Health inspection·September 13, 2025

F 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few 522mg/dl, [MD] notified and said to give sliding scale, order carried out and 6 units of insulin lispro given by LVN B Record review of Resident#1 progress note dated 09/10/25 at 1:39 pm reflected: Resident#1 vital signs were noted to be B/p 158/74, pulse 93, temp 98.0, resp 17 and o2 sat 97% . at 7:30 AM. [Resident#1] was noted to be laying in bed with no concerns noted at that time. Prior to medication administration. Prior to administration of routine Lantus order resident request an addition 6 units of insulin. [LVN A] educated resident that [LVN A] could not administer an addition dose of insulin as that would be double dosing and there isn't an order. [LVN A] administered resident's routine Lantus order at 825 AM.[LVN B] instructed the [resident#1] that [LVN A] would recheck her blood sugar but her husband transported resident from facility. Resident#1 [family member#1] arrived at facility with wheelchair stated, I'm taking [Resident#1] for an evaluation as she was in DKA and we will return later.[ Family member#1] also stated, [Resident#1] knows her body. When asked how did [family member#1] determine she was in DKA. [Resident#1] was seated in wheelchair and smiled at [LVN A] when exciting facility with no distress noted. [LVN A] then received a phone call from [Resident#1 family member#2] aggressively state that [Resident#1] blood sugar was taken at 5:30am and that no one has done anything or even check on [Resident#1].[LVN A] attempt to tell [family member#2] what was done while she continue to call [LVN A] a liar, a neglectful nurse until she hung up. by LVN A Record review of Resident#1 progress notes dated 09/10/25 at 4:54 pm[LVN M ] and [Admin] spoke with [resident#1 family member#1] regarding the status of [Resident#1]and to follow up with any concerns he may have. [Family Member#1] was very appreciative of the care [Resident#1] has received since she admitted to [facility], stating the care has been great and he has no questions or concerns at this time. [Family Member#1] also apologized for [Family Member#2] behavior towards the charge nurse this morning, stating, [Family Member#2] is an alarmist, asking us to disregard anything [Family Member#2] stated as [Family member#1] was the POA. [LVN M ] did reiterate that charge nurse did follow all policies and procedures, following Physician's orders during the care of [Resident#1] this morning. [Family Member#1] agreed and stated that [Resident#1] was just a brittle diabetic, knows her body and wanted to ensure she wasn't in DKA, so [Family Member#1] chose to [Resident#1] to the ER to be evaluated. He also stated that he will be bringing her back to [Facility]. by LVN M Record review of Resident#1 hospital record dated 09/12/25 reflected, Resident#1 was admitted to the hospital at 10:44 am on 09/10/25. Record review reflected Resident#1 was diagnosed with DKA (serious complication of diabetes that occurs when the body lacks sufficient insulin This condition leads to high blood sugar levels and the accumulation of acidic substances called ketones in the body.) Record review revealed Resident#1 insulin level was 364 at 1:55 pm. Record review revealed Resident#1 received intravenous fluids and insulin. An interview on 09/12/25 at 12:30 pm with Resident #1 at the hospital revealed she had been feeling weak and tried to do anything. Resident#1 stated that she did not want to participate in PT which was her main reason for being in the facility to get stronger. Resident#1 stated she knew she was in DKA and wanted to go to the hospital. Resident#1 stated she called her husband because he would get her to the hospital faster than the facility. Resident#1 stated LVN A did not check her blood sugar or give her insulin on 09/10/25 before she left the facility. An interview on 09/12/25 at 12:45pm, the hospital Nurse stated Resident#1 last blood sugar results were 84. Attempted to call LVN A on 09/12/25 at 4:15pm and on 09/13/25 at 12:30 PM, surveyor was not able to leave voicemail. During an interview over the phone at 5:10 am LVN B stated she checked Resident#1 blood sugar around 6:30 am and it was 522. LVN B stated she called the MD and he said to check her blood sugar again at 8am when she received her 8am scheduled insulin and call the MD back. LVN B stated she informed LVN A about Resident#1 current condition. Resident#1 orders were updated in the system. