Health inspection·April 11, 2025

F 0656 areas: Level of Harm - Minimal harm or potential for actual harm *unsteady gait and require assistance with ADL's r/t impaired mobility, generalized weakness, and recent hospitalization with interventions of Encourage adequate footwear, Encourage rest periods throughout the day, Encourage use of assistive devices (however devices not specified as appropriate for this resident), Notify MD and family of any changes in my gait and mobility patterns, Refer to therapy as indicated, and Staff will provide and document level of assistance with ADL's as needed. Residents Affected - Some *occupational therapy r/t upper extremity weakness with interventions of Encourage to be as independent with ADLs, improve functional ability, participate in occupational therapy as ordered, Notify MD and family of any changes in therapy plan, Provide assistive devices to promote independence with ADLs (however no devices specified). *physical therapy r/t lower extremity weakness with interventions of Encourage daily activity to promote strength and endurance, Encourage rest periods throughout the day to increase in stamina, (mechanical lift) transfer as resident allows as needed, participate in physical therapy as ordered, Notify MD and family of any changes to my PT plan, and Perform mobility assessment on admission, quarterly and upon change of condition. *use of mechanical lift r/t my lower extremity weakness and inability to assist with transfers. Bed-bound, Inability to bear weight, Lower extremity weakness and interventions of: Staff to get resident out of bed daily, or as often as the resident wished to be out of bed, Staff to monitor my body alignment during transfers in the mechanical lift to keep resident comfortable and safe during transfers, and Staff to use the mechanical lift at all times during transfers. Grab/transfer bars or bed rails were not mentioned in the care plan as either an intervention or focus. Observation of Resident #3's room and bed on 2/09/2025 at 11:10 AM revealed grab/transfer bar on both sides of the bed raised; resident was sitting in a manual wheelchair asleep at the time of observation. Observation on 2/11/2025 at 8:25 AM of Resident #3's room area and bed revealed the grab/transfer bar remained raised on both sides of bed; resident was sleeping soundly at time of observation and did not wake to his name being spoken. Resident not able to be interviewed. Resident #5 Record review of Resident #5's Face Sheet reflected a [AGE] year-old female who initially admitted to the facility on [DATE]. Resident #5 had relevant diagnoses Of Displaced Fracture Of Lateral Condyle Of Left Tibia, Other Reduced Mobility, Mild Cognitive Impairment, Muscle Weakness (Generalized), Unsteadiness On Feet, Unspecified Abnormalities Of Gait And Mobility, Cognitive Communication Deficit, Unspecified Lack Of Coordination, Repeated Falls, Chronic Obstructive Pulmonary Disease (common lung disease causing restricted air flow and breathing difficulty), Acute Pain Due To Trauma, Paroxysmal Atrial Fibrillation, Scoliosis, Fall On Same Level From Slipping, Tripping And Stumbling Without Subsequent Striking Against Object. Record review of Resident #5's MDS, dated [DATE], reflected a BIMS score of 15, which indicated intact cognition. The Quarterly MDS also showed that Resident #5 was dependent for ambulation and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676351 If continuation sheet Page 2 of 18 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 676351 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/11/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Discovery Village at Southlake 201 Watermere Drive Southlake, TX 76092 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 - Some utilized a manual wheelchair and walker. Resident #5 was noted to have a functional limitation in range of motion in both lower extremities. Resident #5 was noted to need substantial/maximal assistance for toileting hygiene, shower/bathe self, lower body dressing, take off/put on footwear and partial/moderate assistance with upper body dressing. Resident #5 was noted to need substantial/maximal assistance with chair/bed-to-chair transfer and partial/moderate assistance with sit to lying, lying to sitting on side of bed, and sit to stand. Record review of Resident #5's Care Plan, last updated on 3/16/2025, reflected the following focus areas: *physical therapy r/t lower extremity weakness with interventions of Encourage daily activity to promote strength and endurance, Encourage rest periods throughout the day to increase in stamina, Resident will participate in physical therapy as ordered, Notify MD and family of any changes to PT plan, and Perform mobility assessment on admission, quarterly and upon change of condition. * unsteady gait and require assistance with ADL's r/t impaired mobility, gen weakness, pain with interventions of Encourage adequate footwear, Encourage rest periods throughout the day, Encourage use of assistive devices, Notify MD and family of any changes in gait and mobility patterns, Refer to therapy as indicated, and Staff will provide and document level of assistance with ADL's as needed by resident d/t self-ability may fluctuate. * According to fall risk assessment, moderate risk for falls r/t unsteady gait, weakness, decline in functional mobility and needing increased assistance with completing ADL's with interventions of Assist with ADLs as needed, Assure call light is within reach and encourage to use it for assistance as needed, and Encourage to ask for assistance with ADL's. * Alteration in musculoskeletal status r/t recent acute illness, diagnosis, decline in mobility, weakness, disease process. Left Tibial fracture post fall ,acute pain from trauma with interventions of Anticipate and meet needs. Be sure call light is within reach and respond promptly to all requests for assistance, Follow MD orders for weight bearing status. See MD orders and/or PT treatment plan, Give analgesics as ordered by the physician. Monitor and document for side effects and effectiveness * participating in occupational therapy r/t upper extremity