing all residents, but she was terminated, and they trying to find some to take on this responsibility. He stated that if a resident had an excessive weight loss concern and required weekly weigh-ins, the nurse on duty is responsible for completing the weekly weigh in and documenting it. He stated they are in-servicing staff of their daily responsibilities when checking areas such as recording vitals and ensuring resident needs are being met. He advised the risk of the resident's weight not being captured weekly could result in a resident having a sudden decrease in weight and diminished health. Record review of the facility's policy on Weighing and Measuring the Resident, undated, stated The purpose of this procedure are to determine the resident's weight and height, to provide a baseline and an ongoing record of the resident's body weight as an indicator of the nutritional status and medical condition of the resident Review of the facility's Resident Rights - Quality of Life policy, revised August 2020, revealed, Each resident shall be cared for in a manner that promotes and enhances the quality of life, dignity, respect and individuality . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676036 If continuation sheet Page 17 of 25 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 676036 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vista Ridge Nursing & Rehabilitation Center 700 E Vista Ridge Mall Dr Lewisville, TX 75067 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record reviews, the facility failed to ensure that a resident who needed respiratory care was provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 3 (Resident #11, #32, #64) of 3 residents reviewed for respiratory care. Residents Affected - Few The facility failed to ensure Resident #11's and 64's nasal cannulas were bagged and failed to change Resident #32's humidifier on the oxygen concentrator, which exceeded the facility policy of 7 days. These failures could place the residents at risk of not having their respiratory needs met. Findings included: Review of Resident #11's Face Sheet dated 10/24/2023 reflected that resident was a [AGE] year-old female admitted on [DATE]. Relevant diagnoses included unspecified chronic obstructive pulmonary disease, intermittent claudication (muscle pain due to lack of oxygen) of bilateral legs, right shoulder primary osteoarthritis (a type of arthritis that happens when the cartilage that lines your joints is worn down and your bones rub against each other), other intervertebral disc degeneration (age-related wear and tear on discs of the spine, causing pain and instability) of the lumbar region (relating to the lower part of the back), unspecified anxiety disorder, and atherosclerotic (the buildup of fats, cholesterol and other substances in and on the artery walls) heart disease of native coronary artery without angina pectoris (chest pain). Review of Resident #11's Quarterly MDS assessment dated [DATE] reflected that Resident #11 had a moderately intact cognition with a BIMS score of 12. Resident #11 required supervision in bed mobility, transfer, and eating. Resident #11 needed limited assistance in walk in room, walk in corridor, locomotion on unit, locomotion off unit, dressing, toilet use, and personal hygiene. The Quarterly MDS also indicated that the primary reason for admission was medically complex conditions such as unspecified chronic obstructive pulmonary disease, coronary artery disease, and anxiety disorder. Review of Resident #11's Comprehensive Care Plan dated 09/29/2023 reflected that Resident #11 had emphysema (a lung disease that damages the air sacs in the lungs causing shortness of breath)/COPD (chronic obstructive pulmonary disease - a chronic inflammatory lung disease that causes obstructed airflow from the lungs). Observation and interview with Resident #11 on 10/24/2023 beginning at 10:11 AM revealed that Resident #11 was on her wheelchair folding some papers on the overbed table. It was also observed that Resident #11 had an oxygen concentrator at the side of the bed. The oxygen concentrator was off. One end of the nasal cannula was attached to the oxygen concentrator and the other end was noted to be on the floor. Resident #11 stated that her nasal cannula fell on the floor when she took it off. Resident #11 said that she did not know that the nasal cannula should be bagged and that the nurse never gave her a bag to put the nasal cannula when she was not using it. Observation and interview with LVN O on 10/24/2023 beginning at 10:28 AM, LVN O stated that the Resident #11 had been using oxygen supplement since she was transferred to hall 200. LVN O confirmed that Resident # 11 only used her oxygen supplement at night and breathing treatments during the day. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676036 If continuation sheet Page 18 of 25 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 676036 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vista Ridge Nursing & Rehabilitation Center 700 E Vista Ridge Mall Dr Lewisville, TX 75067 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few LVN O said that the nasal cannula should not be on the floor. LVN O added that it should be in a bagged to maintain its cleanliness. LVN O concluded that the best practice is to place the nasal cannula in a bag or somewhere clean . Record review of Resident #64's Face Sheet dated 10/25/23 indicated he was a 89 -year-old male initially admitted on [DATE] and readmitted on [DATE]. Relevant diagnoses included Chronic Obstructive Pulmonary Disease (lung disease), and Syncope and Collapse (fainting). Record review of Resident #64's Active Physician Orders dated 10/25/23 indicated the resident had an active order effective 09/10/23 indicating the following: Change O2 tubing/water every week on Sunday and PRN every night shift every Sun O2 @ 3-4L/Min via NC PRN to maintain O2 sats > 92% every shift for 02 Interview and observation on 10/24/23 at 10:57 AM with ADON N and LVN C, they were shown the resident's nasal canula exposed, laying on top of Resident #64's bed. They advised the resident's cannula should have been placed in a plastic container to avoid it getting contaminated. LVN C stated she would get the resident a new nasal cannula. They stated the risk of the nasal cannula being exposed could result in the resident getting a respiratory infection. Record review of Resident #32's Face Sheet dated 10/25/23 indicated he was a 64 -year-old male initially admitted on [DATE] and readmitted on [DATE]. Relevant diagnoses included Shortness of Breath, and Vascular Dementia (brain damage caused by strokes). Record review of Resident #32's Minimum Data Set (MDS ) dated 10/05/23 revealed she had a Brief Interview for Mental Status (BIMS) score of 07 (severe cognitive impairment). Active diagnosis incudes shortness of breath Record review of Resident #32's Active Physician Orders dated 10/25/23 indicated the resident had an active order effective 12/28/20 indicating the following: O2@2-4L/Min via NC PRN to maintain O2 Sats >92% every 8 hours as needed for O2 sats >92% Observation on 10/24/23 at 11:29 AM of an oxygen concentrator alongside Resident #32's bed and the humidifier attached to the oxygen concentrator dated 10/16. Interview on 10/26/23 at 09:12 AM with LVN A, she stated she had been at the facility for over 13 years on an as needed basis. She stated she was unsure if Resident #32 had orders for an oxygen concentrator. The LVN was asked to review the resident's active orders in the facility's system of record, and she stated that she did observe the resident's active orders for the oxygen concentrator on an as needed bases. She stated staff were required to check the oxygen concentrator for cleanliness, ensure humidifier had been changed out every seven days and refill of the liquid is low, change the tubing, and check the filter for cleanliness. She stated the risk of not servicing the oxygen concentrator weekly could result in the resident respiratory problems and resident could die. Interview with ADON N on 10/26/23 at 09:48 AM, he stated he had been the ADON at the facility for the past 12 years. He stated Resident #32 did not reside on the halls that he covered, and he was unsure if the resident required an oxygen concentrator. He stated that if a resident had orders for an (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676036 If continuation sheet Page 19 of 25 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 676036 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vista Ridge Nursing & Rehabilitation Center 700 E Vista Ridge Mall Dr Lewisville, TX 75067 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 0695 Level of Harm - Minimal harm or potential for actual harm oxygen concentrator on an as needed basis, they would have the machine in the resident's room to be readily available if the resident required oxygen. He stated they will in-serviced staff on changing out the humidifier canisters when empty and on a weekly basis, which is done by the nurse on duty on Sundays . He stated the risk of not servicing the resident's tubing and canisters when scheduled could result in infection control. Residents Affected - Few Interview with Administrator, Director of Nursing, Assistant Director of Nursing, Regional Director of Operation and Regional Clinical Reimbursement (RCR), on 10/25/23 at 2:00 PM revealed they were advised that the oxygen concentrator that was in Resident #32's room had a humidifier canister dated for 10/16, and the humidifier canister should had been changed in seven days (10/23/23). Initially the DON and ADON N stated the resident never needing an oxygen concentrator and they stated the resident never having an oxygen concentrator in his room. Surveyor showed a picture of the oxygen concentrator in the resident's room, and the humidifier canister dated for 10/16 and the DON still denied that this once belonged to the resident. The accessed the resident's active physician orders on PCC and acknowledged that the resident did have active physician orders for an oxygen concentrator on an as needed basis. The DON stated that her staff were trained to service all oxygen concentrators every Sunday, which included changing the fluid in the humidifier, checking the filter, and change the tubing and date it. She also stated that when residents were not using their oxygen concentrator, the nasal cannula should be stored in a container to avoid contamination. The DON stated the risk of not servicing the resident's tubing and canisters when scheduled could result in respiratory problems. Record review of facility policy, Oxygen Administration, undated, revealed The facility shall provide safe oxygen administration. Discard the administration set-up every seven (7) days. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676036 If continuation sheet Page 20 of 25 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 676036 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vista Ridge Nursing & Rehabilitation Center 700 E Vista Ridge Mall Dr Lewisville, TX 75067 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 observation, interview, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for four (Residents #11, Resident #31, Resident #3, and Resident #16 of six residents observed for infection control. Residents Affected - Some The facility failed to ensure that Resident #11's nasal cannula was off the floor. The facility failed to ensure CMA (certified medication aide) C sanitized the blood pressure cuff between Resident #3, Resident #16, and Resident #31. These failures could place the residents at risk of cross-contamination and development of infections. Findings included: Review of Resident #3's Face Sheet dated 10/25/2023 reflected that resident was a [AGE] year-old male admitted on [DATE]. Relevant diagnoses included essential primary hypertension, unspecified dementia, unspecified peripheral vascular disease (a slow and progressive circulation disorder), bilateral hypermetropia (farsightedness of both eyes), and hemiplegia (paralysis of one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (insufficient oxygen in the brain causing stroke) affecting right dominant side. Review of Resident #3's Quarterly MDS assessment dated [DATE] reflected that resident had a moderately intact cognition with a BIMS score of 09. Resident required extensive assistance for bed mobility, transfer, dressing, toilet use, and personal hygiene. Resident also needed limited assistance for walk in room, walk in corridor, locomotion on unit, locomotion off unit, and eating. The Quarterly MDS Assessment also indicated that the primary reason for admission was medically complex conditions such as hypertension, unspecified dementia, peripheral vascular disease, benign prostatic hyperplasia (a condition in men in which the prostate gland is enlarged and not cancerous), and hyponatremia (lower than normal level of sodium in the bloodstream). Review of Resident #3's Comprehensive Care Plan dated 09/03/2023 reflected that resident had hypertension r/t (related to) stroke and is on lisinopril and metoprolol. Two of the interventions were to give anti-hypertensive medications as ordered and obtain blood pressure readings before medication administration and prn (as needed). Review of Resident #3's Physician's order for lisinopril 10 mg dated 06/26/2022 reflected, Give 1 tablet by mouth one time a day for essential (primary) hypertension. Hold for bp of 110/60. Review of Resident #3's Physician's order for metoprolol succinate ER (extended release) tablet 50 mg dated 10/31/2018 reflected, Give 1 tablet by mouth one time a day for essential (primary) hypertension. Hold for bp of 110/60. Review of Resident #3's Physician's order for amlodipine besylate 5 mg dated 06/13/2023 reflected, Give 1 tablet by mouth one time a day for HTN (hypertension). Hold for sbp (systolic blood pressure) < 110 or dbp (diastolic blood pressure) < 60. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676036 If continuation sheet Page 21 of 25 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 676036 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vista Ridge Nursing & Rehabilitation Center 700 E Vista Ridge Mall Dr Lewisville, TX 75067 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 Review of Resident #11's Face Sheet dated 10/24/2023 reflected that resident was a [AGE] year-old female admitted on [DATE]. Relevant diagnoses included unspecified chronic obstructive pulmonary disease, intermittent claudication (muscle pain due to lack of oxygen) of bilateral legs, right shoulder primary osteoarthritis (a type of arthritis that happens when the cartilage that lines your joints is worn down and your bones rub against each other), other intervertebral disc degeneration (age-related wear and tear on discs of the spine, causing pain and instability) of the lumbar region (relating to the lower part of the back), unspecified anxiety disorder, and atherosclerotic (the buildup of fats, cholesterol and other substances in and on the artery walls) heart disease of native coronary artery without angina pectoris (chest pain). Review of Resident #11's Quarterly MDS assessment dated [DATE] reflected that Resident #11 had a moderately intact cognition with a BIMS score of 12. Resident #11 required supervision in bed mobility, transfer, and eating. Resident #11 needed limited assistance in walk in room, walk in corridor, locomotion on unit, locomotion off unit, dressing, toilet use, and personal hygiene. The Quarterly MDS also indicated that the primary reason for admission was medically complex conditions such as unspecified chronic obstructive pulmonary disease, coronary artery disease, and anxiety disorder. Review of Resident #11's Comprehensive Care Plan dated 09/29/2023 reflected that Resident #11 had emphysema/COPD (chronic obstructive pulmonary disease). The interventions did not include use of oxygen supplement administration. Review of Resident #11's Physician's Order on 10/24/2023 reflected no physician's order for oxygen supplement. Review of Resident #16's Face Sheet dated 10/25/2023 reflected that resident was a [AGE] year-old female admitted on [DATE]. Relevant diagnoses included essential (primary) hypertension, unspecified dementia, unspecified and recurrent major depressive disorder, type 