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676268 If continuation sheet Page 2 of 9 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 676268 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/13/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villages of Lake Highlands 8615 Lullwater Dr Dallas, TX 75238 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 - Immediate jeopardy to resident health or safety Residents Affected - Few During an interview on 09/13/25 at 2:30 pm, the Medical Director stated he was called about Resident #1's blood sugar reading being in the 500's on 09/10/25 about 6:45 am. The Medical Director stated he sent new orders and additional monitoring steps for Resident#1. The Medical Director stated staff had to check Resident#1 blood sugars before giving insulin to make sure the right number of units are given. The Medical Director stated staff cannot falsify documentation because that will put residents in the facility health at risk. The non-compliance was identified as past non-compliance (PNC). The IJ began on 09/10/25 and ended on 09/12/25. The facility had corrected the non-compliance before the state's investigation began. During an interview on 09/12/25 at 3:30 pm, with the Admin and the CN/DON, the CN/DON stated the facility implemented the following interventions and procedures to ensure residents received necessary care/treatment to prevent serious injury or harm: revised Diabetic protocol with the Medical Director, QAPI meeting with Medical Director, diabetic resident audited daily for a week then weekly for a month and then monthly after, in-service on ANE, recognizing the signs and symptoms of hypoglycemia/hyperglycemia, record review of Emergency QAPI plan dated 09/11/25, signed by MD, Admin, the CN/DON. The CN/DON stated staff have had competency testing blood sugars, given insulin, abuse/neglect and documentation. The CN/DON stated LVN A was suspended after Resident#1 family stated he did not do her blood sugar check on 09/10/25. The CN/DON stated after investigating the incident, LVN A stated he did not check Resident#1 blood sugar and used LVN B readings the morning of 09/10/25. The CN/DON and Admin reported LVN A license to the BON on 09/11/25. The Admin and DON terminated LVN A on 09/12/25. The CN/DON except staff to follow the orders, check blood sugars, use proper hygiene and document their own observation. Observation and interview on 09/12/25 between 3:30 pm to 4:00 pm revealed LVN C completed a mock trial and went over the process of taking blood sugars, giving insulin, and completing documentation. During an interview and observation round on 09/12/25 at 4:30 pm, the surveyor observed LVN C take Resident#2's Blood sugar, sanitize machine and area, complete and document findings in the TAR. LVN C stated documenting false information will result in termination, and your license being reported to the board. During an interview on 09/12/25 4:30 pm to 5:30 pm LVN C, LVN H, LVN I, LVN B, LVN N, RN O and ADON P were knowledge about updated policy and procedures for the diabetic residents, abuse/neglect and documentation. During interviews over the phone on 09/13/25 between 4:00 am to 5:00 am, LVN E, LVN F, LVN G stated documenting false information would result in termination, and their license being reported to the board. LVN E, LVN F, LVN G stated nurses could only document the readings that he or she observed. LVN E, LVN F, LVN G stated documenting incorrect information could result in possible harm or death. LVN E, LVN F, LVN G were knowledge about updated policy and procedures for the diabetic residents, signs/symptoms of hypo/hyperglycemia, abuse/neglect and documentation. During interviews on 09/13/25 between 10:30 am and 11:25 am, LVN D LVN J, LVN K and LVN L were able to describe and give examples of abuse/neglect, updated policy for diabetics, documentation, and sign/symptoms for hypo/hyperglycemia. LVN D LVN J, LVN K and LVN L stated if a resident blood sugar tested too high or too low the nurse had to monitor the resident and recheck blood sugar in 30 minutes. During an interview and observation round on 09/13/25 at 11:30 am, surveyor observed LVN D take Resident#3, Resident#4, Resident#5's Blood sugar, sanitize machine and area, complete and document findings in the TAR. LVN D stated that nurses could not document the previous nurse readings, nurses could only document their own observed readings. LVN D stated that documenting false information would result in termination, and their license would be reported to the board. LVN D stated residents could be in danger of not getting enough medication or too much that could be harmful. During interviews on 09/13/25 between 11:45 am to 12:15 pm, Resident #2, Resident#3, Resident#4 and Residents#5 did not have any concerns about blood sugars or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676268 If continuation sheet Page 3 of 9 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 676268 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/13/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villages of Lake Highlands 8615 Lullwater Dr Dallas, TX 75238 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 - Immediate jeopardy to resident health or safety Residents Affected - Few receiving diabetic medications. Attempted to call LVN A on 09/13/25 at 12:30pm, the surveyor was not able to leave voicemail. During an