weakness with interventions of Encourage to be as independent with ADLs to improve functional ability, Engage in memory/recall activities to improve cognition, participate in occupational therapy as ordered, and Notify MD and family of any changes in therapy plan Grab/transfer bars or bed rails were not mentioned in the care plan as either an intervention or focus. Observation on 04/09/2025 at 12:34 PM of Resident #5's room area and bed revealed that the bed had grab/transfer bars raised on both sides. The resident was not in the room at the time. Observation on 04/11/2025 at 8:29 AM of Resident #5's room area and bed revealed the grab/transfer bars raised. Resident #30 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676351 If continuation sheet Page 3 of 18 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 676351 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/11/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Discovery Village at Southlake 201 Watermere Drive Southlake, TX 76092 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 - Some Record review of Resident #30's Face Sheet reflected a [AGE] year-old female who initially admitted to the facility on [DATE]. Resident #30 had relevant diagnoses of Partial Traumatic Amputation of Left Foot, Non-Pressure Chronic Ulcer of Other Part of Left Foot With Unspecified Severity, Unspecified Open Wound Left Foot, Atherosclerosis (buildup of substances in and on the artery walls) Of Native Arteries Of Extremities With Gangrene (condition where body tissues die due to a lack of blood supply or infection) Left Leg, Muscle Weakness (Generalized), Unsteadiness on Feet, Type 2 Diabetes Mellitus With Diabetic Neuropathy (disease that occurs when the body does not respond properly to insulin leading to high blood sugar levels), Atherosclerosis of Native Arteries of Left Leg With Ulceration (open sore or break in the skin or mucous membrane) of Other Part of Foot, and Age-Related Osteoporosis Without Current Pathological Fracture. Record review of Resident #30's MDS, dated [DATE], reflected a BIMS score of 05, which indicated a severe cognitive impairment. The Quarterly MDS also showed that Resident #30 utilized a manual wheelchair for mobility. Resident #30 was indicated to be functionally dependent for toilet hygiene and putting on/taking off footwear, needed substantial/maximal assistance with lower body dressing and shower and bathe self, while needing partial/moderate assistance with upper body dressing. Resident #30 was noted to need substantial/maximal assistance with roll left and right, sit to lying, lying to sitting on side of the bed, sit to stand, chair/bed-to-chair transfer. Record review of Resident #30's Care Plan, last updated 3/20/2025, reflected the following focus areas: * unsteady gait and require assistance with ADL's r/t impaired mobility, gen weakness, pain with interventions of Encourage daily activity to improve in conditioning and strength, Encourage rest periods throughout the day, Encourage use of assistive devices, Notify MD and family of any changes in gait and mobility patterns, Refer to therapy as indicated, Staff will provide and document level of assistance with ADL's as needed by resident d/t self-ability may fluctuate * unsteady gait and require assistance with ADL's r/t impaired mobility, gen weakness, pain with interventions of BED MOBILITY self care performance is up to extensive/total assistance x1-2 staff, TOILETING self care performance is up to extensive/total assistance x1-2 staff, and TRANSFERRING self care performance is up to extensive/total assistance x1-2 * moderate risk for falls r/t unsteady gait, weakness, decline in functional mobility and needing increased assistance with completing ADL's with interventions of Assist with ADLs as needed, Assure call light is within reach and encourage to use it for assistance as needed, Encourage to ask for assistance with ADL's * participating in occupational therapy r/t upper extremity weakness with interventions of Encourage to be as independent with ADLs as can to improve my functional ability, Engage in memory/recall activities to improve cognition, participate in occupational therapy as ordered, Notify MD and family of any changes in therapy plan, and Provide assistive devices to promote independence with ADLs * participating in physical therapy r/t lower extremity weakness with interventions of Encourage daily activity to promote strength and endurance, Encourage rest periods throughout the day to increase in stamina, participate in physical therapy as ordered, Notify MD and family of any changes to PT plan, Perform mobility assessment on admission, quarterly and upon change of condition, and Provide (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676351 If continuation sheet Page 4 of 18 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 676351 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/11/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Discovery Village at Southlake 201 Watermere Drive Southlake, TX 76092 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 assistive devices for use in ambulation. Level of Harm - Minimal harm or potential for actual harm Grab/transfer bars or bed rails were not mentioned in the care plan as either an intervention or focus. Residents Affected - Some Observation on 04/09/2025 at 12:40 PM of Resident #30 room area and bed revealed that the bed had grab/transfer bars raised on both sides. The resident was in the room at the time sitting in her manual wheelchair enjoying lunch. The resident was not able to be interviewed due to cognitive decline. Observation on 04/10/2025 at 8:39 AM of Resident #30's room area and bed revealed the grab/transfer bars in the raised position on both sides of the bed. Resident #34 Record review of Resident #34's Face Sheet reflected an [AGE] year-old female who initially admitted to the facility on [DATE]. Resident #34 had relevant diagnoses of Displaced Intertrochanteric Fracture of Left Femur (fracture of the femur (thigh) bone in the hip joint), Acute Pain Due to Trauma, Fall on Same Level From Slipping, Tripping And Stumbling