Health inspection·December 1, 2025

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, interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and time frames that met the residents clinical and psychosocial needs that were identified in the comprehensive assessment for 1 (Resident #14) out of 5 residents reviewed for comprehensive person-centered care plans. The facility failed to ensure that Resident #14's Comprehensive Care Plan included the following:1. The facility failed to ensure that Resident #14's Comprehensive Care Plan included physician orders for hip precautions.2. The facility failed to ensure that Resident #14's Comprehensive Care Plan included physician orders for her toe-touch weight bearing status.3. The facility failed to ensure that Resident 14's Comprehensive Care Plan included physician orders for Full Code Advanced Status. These failures could place residents at risk of having received inadequate interventions not individualized to their care needs and diagnoses. Findings Included:Record review of Resident #14's admission face sheet dated 10/06/25 reflected she was an [AGE] year-old female was originally admitted to the facility on [DATE] and readmitted on [DATE] with active diagnoses that included: aftercare following joint replacement surgery, pain in right hip, aftercare following explanation of hip joint prothesis, and inflammatory reaction due to internal right hip prosthesis with subsequent encounters effusion of the right hip, generalized muscle weakness, chronic pain syndrome, and abnormalities of gait and mobility, lack of coordination, and COPD (a group of lung diseases that cause ongoing airflow obstruction and breathing difficulties). Record review of Resident #14's readmission MDS assessment dated [DATE], reflected a BIMS score of 15 indicating that her memory was cognitively intact. Resident #14's MDS Assessment reflected that she had an impairment on one side of her lower extremity (hip, knee, ankle, foot). Resident #14 required assistance with her ADL's for eating (Setup or clean-up assistance), Oral Hygiene (Supervision or touching assistance), Shower/bath (Substantial/maximal assistance), Upper body dressing (Supervision or touching assistance), Lower body dressing (Substantial/maximal assistance), Putting on/taking off footwear (Substantial/maximal assistance), Roll left and right (Substantial/maximal assistance), Sit to lying (Substantial/maximal assistance), Lying to sitting on side of bed (Substantial/maximal assistance). Resident #14 Urinary and Bowel Continence was always incontinent. Resident #14 had active diagnoses of Other Orthopedic Conditions. Resident #14's Pain Assessment Interview revealed that she had frequent pain or hurting with occasional pain during sleep. Record review of Resident #14's Care Plan dated 09/16/2025 reflected, Special Instructions: Max assist x 2 with transfers Problem: The resident is dependent on staff for meeting emotional, intellectual, physical, and social needs r/t Physical Limitationsdaily routine needs.Date Initiated: 09/18/2025Revision on: 09/18/2025 Goals: The resident will maintain involvement in cognitive stimulation, social activities as desired through review date.Date Initiated: 09/18/2025Target Date: 09/24/2025 Interventions: Encourage ongoing family involvement. Invite the resident's family Page 1 of 5 676268 676268 12/01/2025 Villages of Lake Highlands 8615 Lullwater Dr Dallas, TX 75238