interview on 09/13/25 at 2:00 pm, the PCP stated Resident#1 was a Type one diabetic, and her blood sugar usually was 400 and could change quickly. The PCP stated blood sugars had to be checked before given insulin. The PCP stated Resident#1 had a history of being non-compliant with her diet and DKA in the past. Record review of facility Emergency QAPI meeting and sign sheet, dated 09/11/25 reflected: Identification of concern: On 09/11/25, the facility identified a serious concern regarding a nurse failing to check residents' blood sugars as ordered and falsifying documentation of a blood sugar reading. The a facility immediately Conducted a review of diabetic residents' charts and practices. It was determined that staff competency, documentation, integrity and monitoring system were Compliant with facility protocols, nursing practice and regulatory requirements. This emergency QAPI plan is developed in response to the isolated and the purpose of this plans to.Ensure resident safety by preventing neglect, reinforce accurate timely and honest documentation. Verify staff competency in performing blood glucose check and administering insulin. Maintain monitoring and auditing practices for accountability and compliance. Root cause analysis and corrective actions:1. resident safety review: The Don/designee immediately reviewed our residents with diabetes to ensure to ensure blood sugars were properly checked and treatment provided as needed on 9/11/2025.2. Chart Audit: The facility initiated daily audits of 100% of diabetic charts beginning on 9/11/2025 to ensure blood sugar checks and insulin administration were completed and documented accurately. This will continue daily for two weeks, then weekly for six weeks, then monthly until compliance is sustained for three consecutive months.3. Competency checks- blood sugar monitoring. All licensed nurses begin. Return demonstration on 9/11/2025 to verify competency in performing blood glucose checks completely, including infection control, accurate use of the glucometer. Notification of the physician when warranted. correct documentation.4. Competency, check insulin administration: All licensed nurses begin return to demonstrations on insulin administration on 9/11/2025. Competency includes dosage verification, injection techniques, resident monitoring, and documentation.5. Education on neglect and documentation. The Executive Director/Designee provided mandatory and services beginning 9/11/2025 for all nursing staff on: resident neglect related to miss blood sugars. Legal and ethical consequences of falsifying documentation.6. Random spot checks. Supervisors will conduct unannounced direct observation of staff performing blood sugar checks and insulin administration to ensure compliance and procedures.7. Accountability: Staff who failed to check blood sugars as ordered or falsely documentation or face disciplinary actions up to and including termination. #8. Oversight The DON/ designee will continue to oversee diabetic care and staff compliance audits. Results will be reported to the Administrator, Medical Director and QAPI Committee for ongoing review.9. Emergency QAPI Meeting: The facility held an emergency QAPI meeting on 9/11/2025 to discuss their concerns and implement corrective actions and engage the Medical Director in oversight.10. Facility Actions: The investigation determined the nurse did not check the resident blood sugar and falsified his actions by documenting a blood sugar of 522. The nurse was reported to the Texas Board of Nursing on 9/11/25, was immediately suspended from work, and the facility has terminated the nurse employment on 9/12./2025.11. QAPI Statement Any staff members found to have engaged in false documentation or neglect will face immediate disciplinary action, up to and including termination and reporting to the State Board of Nursing according to facility policy and state law. The facility reported the incident to HHSC on 9/11/25 after Resident#1 family reported the incident. Record review of chart audit of diabetic residents started on 09/11/25. Record review of the BON complaint form dated 09/11/25 completed by the CN/DON reflected: on 09/10/25 at 6:40 am LVN B check resident#1 one blood sugar and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676268 If continuation sheet Page 4 of 9 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 676268 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/13/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villages of Lake Highlands 8615 Lullwater Dr Dallas, TX 75238 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 - Immediate jeopardy to resident health or safety Residents Affected - Few received a reading of 522. The physician was notified and gave order to administer sliding scale insulin and monitor resident around 8:00 AM LVN B administered Resident#1 Scheduled Lantus 23 unit via route subcutaneous. Documentation shows LVN A noted