Without Subsequent Striking Against Object, Unspecified Lack of Coordination, Other Reduced Mobility, Cognitive Communication Deficit, Unspecified Abnormalities of Gait And Mobility, Type 2 Diabetes Mellitus Without Complications (where the body either does not produce enough insulin or does not use insulin efficiently), Other Thrombophilia (condition where the blood clots more easily than it should), and Unspecified Dementia. Record review of Resident #34's Quarterly MDS, dated [DATE], reflected a BIMS score of 13, which indicated an intact cognition. The Quarterly MDS also showed that Resident #5 had a prior functional range of motion limitation with lower extremities and utilized a wheelchair of ambulation. Resident #34 was indicated in self-care to be substantial/maximal assistance with toileting hygiene, shower/bathe self, lower body dressing, and putting on/taking off footwear. Resident #34 was indicated to need partial/moderate assistance for upper body dressing. Resident #34 was noted to be substantial/maximal assistance in mobility areas of roll left and right, sit to lying, lying to sitting on side of bed, sit to stand, and chair/bed-to-chair transfer. Record review of Resident #34's Care Plan, last updated 3/16/2025, reflected the following focus areas: * moderate risk for falls r/t unsteady gait, weakness, decline in functional mobility and needing increased assistance with completing ADL's with interventions of Assist with ADLs as needed, Assure call light is within reach and encourage to use it for assistance as needed, and Encourage to ask for assistance with ADL's * participating in physical therapy r/t lower extremity weakness with interventions of Encourage daily activity to promote strength and endurance, Encourage rest periods throughout the day to increase in stamina, participate in physical therapy as ordered, Notify MD and family of any changes to PT plan, Perform mobility assessment on admission, quarterly and upon change of condition, and Provide assistive devices for use in ambulation. * participating in occupational therapy r/t upper extremity weakness with interventions of Encourage to be as independent with ADLs as can to improve my functional ability, Engage in memory/recall activities to improve cognition, participate in occupational therapy as ordered, Notify MD and family (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676351 If continuation sheet Page 5 of 18 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 676351 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/11/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Discovery Village at Southlake 201 Watermere Drive Southlake, TX 76092 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 of any changes in therapy plan, and Provide assistive devices to promote independence with ADLs. Level of Harm - Minimal harm or potential for actual harm *unsteady gait and require assistance with ADL's r/t impaired mobility, gen weakness, pain, s/p surgery left femur fracture with interventions of Encourage adequate footwear, Encourage rest periods throughout the day, Encourage use of assistive devices, Notify MD and family of any changes in gait and mobility patterns, Refer to therapy as indicated, and Staff will provide and document level of assistance with ADL's as needed by resident d/t self-ability may fluctuate Residents Affected - Some Grab/transfer bars or bed rails were not mentioned in the care plan as either an intervention or focus. Observation on 04/09/2025 at 1:00 PM of Resident #34's room area and bed revealed that the bed had grab/transfer bars raised on both sides. The resident was not in the room at the time. Observation on 04/10/2025 at 9:20 AM of Resident #34's room area and bed revealed the grab/transfer bar raised on both sides of the bed. The resident was sitting in a recliner at bedside and visiting with a guest. Interview with Resident #34 revealed she has always wondered why the rails are up so close to her head and she wishes they were further down on the bed instead close by her face when she goes to sleep. Interview on 04/11/2025 at 12:00 PM with LVN 2 revealed no known residents in the facility needed side rails. LVN 2 stated being aware that some residents were using grab/transfer bars for safety and to help the resident getting up and scooting themselves up/repositioning in bed. LVN 2 was unsure about the facility's policy on grab/transfer bars and stated residents should have been assessed first because the grab/transfer bars can be a type of restraint. LVN 2 revealed being unsure if there should have been a consent form for grab/transfer bars. LVN 2 revealed that the grab/transfer bars should have been care planned. Interview on 04/11/2025 at 12:10 PM with RN 3 revealed some residents came to the facility due to fractures; the grab/transfer bars helped them with transferring and repositioning in bed. RN 3 revealed t either therapy or the DON should have done the assessment for the grab/transfer bars. RN 3 revealed was not sure if there was a policy for the grab/transfer bars and was not sure if the resident should be consented to use the grab/transfer bars. RN 3 revealed it should have been care planned. RN 3 informed the risk of grab/transfer bars having been used before assessment was an accident. Interview on 04/11/2025 at 12:12 PM with CNA 1 revealed the residents use the grab/transfer bars to reposition when in bed however was not sure if there was a policy or of any residents having had an accident from the grab/transfer bars. CNA 1 revealed was unsure if grab/transfer bars should have been care planned and deferred to the nurses to provide a response. Interview on 04/11/2025 at 12:16 PM with DON revealed he did not know if the facility had a policy related to bed rails & grab/transfer bars and he deferred to the Administrator. DON revealed the facility should have a policy but did not know the policy. DON informed grab/transfer bar assessments should have been done by PT, not by nurses. DON stated there should not be a risk to resident's safety because they were grab/transfer bars and not a bed rail. DON was not able to answer if grab/transfer bars should be care planned, again referred to Administrator for answer. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676351 If continuation sheet Page 6 of 18 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 676351 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/11/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Discovery Village at Southlake 201 Watermere Drive Southlake, TX 76092 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 - Some Interview on 04/11/2025 at 12:43 PM with ADM revealed that grab/assist bars were on all the resident beds unless the bed was rented and did not come with the grab/assist bars, or the bed was provided by a hospice agency without the grab/assist bars. ADM revealed that since the grab/assist bars did not fit the description for bed rails/side rails, and residents use for repositioning and to aid in getting in and out of the bed, they were not a risk of danger or a restraint. ADM further revealed that a safety assessment was not necessary since the grab/assist bars had never been a safety issue. ADM revealed that a consent was not requested since residents wanted the grab/assist bars on the beds. ADM informed that if a resident did not want the grab/assist bars the facility would rent a bed without them. ADM revealed that grab/assist bars were not care planned as the bars had never been an issue, the facility had never had any accident or incident due to the grab/transfer bars. ADM revealed that the DON should have known the policy and requirements for a resident bed to have grab/transfer bars. Record Review of the facility's Care Plans, Comprehensive Person-Centered, Nursing Services Policy and Procedure Manual for Long-[NAME] Care ©200I MED-PASS, Inc. (Revised March 2022), policy statement was 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. The policy interpretation and implementation stated: 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 . 3. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment . 7. The comprehensive, person-centered care plan: a. includes measurable objectives and timeframes; . 9. Care plan interventions are chosen only after 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. 10. When possible, interventions address the underlying source(s) of the problem area(s), not just symptoms or triggers. 11. Assessments of residents are ongoing and care plans are revised as information about the residents and the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676351 If continuation sheet Page 7 of 18 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 676351 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/11/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Discovery Village at Southlake 201 Watermere Drive Southlake, TX 76092 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 residents' conditions change. 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: 676351 If continuation sheet Page 8 of 18 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 676351 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/11/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Discovery Village at Southlake 201 Watermere Drive Southlake, TX 76092 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 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to assess the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation for 4 of 7 residents (Resident #3, #5, #30, and Resident #34) rooms observed for bed rails/grab/transfer bars. The facility did not have informed consent and assessment of the residents for appropriateness or risk of entrapment for bed rails or grab/transfer bars for Residents #3, #5, #30, and Resident #34. This failure could place residents who used bed rails/grab/transfer bars at risk of injury or entrapment not being assessed for appropriateness for bed rails or grab bars, resident/responsible party not being aware of the risks posed by bed rails/grab/transfer bars, and informed consent for the potential dangers posed by grab/transfer bars or bed rails not being obtained from the resident or responsible party. Findings included: Resident #3 Record Review of Resident #'3s Face Sheet reflected an [AGE] year-old male who initially admitted to the facility on [DATE]. Resident #3 had relevant diagnoses of Unspecified Atrial Fibrillation (a type of arrhythmia where the heart's upper chambers (atria) beat irregularly and out of sync with the lower chambers (ventricles), and the specific details about its behavior (how long it lasts, how often it occurs, etc.) are not known); Aphasia Following Unspecified Cerebrovascular Disease (language disorder that can happen after a stroke where the cause is not specifically identified); Unspecified Abnormalities Of Gait And Mobility, Unspecified Lack Of Coordination, Cognitive Communication Deficit, Unspecified Dementia (loss of memory and other thinking abilities that interferes with daily living); Alzheimer's Disease (progressive neurodegenerative disorder that affects memory, thinking, and behavior); Other Transient Cerebral Ischemic Attacks (temporary disruption of blood flow to the brain) and Related Syndromes; and Other Lack Of Coordination. Record Review of Resident #3's MDS, dated [DATE], reflected a BIMS score of 14 indicating intact cognition. Resident #3 was noted to use a manual wheelchair for mobility. Resident #3 was noted to need substantial/maximal assistance for self-care categories of toileting, shower/bathing, upper body dressing, and was dependent for lower body dressing and putting on/taking off footwear. Resident #3 was noted to need substantial/maximal assistance in the mobility categories of sit to stand, chair/bed-to-chair transfer, toilet transfer, and tub/shower transfer. Resident #3 was noted to need partial/moderate assistance with roll left and right, sit to lying, and lying to sitting on side of the bed. Record review of Resident #3's Care Plan, last updated on 2/08/2025, reflected the following focus areas: *unsteady gait and require assistance with ADL's r/t impaired mobility, generalized weakness, and recent hospitalization with interventions of Encourage adequate footwear, Encourage