2 diabetes with hyperglycemia (high blood sugar in the blood stream), and morbid (severe) obesity with alveolar hypoventilation (breathing that is too shallow or too slow to meet the needs of the body). Review of Resident #16's Quarterly MDS assessment dated [DATE] reflected that Resident #16 was cognitively intact with a BIMS score of 15. Resident required extensive assistance for bed mobility, transfer, dressing, toilet use, and personal hygiene. The Quarterly MDS Assessment also indicated that the primary reason for admission was medically complex conditions such as hypertension, unspecified dementia, and diabetes mellitus. Review of Resident #16's Comprehensive Care Plan dated 10/17/2023 reflected that resident had hypertension and is on lisinopril 20 mg PO QD. Two of the interventions were to give anti-hypertensive medications as ordered and obtain blood pressure readings before medication administration and prn. Review of Resident #16's Physician's order for lisinopril 20 mg dated 10/30/2018 reflected, Give 1 tablet by mouth one time a day for essential (primary) hypertension. Hold for bp of 110/60. Review of Resident #31's Face Sheet dated 10/25/2023 reflected that resident was a [AGE] year-old female admitted on [DATE]. Relevant diagnoses included essential (primary) hypertension, unspecified chronic obstructive pulmonary disease, unspecified atrial fibrillation (an irregular, rapid heartbeat), unspecified schizophrenia, and type 2 diabetes mellitus. Review of Resident #31's Quarterly MDS assessment dated [DATE] reflected that Resident #31 had a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676036 If continuation sheet Page 22 of 25 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 676036 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vista Ridge Nursing & Rehabilitation Center 700 E Vista Ridge Mall Dr Lewisville, TX 75067 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 moderately intact cognition with a BIMS score of 10. Resident #31 required extensive assistance for bed mobility, dressing, toilet use, and personal hygiene. Supervision required for eating. The Quarterly MDS Assessment also indicated that the primary reason for admission was medically complex conditions such as hypertension, chronic obstructive pulmonary disease, and diabetes mellitus. Review of Resident #31's Comprehensive Care Plan dated 10/06/2023 reflected that resident had hypertension (HTN) and is on Toprol as ordered. One of the interventions was give anti-hypertensive medications as ordered. Review of Resident #31's Physician's order for metoprolol succinate ER (extended release) 25 mg, Give 1 tablet by mouth one time a day for HTN. Hold all BP meds if BP < 100/60. Observation and interview with Resident #11 on 10/24/2023 beginning at 10:11 AM revealed that Resident #11 was on her wheelchair folding some papers on the overbed table. It was also observed that Resident #11 had an oxygen concentrator at the side of the bed. The oxygen concentrator was off. One end of the nasal cannula was attached to the oxygen concentrator and the other end was noted to be on the floor. Resident #11 stated that she placed her nasal cannula on the side table when she woke. Resident #11 added she did not notice that it fell on the floor. Resident #11 said that she did not know that the nasal cannula should be bagged and that the nurse never gave her a bag to put the nasal cannula in when she was not using it. Observation and interview with LVN O on 10/24/2023 beginning at 10:28 AM, LVN O stated that the Resident #11 had been using oxygen supplement since she was transferred to hall 200. LVN O confirmed that Resident #11 only used her oxygen supplement at night and breathing treatments during the day. LVN O said that the nasal cannula should not be on the floor. LVN O added that it should be in a bagged when not in use because a dirty nasal cannula could cause infection or cross contamination. LVN O then said that she would replace it immediately. LVN O went out of the room to get a new nasal cannula. Observation on 10/25/2023 at 7:52 AM revealed that CMA C picked up the blood pressure cuff from the medication cart. CMA C placed the blood pressure cuff on Resident #31's arm. After the blood pressure reading was completed, CMA C placed the blood pressure cuff on top of the medication cart and prepared the medications for Resident #31. The blood pressure cuff was not sanitized. CMA C then went ahead and administered the medication. Observation on 10/25/2023 at 8:03 AM revealed that after giving the medication to Resident #31, CMA C went straight to Resident #3 and placed the blood pressure cuff on Resident #3's arm. After the blood pressure reading was completed, CMA C placed the blood pressure cuff on top of the medication cart and then prepared and gave the medications to Residents #3. The blood pressure cuff was not sanitized. Observation on 10/25/2023 at 8:16 AM revealed that CMA C picked up the blood pressure cuff from the medication cart. CMA C placed the blood pressure cuff on Resident #16's arm. After the blood pressure reading was completed, CMA C placed the blood pressure cuff on the medication cart. CMA C prepared and gave the medications to Resident #16. The blood pressure cuff was not sanitized. Interview with CMA C on 10/25/2023 at 8:29 AM, CMA C stated that he obtained the blood pressure of the residents before giving the medication for hypertension. CMA C stated that he washed