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few to attend special events, activities, meals.Date Initiated: 09/18/2025 Invite the resident to scheduled activities.Date Initiated: 09/18/2025 Provide with activities calendar. Notify resident of any changes to the calendar of activities.Date Initiated: 09/18/2025 Thank resident for attendance at activity function.Date Initiated: 09/18/2025. Record review of Resident #14's Care Plan reflected no information regarding Advanced Directives. Record review of Resident #14's Discharge from the hospital dated 09/16/2025 reflected, TTWB, Partial Weight Bearing, Physical Therapy and Occupational Therapy. Record review of Resident #14's Physician Orders reflected an Active Phone Order on 09/16/2025 of Full Code. Record review of the facility's Admission/Discharge Report for 4/6/2025 to 10/6/2025, revealed that Resident #14 was originally admitted to the facility from an acute care hospital on [DATE]. Resident #14 was discharged from the facility to an acute care hospital on [DATE]. Resident #14 was readmitted to the facility from an acute care hospital on [DATE]. In an interview and Observation of Resident #14 on 10/06/25 at 11:14 AM, revealed that she was alert and oriented and lying in bed. Resident #14 stated that she had been a resident at the facility for 3 weeks. Resident #14 stated that she was originally admitted to the facility after having surgery on her left hip. Resident #14 stated that she was originally admitted to the facility sometime during the first week of September 2025. She stated that during her 1st stay at the facility, she had been at the facility about 1 week and was in pain and told the staff that she needed to go to the hospital because she was in a lot of pain. Resident #14 stated that she informed staff that she was in pain and they notified her physician who told the staff to have her sent to the ER because of her pain. Resident #14 stated that she had to have a second surgery on her hip and was at the hospital for a week and returned to the facility. Resident #14 stated that her pain had been managed since returning to the facility. Resident #14 stated that she is her own RP, but stated that her FM is involved with her care management. Resident #14 stated that she did not recall being involved in a Care Plan Meeting with the staff at the facility. On 10/06/25 at 12:02 PM, an attempted telephone call to Resident #14's Physician was unsuccessful. In an interview with Part-Time MDS Coordinator B on 10/06/2025 at 1:00 PM revealed, she had been employed at the facility for 11 years. She stated that MDS Coordinator E and MDS Coordinator F are the Full-Time MDS Coordinators at the facility. She stated that both MDS Coordinator E and MDS Coordinator F were currently unavailable due to both being on Leave. She stated that the MDS Assessment for Resident #14 was completed and both MDS Coordinators were to make sure that the Care Plan for Resident #14 included all the information that was pertinent to the care of the resident. MDS Coordinator B stated that she was unfamiliar with Resident #14. She stated that both MDS Coordinator E and MDS Coordinator F dropped the ball with this resident's Care Plan and were responsible for ensuring that Resident #14's Care Plan was completed in a timely manner. She stated that she is currently retired and had worked over 30 years as a MDS Coordinator. She stated that she assists the facility as the MDS Coordinator when both MDS Coordinators are on Leave. She stated that [Resident #14] was originally admitted to the facility on [DATE] and was discharged from the facility on 09/09/25. She stated that [Resident #14] was readmitted to the facility on [DATE] and her Care Plan should have been completed 13 days after [Resident #14's] readmission to the facility. MDS Coordinator B stated that there should have been more information, such as her hip precautions from her hospital discharge paperwork, infection of the right hip and COPD should have been addressed. She stated that there was a risk to Resident #14's Care Plan not being completed is that staff would not have available to them the care information needed that was pertinent to the care of the resident. She stated that harm could be caused to Resident #14 if her Care Plan was not completed. She stated that [Resident #14] recently had hip surgery and she was a complex resident and there could have been cause for her to 676268 Page 2 of 5 676268 12/01/2025 Villages of Lake Highlands 8615 Lullwater Dr Dallas, TX 75238

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few have some injuries if staff were not aware of the care she needed that was not on her current Care Plan. On 10/06/25 at 2:05 PM, an attempted telephone call to Resident #14's Pain Management doctor was unsuccessful. On 10/06/25 at 2:15 PM, an attempted telephone call to Resident #14's FM was unsuccessful. In an interview with ADON C on 10/07/25 at 9:33 AM, she stated that she had been employed at the facility for 6 years. ADON C stated that she was unaware that Resident #14's current Care Plan was not updated. ADON C stated that Resident #14 recently had 2 hip surgeries which included hip precautions. ADON C stated that Resident #14's Advanced Directives, Pain Management and Hip Precautions should have been added to her Care Plan. ADON C stated that the MDS Coordinators were responsible for completing the residents Care Plans. ADON C stated that the CNO was responsible for ensuring that each residents Care Plan met their needs. She stated that Care Plans are utilized by staff to minimize the risk of any further injuries to the resident. She stated that she did not feel that there was any harm caused to Resident #14 with the current Care Plan in her EHR. In an interview on 10/07/25 at 11:07 AM with CNO A, CNO A stated that Resident #14's Care Plan should have been completed within 13 days after she was readmitted to the facility. CNO A stated that [Resident #14] was admitted to the facility on [DATE] and went to the hospital on [DATE] and was discharged from the facility. CNO A stated that [Resident #14] returned to the facility on [DATE] and was readmitted to the facility. CNO A stated that [Resident #14's] current Care Plan was incomplete and did not include the information that is needed for her Care Plan to be completed, such as her Advanced Directives and information regarding her recent hip surgeries. She stated that it the MDS Coordinators responsibility to ensure that the residents Care Plans are completed in a timely manner. She stated that she thinks that when [Resident #14] returned to the facility, her Care Plan completion fell through the cracks because of the timeframes from when she was admitted , discharged and readmitted to the facility were misconstrued and her Care Plan fell through the cracks. CNO A stated that she performed monthly Audit Checks on resident Care Plans, but Resident #14's Care Plan was overlooked. CNO A stated that she will implement a plan to ensure that resident Care Plan are audited every morning. CNO A stated that she did not feel that there was any risks, or harm caused to Resident #14 with the current Care Plan in her EHR. In a telephone interview on 10/07/2025 at 11:30 AM with Director of Social Services, revealed that he had been employed at the facility for a year. The Director of Social Services revealed that he met with Resident #14 upon her admission to the facility. He stated that the facility's Nurse Case Manager and Director of Rehabilitation also were present to establish a plan of care and review safe discharge planning. The Director of Social Services revealed that he did not recall any collaboration with the residents plan of care, but does recall having a Collaborative Care Plan meeting. The Director of Social Services stated that the importance of Care Plans is to direct staff on how to properly care for each residents need of care. The Director of Social Services stated that not having a personalized plan of care can potentially lead to the risk of crucial resident care being missed. Record review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, dated 2001 and revised, December 2016 reflected, Policy Statement:A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation:1. The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident.2. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment.3. The IDT includes:a. The Attending Physician;b. A registered nurse who has responsibility for the resident;c. A nurse aide who has responsibility 676268 Page 3 of 5 676268 12/01/2025 Villages of Lake Highlands 8615 Lullwater Dr Dallas, TX 75238