rest periods throughout the day, Encourage use of assistive devices (however devices not specified as appropriate for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676351 If continuation sheet Page 9 of 18 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 676351 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/11/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Discovery Village at Southlake 201 Watermere Drive Southlake, TX 76092 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 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some this resident), Notify MD and family of any changes in my gait and mobility patterns, Refer to therapy as indicated, and Staff will provide and document level of assistance with ADL's as needed. *occupational therapy r/t upper extremity weakness with interventions of Encourage to be as independent with ADLs, improve functional ability, participate in occupational therapy as ordered, Notify MD and family of any changes in therapy plan, Provide assistive devices to promote independence with ADLs (however no devices specified). *physical therapy r/t lower extremity weakness with interventions of Encourage daily activity to promote strength and endurance, Encourage rest periods throughout the day to increase in stamina, (mechanical lift) transfer as resident allows as needed, participate in physical therapy as ordered, Notify MD and family of any changes to my PT plan, and Perform mobility assessment on admission, quarterly and upon change of condition. *use of mechanical lift r/t my lower extremity weakness and inability to assist with transfers. Bed-bound, Inability to bear weight, Lower extremity weakness and interventions of: Staff to get resident out of bed daily, or as often as the resident wished to be out of bed, Staff to monitor my body alignment during transfers in the mechanical lift to keep resident comfortable and safe during transfers, and Staff to use the mechanical lift at all times during transfers. Grab/transfer bars or bed rails were not mentioned in the care plan as either an intervention or focus. Electronic Health Record had no assessment or consent for bed rails or grab/transfer bars. Observation of Resident #3's room and bed on 2/09/2025 at 11:10 AM revealed grab/transfer bar on both sides of the bed raised; resident was sitting in a manual wheelchair asleep at the time of observation. Observation on 2/11/2025 at 8:25 AM of Resident #3's room area and bed revealed the grab/transfer bar remained raised on both sides of bed; resident was sleeping soundly at time of observation and did not wake to his name being spoken. Resident not able to be interviewed. Resident #5 Record review of Resident #5's Face Sheet reflected a [AGE] year-old female who initially admitted to the facility on [DATE]. Resident #5 had relevant diagnoses Of Displaced Fracture Of Lateral Condyle Of Left Tibia, Other Reduced Mobility, Mild Cognitive Impairment, Muscle Weakness (Generalized), Unsteadiness On Feet, Unspecified Abnormalities Of Gait And Mobility, Cognitive Communication Deficit, Unspecified Lack Of Coordination, Repeated Falls, Chronic Obstructive Pulmonary Disease (common lung disease causing restricted air flow and breathing difficulty), Acute Pain Due To Trauma, Paroxysmal Atrial Fibrillation, Scoliosis, Fall On Same Level From Slipping, Tripping And Stumbling Without Subsequent Striking Against Object. Record review of Resident #5's MDS, dated [DATE], reflected a BIMS score of 15, which indicated intact cognition. The Quarterly MDS also showed that Resident #5 was dependent for ambulation and utilized a manual wheelchair and walker. Resident #5 was noted to have a functional limitation in range of motion in both lower extremities. Resident #5 was noted to need substantial/maximal assistance for toileting hygiene, shower/bathe self, lower body dressing, take off/put on footwear and partial/moderate assistance with upper body dressing. Resident #5 was noted to need substantial/maximal assistance with chair/bed-to-chair transfer and partial/moderate assistance with sit to lying, lying to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676351 If continuation sheet Page 10 of 18 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 676351 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/11/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Discovery Village at Southlake 201 Watermere Drive Southlake, TX 76092 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 0700 sitting on side of bed, and sit to stand. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #5's Care Plan, last updated on 3/16/2025, reflected the following focus areas: Residents Affected - Some *physical therapy r/t lower extremity weakness with interventions of Encourage daily activity to promote strength and endurance, Encourage rest periods throughout the day to increase in stamina, Resident will participate in physical therapy as ordered, Notify MD and family of any changes to PT plan, and Perform mobility assessment on admission, quarterly and upon change of condition. * unsteady gait and require assistance with ADL's r/t impaired mobility, gen weakness, pain with interventions of Encourage adequate footwear, Encourage rest periods throughout the day, Encourage use of assistive devices, Notify MD and family of any changes in gait and mobility patterns, Refer to therapy as indicated, and Staff will provide and document level of assistance with ADL's as needed by resident d/t self-ability may fluctuate. * According to fall risk assessment, moderate risk for falls r/t unsteady gait, weakness, decline in functional mobility and needing increased assistance with completing ADL's with interventions of Assist with ADLs as needed, Assure call light is within reach and encourage to use it for assistance as needed, and Encourage to ask for assistance with ADL's. * Alteration in musculoskeletal status r/t recent acute illness, diagnosis, decline in mobility, weakness, disease process. Left Tibial fracture post fall ,acute pain from trauma with interventions of Anticipate and meet needs. Be sure call light is within reach and respond