or sanitized his hands before and after giving medications. When asked what should be done after using the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676036 If continuation sheet Page 23 of 25 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 676036 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vista Ridge Nursing & Rehabilitation Center 700 E Vista Ridge Mall Dr Lewisville, TX 75067 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 blood pressure cuff and before using it to another resident, CMA C replied that it should be cleaned with a sanitizing wipe. CMA C then unlocked the medication cart and opened the last drawer and pulled a piece of sanitizing wipes and started sanitizing the blood pressure cuff. CMA C then acknowledged that he forgot to sanitize the blood pressure cuff in between residents when he took the blood pressure of the residents. CMA C stated that this action could cause infection to transfer from one resident to another. Residents Affected - Some Interview with LVN O on 10/25/2023 at 8:40 AM, LVN O stated that the blood pressure cuff should be sanitized in between residents. If the blood pressure cuff was not sanitized, it could cause cross contaminations and infection control issues. Interview with CNA H on 10/25/2023 at 10:25 AM, CNA H stated that the nasal cannula should be placed in a bag if not in use. CNA H said that whoever was getting the resident up should put the nasal cannula inside the bag. CNA H further said that the resident, visitors, and staff could trip from the tubing of the nasal cannula and fall. CNA H added that if the nasal cannula was touching something that was not clean, it could cause infection because the cannula will be contaminated. Interview with CNA G on 10/25/2023 at 10:36 AM, CNA G stated that the nasal cannula should not be on the floor because the floor is not clean. CNA G pointed out that the nasal cannula should be placed in a bag if not in use. CNA G added that the resident might catch a disease if the nasal cannula is dirty. Interview with LVN B on 10/25/2023 at 11:06 AM, LVN B stated that the residents with respiratory failures usually had an oxygen supplement. LVN B said that nasal cannula should be bagged when not in use. LVN B said that this could be an infection control issue because the residents might catch an infection and then transfer it to other residents and staff. LVN B added that blood pressure must be sanitized after every use and in between residents to prevent cross contaminations, Interview with ADON N on 10/26/2023 at 7:49 AM, ADON N stated that the blood pressure cuff should be sanitized after every use or after every resident. ADON N said that if the blood pressure cuff is not sanitized, it could cause cross contamination and spread of infection. ADON N said that not sanitizing the blood pressure cuff could also cause the development of new infections. ADON N further added that nasal cannula should be bagged and should be off the floor. A dirty nasal cannula could exacerbate respiratory issues. ADON concluded that staff should do their rounds were expected to ensure that all the nasal cannula were off the floor. ADON N said that the expectation also was for the blood pressure cuff would be sanitized in between residents. Interview with DON on 10/26/2023 at 8:09 AM, the DON stated the nasal cannula should be placed in a bag or anywhere where it will not be contaminated. This should be done to prevent infection especially of those residents that are immunocompromised (The immune system's defenses are low resulting to inability to fight off infections and diseases). The DON added that the blood pressure cuff should be sanitized in between use to prevent cross contaminations. The DON said that the expectation was for the staff to ensure that then nasal cannula were off the floor and bagged when not in use and that the blood pressure cuff be sanitized after every use. The DON concluded that moving forward, she will monitor staff's adherence to the policy to ensure the best possible care. Interview with the Administrator on 10/26/2023 at 8:23 AM, the Administrator stated that, in general, a system failure was identified and realized. The Administrator said that this oversight would be addressed to ensure quality of care and quality of life for the residents. The Administrator added (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676036 If continuation sheet Page 24 of 25 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 676036 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vista Ridge Nursing & Rehabilitation Center 700 E Vista Ridge Mall Dr Lewisville, TX 75067 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 that it should in a place where the resident could reach it so that their needs could be addressed. The Administrator concluded that the expectation is that the staff would do their due diligence and check the residents more often. Record review of facility's policy Infection Prevention and Control Program, revealed An infection and control program is established and maintained to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infections. Record review of facility's policy Blood Pressure Cuff Disinfecting Policy and Procedure, revealed . Cleaning blood pressure cuffs between resident use will help prevent cross contamination, including the spread of bacteria. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676036 If continuation sheet Page 25 of 25