blood sugar of 522 at 8:00am administration. Resident#1 family member reported LVN A did not take Resident#1 blood sugar. When questioning LVN A did not collect glucose reading before administering the Lantus, he replied, I did not When further questioned where this 522 reading he enters came from, he stated, It was the one collected by other nurse at 6:40 am. Resident is currently in the hospital for DKA. Record review of in-service training dated 09/11/25 titled care of patients with diabetes reflected, monitoring patient, checking blood sugars, measuring and administering insulin, follow up, notifying MD and documentation. Record review of LVN A's termination documentation reflected:LVN A was terminated on 09/12/25 with LVN A signature. Record review of chart audit of diabetic residents started on 09/12/25. Record review of the facility's in-Service Training: Zero Tolerance for Falsifying Documentation, undated, and reflected:19 staff participated in the in-serviceLearning Objectives1. Understand the facility's zero-tolerance policy for falsifying documentation.2. Recognizing how failing to provide care but documenting care was provided constitutes both neglect and fraudulent documentation.3. Demonstrate knowledge of correct procedures for documentation.4. Identify the disciplinary consequences of falsifying documentation.________________________________________Content1. What is Falsification of Documentation? Recording information in the medical record that is not true, not performed, or intentionally altered. Examples include:o Documenting a blood sugar reading that was not actually taken.o Signing off medications or treatments that were not provided.o Changing a resident's vital signs to appear within normal limits.o Backdating entries or forging signatures. o Changing test results or omitting critical details. o Ghost entries for care that never occurred.________________________________________2. Why is This Serious? Resident Safety: Missing or falsified provision of care can lead to residents not receiving what they need to ensure they are safe and could include hospitalization or death. Inaccurate records can lead to misdiagnoses, improper treatment, and dangerous medical errors. Neglect: Failing to provide care as ordered is considered neglect and violates residents' rights to proper care. Legal & Regulatory Consequences: Falsification can result in serious legal action, including criminal charges, fines, and civil lawsuits, especially in cases of fraud or medical malpractice. This can result in loss of licensure, fines, or termination. Healthcare professionals, such as nurses, can face licensing suspension, revocation, or probation from their state board for fraudulent documentation.________________________________________3. Facility Zero Tolerance Policy Falsifying documentation in any form is strictly prohibited. No Tolerance Standard:o Any employee found falsifying documentation will face disciplinary action, up to and including termination of employment.o Repeated or intentional violations may be reported to the state licensing board and law enforcement if fraud or resident harm is involved.________________________________________4. Staff Responsibility Provide care exactly as ordered. Document only what you did, when you did it, and the actual results. Ask for clarification if you are unsure of an order or what documentation is required. Report errors and mistakes in a timely manner. Record review of facility Post-Test: Zero Tolerance for Falsifying Documentation, undated reflected: 19 staff had participated in the post test for zero tolerance for Falsifying Documentation Staff results reflected a score of 100%Record review of facility post- test: Abuse, Neglect and Misappropriation dated 09/11/25 reflected,45 staff participated in the post with a score of 100%.1. Abuse id defined as : The intentional infliction of physical harm, pain, or mental anguish2. Neglect occurs when staff: Intentionally fail to provide needed care or services3. Misappropriation of resident property means: Intentionally using or taking a resident's money, belonging, or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676268 If continuation sheet Page 5 of 9 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 676268 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/13/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villages of Lake Highlands 8615 Lullwater Dr Dallas, TX 75238 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 - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete property without consent.4. All staff considered mandatory reporters of abuse, neglect and misappropriation5. If you witness or suspect abuse, neglect, or misappropriation, your first responsibility is to:-I have attended training on abuse, neglect, and misappropriation-I understand the definitions, signs, and reporting requirements-I understand that I am a mandatory reporter and must immediately report any suspected or witnessed abuse, neglect, or misappropriation.