promptly to all requests for assistance, Follow MD orders for weight bearing status. See MD orders and/or PT treatment plan, Give analgesics as ordered by the physician. Monitor and document for side effects and effectiveness * participating in occupational therapy r/t upper extremity weakness with interventions of Encourage to be as independent with ADLs to improve functional ability, Engage in memory/recall activities to improve cognition, participate in occupational therapy as ordered, and Notify MD and family of any changes in therapy plan Grab/transfer bars or bed rails were not mentioned in the care plan as either an intervention or focus. Electronic Health Record had no assessment or consent for bed rails or grab/transfer bars. Observation on 04/09/2025 at 12:34 PM of Resident #5's room area and bed revealed that the bed had grab/transfer bars raised on both sides. The resident was not in the room at the time. Observation on 04/11/2025 at 8:29 AM of Resident #5's room area and bed revealed the grab/transfer bars raised. Resident #30 Record review of Resident #30's Face Sheet reflected a [AGE] year-old female who initially admitted to the facility on [DATE]. Resident #30 had relevant diagnoses of Partial Traumatic Amputation of Left Foot, Non-Pressure Chronic Ulcer of Other Part of Left Foot With Unspecified Severity, Unspecified Open Wound Left Foot, Atherosclerosis (buildup of substances in and on the artery walls) Of Native Arteries Of Extremities With Gangrene (condition where body tissues die due to a lack of blood (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676351 If continuation sheet Page 11 of 18 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 676351 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/11/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Discovery Village at Southlake 201 Watermere Drive Southlake, TX 76092 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 0700 Level of Harm - Minimal harm or potential for actual harm supply or infection) Left Leg, Muscle Weakness (Generalized), Unsteadiness on Feet, Type 2 Diabetes Mellitus With Diabetic Neuropathy (disease that occurs when the body does not respond properly to insulin leading to high blood sugar levels), Atherosclerosis of Native Arteries of Left Leg With Ulceration (open sore or break in the skin or mucous membrane) of Other Part of Foot, and Age-Related Osteoporosis Without Current Pathological Fracture. Residents Affected - Some Record review of Resident #30's MDS, dated [DATE], reflected a BIMS score of 05, which indicated a severe cognitive impairment. The Quarterly MDS also showed that Resident #30 utilized a manual wheelchair for mobility. Resident #30 was indicated to be functionally dependent for toilet hygiene and putting on/taking off footwear, needed substantial/maximal assistance with lower body dressing and shower and bathe self, while needing partial/moderate assistance with upper body dressing. Resident #30 was noted to need substantial/maximal assistance with roll left and right, sit to lying, lying to sitting on side of the bed, sit to stand, chair/bed-to-chair transfer. Record review of Resident #30's Care Plan, last updated 3/20/2025, reflected the following focus areas: * unsteady gait and require assistance with ADL's r/t impaired mobility, gen weakness, pain with interventions of Encourage daily activity to improve in conditioning and strength, Encourage rest periods throughout the day, Encourage use of assistive devices, Notify MD and family of any changes in gait and mobility patterns, Refer to therapy as indicated, Staff will provide and document level of assistance with ADL's as needed by resident d/t self-ability may fluctuate * unsteady gait and require assistance with ADL's r/t impaired mobility, gen weakness, pain with interventions of BED MOBILITY self care performance is up to extensive/total assistance x1-2 staff, TOILETING self care performance is up to extensive/total assistance x1-2 staff, and TRANSFERRING self care performance is up to extensive/total assistance x1-2 * moderate risk for falls r/t unsteady gait, weakness, decline in functional mobility and needing increased assistance with completing ADL's with interventions of Assist with ADLs as needed, Assure call light is within reach and encourage to use it for assistance as needed, Encourage to ask for assistance with ADL's * participating in occupational therapy r/t upper extremity weakness with interventions of Encourage to be as independent with ADLs as can to improve my functional ability, Engage in memory/recall activities to improve cognition, participate in occupational therapy as ordered, Notify MD and family of any changes in therapy plan, and Provide assistive devices to promote independence with ADLs * participating in physical therapy r/t lower extremity weakness with interventions of Encourage daily activity to promote strength and endurance, Encourage rest periods throughout the day to increase in stamina, participate in physical therapy as ordered, Notify MD and family of any changes to PT plan, Perform mobility assessment on admission, quarterly and upon change of condition, and Provide assistive devices for use in ambulation. Grab/transfer bars or bed rails were not mentioned in the care plan as either an intervention or focus. Electronic Health Record had no assessment or consent for bed rails or grab/transfer bars. Observation on 04/09/2025 at 12:40 PM of Resident #30 room area and bed revealed that the bed had grab/transfer bars raised on both sides. The resident was in the room at the time sitting in her (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676351 If continuation sheet Page 12 of 18 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 676351 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/11/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Discovery Village at Southlake 201 Watermere Drive Southlake, TX 76092 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 0700 manual wheelchair enjoying lunch. The resident was not able to be interviewed due to cognitive decline. Level of Harm - Minimal harm or potential for