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few for the resident;d. A member of the food and nutrition services staff;e. The resident and the resident's legal representative (to the extent practicable); andf. Other appropriate staff or professionals as determined by the resident's needs or as requested by the resident.4. Each resident's comprehensive person-centered care plan will be consistent with the resident's rights to participate in the development and implementation of his or her plan of care, including the right to:a. Participate in the planning process;b. Identify individuals or roles to be included;c. Request meetings;d. Request revisions to the plan of care;e. Participate in establishing the expected goals and outcomes of care;f. Participate in determining the type, amount, frequency and duration of care;g. Receive the services and/or items included in the plan of care; andh. See the care plan and sign it after significant changes are made.5. The resident will be informed of his or her right to participate in his or her treatment.6. An explanation will be included in a resident's medical record if the participation of the resident and his/her resident representative for developing the resident's care plan is determined to not be practicable.7. The care planning process will:a. Facilitate resident and/or representative involvement;b. Include an assessment of the resident's strengths and needs; andc. Incorporate the resident's personal and cultural preferences in developing the goals of care.8. The comprehensive, person-centered care plan will:a. Include measurable objectives and timeframes;b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.c. Describe services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment;d. Describe any specialized services to be provided as a result of PASARR recommendations;e. Include the resident's stated goals upon admission and desired outcomes;f. Include the resident's stated preference and potential for future discharge, including his or her desire to return to the community and any referrals made to local agencies or other entities to support such a desire;g. Incorporate identified problem areas;h. Incorporate risk factors associated with identified problems;i. Build on the resident's strengths;j. Reflect the resident's expressed wishes regarding care and treatment goals;k. Reflect treatment goals, timetables and objectives in measurable outcomes;l. Identify the professional services that are responsible for each element of care;m. Aid in preventing or reducing decline in the resident's functional status and/or functional levels;n. Enhance the optimal functioning of the resident by focusing on the rehabilitative program; [NAME]. Reflect currently recognized standards of practice for problem areas and conditions.9. Areas of concern that are identified during the resident assessment will be evaluated before interventions are added to the care plan.10. Identifying problem areas and their causes, and developing interventions that are targeted and meaningful to the resident, are the endpoint of an interdisciplinary process.a. No single discipline can manage an approach in isolation.b. The resident's physician (or primary healthcare provider) is integral to this process.11. Care plan interventions are chosen only after careful data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making.a. When possible, interventions address the underlying source(s) of the problem area(s), not just addressing only symptoms or triggers.b. Care planning individual symptoms in isolation may have little, if any, benefit for the resident.12. The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required comprehensive assessment (MDS).13. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change.14. The Interdisciplinary Team must review and update the care plan:a. When there has been a significant change in the resident's condition;b. When the desired outcome is not met;c. When the resident has 676268 Page 4 of 5 676268 12/01/2025 Villages of Lake Highlands 8615 Lullwater Dr Dallas, TX 75238

F 0656 Level of Harm - Minimal harm or potential for actual harm been readmitted to the facility from a hospital stay; andd. At least quarterly, in conjunction with the required quarterly MDS assessment.15. The resident has the right to refuse to participate in the development of his/her care plan and medical and nursing treatments. Such refusals will be documented in the resident's clinical record in accordance with established policies. Residents Affected - Few 676268 Page 5 of 5