-I understand that failure to follow reporting procedures may result in disciplinary action, up tp and including termination, and potential legal consequences. Event ID: Facility ID: 676268 If continuation sheet Page 6 of 9 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 676268 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/13/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villages of Lake Highlands 8615 Lullwater Dr Dallas, TX 75238 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to maintain medical records on each resident that are accurately documented for 1 (Resident #1) of 5 residents reviewed for administration. The facility failed to ensure Resident #1 had accurate TAR documentation in the EHR on 09/10/25 for Resident #1's blood sugar checks, Humalog Kwik pen injection, and insulin lispro 100 unit/ml injection by LVN A . The non-compliance was identified as past non-compliance (PNC). The PNC began on 09/10/25 and ended on 09/12/25 and the facility had corrected the non-compliance before the state's investigation began. This failure could place residents at risk of not receiving the proper care or treatment and services.Findings included:Record review of Resident #1's face sheet, dated 09/12/25 reflected, she was a [AGE] year-old female who was admitted [DATE] and diagnosed with but not limited to: Type 2 Diabetes Mellitus (chronic disease characterized by high blood sugar) with diabetic chronic kidney disease(Diabetic nephropathy affects the kidneys' usual work of removing waste products and extra fluid from the body), end stage renal disease (chronic kidney disease progresses to a point where the kidneys lose nearly all their filtering ability. atherosclerotic heart disease of native coronary artery without angina pectoris (A condition where the arteries supplying blood to the heart become narrowed due to the accumulation of plaquette and altered mental status unspecified. Record review of Resident #1's MDS assessment, dated 09/10/25 reflected his BIMS score was 06 which indicated severe cognitive impairment. Record review of Resident#1 orders reflected: HumaLOG KwikPen Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Lispro)Inject as per sliding scale: if 70 - 240 = 0 UNITS <70 INSTITUTE HYPOLYCEMIA PROTOCOL AND CALL MD;241 - 300 = 2 UNITS; 301 - 350 = 3 UNITS; 351 - 400 = 4 UNITS >400 GIVE 5 UNITS AND CALL MD,subcutaneously at bedtime for DM start date on 09/05/25 at 6:00pm. Insulin Glargine Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Glargine)Inject 23 unit subcutaneously one time a day for DM start date of 09/10/25 at 8am INSULIN LISPRO 100 UNIT/ML VL Inject as per sliding scale: if 70 - 130 = 0 UNIT <70 INSTITUTE HYPOGLYCEMIA PROTOCOL AND CALL MD; 131 - 180 = 1 UNIT; 181 - 240 = 2 UNITS; 241 - 300 = 3 UNITS; 301 - 350 = 4 UNITS; 351 - 400 = 5 UNITS >400 GIVE 6 UNITS AND CALL MD, subcutaneously before meals and at bedtime related to TYPE 2 DIABETES MELLITUS WITH DIABETIC CHRONIC KIDNEYDISEASE (E11.22) start date of 09/08/25 at 7:30 am Record review of Resident#1 TAR for the month of September 2015 reflected on 09/10/25:At 7:30am Resident#1 blood sugar was 522 and injected 9 units of Insulin Lispro 100unit/ML signed by LVN B At 8:00 am Resident#1 blood sugar was 522 and injected 23 units of Insulin Glargine 100 unit/ml, signed by LVN A At 11:30 am Resident#1 blood sugar was 522 and injected 9 units of Insulin Lispro 100unit/ML, signed by LVN A At 4:30 pm Resident#1 blood sugar was 522 and injected 4 units of Insulin Lispro 100unit/ML, signed by LVN A At 8:00 pm Resident#1 blood sugar was 522 and injected 1 units of Insulin Lispro 100unit/ML, signed by LVN A At 6:00 pm Resident#1 sugar was 522 and injected with 4 units of Humalog kwik pen, signed by LVN A Record review of Resident #1's hospital records dated 09/12/25 reflected, Resident#1 was admitted to the hospital 10:44 am on 09/10/25. Record review reflected Resident#1 was diagnosed with DKA (serious complication of diabetes that occurs when the body lacks sufficient insulin This condition leads to high blood sugar levels and the accumulation of acidic substances called ketones in the body.) Record review revealed Resident#1 insulin level was 364 at 1:55 pm. Record review revealed Resident#1 received intravenous fluids and insulin). During an interview on 09/13/25 at 2:30 pm, the Medical Director stated he was called about Resident #1's blood sugar reading being in the 500's on 09/10/25 about 6:45 am. The Medical Director stated he sent new orders and additional monitoring steps for Resident#1. The (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676268 If continuation sheet Page 7 of 9 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 676268 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/13/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villages of Lake Highlands 8615 Lullwater