actual harm Observation on 04/10/2025 at 8:39 AM of Resident #30's room area and bed revealed the grab/transfer bars in the raised position on both sides of the bed. Residents Affected - Some Resident #34 Record review of Resident #34's Face Sheet reflected an [AGE] year-old female who initially admitted to the facility on [DATE]. Resident #34 had relevant diagnoses of Displaced Intertrochanteric Fracture of Left Femur (fracture of the femur (thigh) bone in the hip joint), Acute Pain Due to Trauma, Fall on Same Level From Slipping, Tripping And Stumbling Without Subsequent Striking Against Object, Unspecified Lack of Coordination, Other Reduced Mobility, Cognitive Communication Deficit, Unspecified Abnormalities of Gait And Mobility, Type 2 Diabetes Mellitus Without Complications (where the body either does not produce enough insulin or does not use insulin efficiently), Other Thrombophilia (condition where the blood clots more easily than it should), and Unspecified Dementia. Record review of Resident #34's Quarterly MDS, dated [DATE], reflected a BIMS score of 13, which indicated an intact cognition. The Quarterly MDS also showed that Resident #5 had a prior functional range of motion limitation with lower extremities and utilized a wheelchair of ambulation. Resident #34 was indicated in self-care to be substantial/maximal assistance with toileting hygiene, shower/bathe self, lower body dressing, and putting on/taking off footwear. Resident #34 was indicated to need partial/moderate assistance for upper body dressing. Resident #34 was noted to be substantial/maximal assistance in mobility areas of roll left and right, sit to lying, lying to sitting on side of bed, sit to stand, and chair/bed-to-chair transfer. Record review of Resident #34's Care Plan, last updated 3/16/2025, reflected the following focus areas: * moderate risk for falls r/t unsteady gait, weakness, decline in functional mobility and needing increased assistance with completing ADL's with interventions of Assist with ADLs as needed, Assure call light is within reach and encourage to use it for assistance as needed, and Encourage to ask for assistance with ADL's * participating in physical therapy r/t lower extremity weakness with interventions of Encourage daily activity to promote strength and endurance, Encourage rest periods throughout the day to increase in stamina, participate in physical therapy as ordered, Notify MD and family of any changes to PT plan, Perform mobility assessment on admission, quarterly and upon change of condition, and Provide assistive devices for use in ambulation. * participating in occupational therapy r/t upper extremity weakness with interventions of Encourage to be as independent with ADLs as can to improve my functional ability, Engage in memory/recall activities to improve cognition, participate in occupational therapy as ordered, Notify MD and family of any changes in therapy plan, and Provide assistive devices to promote independence with ADLs. *unsteady gait and require assistance with ADL's r/t impaired mobility, gen weakness, pain, s/p surgery left femur fracture with interventions of Encourage adequate footwear, Encourage rest periods throughout the day, Encourage use of assistive devices, Notify MD and family of any changes in gait and mobility patterns, Refer to therapy as indicated, and Staff will provide and document level of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676351 If continuation sheet Page 13 of 18 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 676351 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/11/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Discovery Village at Southlake 201 Watermere Drive Southlake, TX 76092 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 0700 assistance with ADL's as needed by resident d/t self-ability may fluctuate Level of Harm - Minimal harm or potential for actual harm Grab/transfer bars or bed rails were not mentioned in the care plan as either an intervention or focus. Electronic Health Record had no assessment or consent for bed rails or grab/transfer bars. Residents Affected - Some Observation on 04/09/2025 at 1:00 PM of Resident #34's room area and bed revealed that the bed had grab/transfer bars raised on both sides. The resident was not in the room at the time. Observation on 04/10/2025 at 9:20 AM of Resident #34's room area and bed revealed the grab/transfer bar raised on both sides of the bed. The resident was sitting in a recliner at bedside and visiting with a guest. Interview with Resident #34 revealed she has always wondered why the rails are up so close to her head and she wishes they were further down on the bed instead close by her face when she goes to sleep. Interview on 04/11/2025 at 12:00 PM with LVN 2 revealed having been unsure about the facility's policy on grab/transfer bars and stated residents should have been assessed first because the grab/transfer bars can be a type of restraint. LVN 2 revealed unsure if there should have been a consent form for grab/transfer bars. Interview on 04/11/2025 at 12:10 PM with RN 3 revealed was not sure if there was a policy for the grab/transfer bars and was not sure if the resident should be consented to use the grab/transfer bars. RN 3 informed the risk of grab/transfer bars having been used before assessment was an accident. Interview on 04/11/2025 at 12:16 PM with DON revealed he did not know if the facility had a policy related to bed rails & grab/transfer bars and he deferred to the Administrator. DON revealed the facility should have a policy but did not know the policy. DON informed grab/transfer bar assessments should have been done by PT, not by nurses. DON stated there should not be a risk to resident's safety because they were grab/transfer bars and not a bed rail. Interview on 04/11/2025 at 12:43 PM with ADM revealed that the facility received the beds with the grab/assist bars already installed. The ADM informed that grab/assist bars were on all the resident beds unless the bed was rented and did not come with the grab/assist bars, or the bed was provided by a hospice agency without the grab/assist bars. ADM