Dr Dallas, TX 75238 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Medical Director stated staff had to check Resident#1 blood sugars before giving insulin to make sure the right number of units are given. The Medical Director stated staff cannot falsify documentation because that will put residents in the facility health at risk. The non-compliance was identified as past non-compliance (PNC). The PNC began on 09/10/25 and ended on 09/12/25. The facility had corrected the non-compliance before the state's investigation began. During an interview on 09/12/25 at 3:30 pm, The CN/DON stated staff have had competency testing blood sugars, given insulin, abuse/neglect and documentation. The CN/DON stated LVN A was suspended after Resident#1 family stated he did not do her blood sugar check on 09/10/25. The CN/DON stated after investigating the incident, LVN A stated he did not check Resident#1 blood sugar and used LVN B readings the morning of 09/10/25. The CN/DON and Admin reported LVN A license to the BON on 09/11/25. The Admin and DON terminated LVN A on 09/12/25. The CN/DON except staff to follow the orders, check blood sugars, use proper hygiene and document their own observation. During an interview on 09/12/25 at 4:30 pm LVN C stated documenting false information will result in termination, and your license being reported to the board. During an interview over the phone on 09/13/25 between 4:00am to 5:00am, LVN E, LVN F, LVN G stated documenting false information will result in termination, and your license being reported to the board. LVN E, LVN F, LVN G stated nurses can only document the readings that he or she observed. LVN E, LVN F, LVN G stated documenting incorrect information could result in possible harm or death. During an interview with the CN/DON on 09/13/25 3:30 pm she stated purposely documenting wrongful information will result in suspension until investigation was completed, termination and license reported to the appropriate state board. The CN/DON stated residents can have a decline in health from falsifying documentation. Record review of falsifying documentation in-service, dated 09/11/25 reflected:Learning Objectives1. Understand the facility's zero-tolerance policy for falsifying documentation.2. Recognizing how failing to provide care but documenting care was provided constitutes both neglect and fraudulent documentation.3. Demonstrate knowledge of correct procedures for documentation.4. Identify the disciplinary consequences of falsifying documentation.Content1. What is Falsification of Documentation? Recording information in the medical record that is not true, not performed, or intentionally altered. Examples include:o Documenting a blood sugar reading that was not actually taken.o Signing off medications or treatments that were not provided.o Changing a resident's vital signs to appear within normal limits.o Backdating entries or forging signatures. o Changing test results or omitting critical details. o Ghost entries for care that never occurred.2. Why is This Serious? Resident Safety: Missing or falsified provision of care can lead to residents not receiving what they need to ensure they are safe and could include hospitalization or death. Inaccurate records can lead to misdiagnoses, improper treatment, and dangerous medical errors. Neglect: Failing to provide care as ordered is considered neglect and violates residents' rights to proper care. Legal & Regulatory Consequences: Falsification can result in serious legal action, including criminal charges, fines, and civil lawsuits, especially in cases of fraud or medical malpractice. This can result in loss of licensure, fines, or termination. Healthcare professionals, such as nurses, can face licensing suspension, revocation, or probation from their state board for fraudulent documentation.3. Facility Zero Tolerance Policy Falsifying documentation in any form is strictly prohibited. No Tolerance Standard:o Any employee found falsifying documentation will face disciplinary action, up to and including termination of employment.o Repeated or intentional violations may be reported to the state licensing board and law enforcement if fraud or resident harm is involved.4. Staff Responsibility Provide care exactly as ordered. Document only what you did, when you did it, and the actual results. Ask for clarification if you are unsure of an order or what documentation is required. Report errors and mistakes in a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676268 If continuation sheet Page 8 of 9 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 676268 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/13/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villages of Lake Highlands 8615 Lullwater Dr Dallas, TX 75238 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 0842 timely manner. 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: 676268 If continuation sheet Page 9 of 9