revealed that since the grab/assist bars did not fit the description for bed rails/side rails, and residents use for repositioning and to aid in getting in and out of the bed, they were not a risk of danger or a restraint. ADM further revealed that a safety assessment was not necessary since the grab/assist bars had never been a safety issue. ADM revealed that a consent was not requested since residents wanted the grab/assist bars on the beds. ADM informed that if a resident did not want the grab/assist bars the facility would rent a bed without them. ADM informed that the maintenance director and nursing staff would evaluate beds for safety and functioning every quarter or as needed. ADM revealed that grab/assist bars were not care planned as the bars had never been an issue, the facility had never had any accident or incident due to the grab/transfer bars. ADM revealed that the DON should have known the policy and requirements for a resident bed to have grab/transfer bars. Record Review of the facility's Bed Safety and Bed Rails policy from Nursing Services Policy and Procedure Manual for Long-Term Care ©2001 MED-PASS, Inc. Version 1.2 (HSMAPL0088), Revision date August 2022, states the purpose is Resident beds meet the safety specifications established by the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676351 If continuation sheet Page 14 of 18 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 676351 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/11/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Discovery Village at Southlake 201 Watermere Drive Southlake, TX 76092 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 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Hospital Bed Safety Workgroup. The use of bed rails is prohibited unless the criteria for use of bed rails have been met. Relevant sections include: Definition: 1. Bed rails are adjustable metal or rigid plastic bars that attach to the bed. They are available in a variety of types, shapes, and sizes ranging from full to one-half, one- quarter, or one-eighth lengths. Some bed rails are not designed as part of the bed by the manufacturer and may be installed on or used along the side of a bed. For the purpose of this policy bed rails include: a. side rails; b. safety rails; and c. grab/assist bars. General Guidelines: 3. The use of bed rails or side rails (including temporarily raising the side rails for episodic use during care} is prohibited unless the criteria for use of bed rails have been met, including attempts to use alternatives, interdisciplinary evaluation, resident assessment, and informed consent.3. Upon admission, readmission, with routine quarterly or significant change MDS and PRN, therapy/designee will complete the Side Rail Utilization Assessment, or equivalent form to determine the resident's symptoms, risk of entrapment and rationales for using side rails prior to implementation. When used for mobility or transfer, the assessment will include a review of the resident's: 4. Prior to the installation or use of a side or bed rail, alternatives to the use of side or bed rails are attempted . 5. If attempted alternatives do not adequately meet the resident's needs the resident may be evaluated for the use of bed rails. This interdisciplinary evaluation includes: a. an evaluation of the alternatives to bed rails that were attempted and how these alternatives failed to meet the resident's needs; b. the resident's risk associated with the use of bed rails; c. input from the resident and/or representative; and d. consultation with the attending physician.7. Least Restrictive devices will be reviewed and recommendations if indicated will be attempted prior to use of siderails (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676351 If continuation sheet Page 15 of 18 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 676351 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/11/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Discovery Village at Southlake 201 Watermere Drive Southlake, TX 76092 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 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 7. The resident assessment also determines potential risks to the resident associated with the use of bed rails, including the following: a. Accident hazards: (1) The resident could attempt to climb over, around, between, or through the rails, or over the foot board; and/or (2} A resident or part of his/her body could be caught between rails, the openings of the rails, or between the bed rails and mattress . c. Psychosocial outcomes: (1) Creates an undignified self-image and alters the resident's self-esteem; (2) Contributes to feelings of isolation; and/or (3) Induces agitation or anxiety. 8. Before using bed rails for any reason, the staff shall inform the resident or representative about the benefits and potential hazards associated with bed rails and obtain informed consent. The following information will be included in the consent: a. The assessed medical needs that will be addressed with the use of bed rails; b. The resident's risks from the use of bed rails and how these will be mitigated; c. The alternatives that were attempted but failed to meet the resident's needs; and d. The alternatives that were considered but not attempted and the reasons. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676351 If continuation sheet Page 16 of 18 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 676351 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/11/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Discovery Village at Southlake 201 Watermere Drive Southlake, TX 76092 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food safety in the facility's only kitchen observed for food safety. 1. The facility failed to remove five dented cans from the dry food storage area. 2. The facility failed to label a plastic container in the dry food storage area. The failures could place residents at risk for food-borne illness. Findings included: In an observation on 04/09/25 at 10:35 AM of the dry food storage area reflected one plastic container, with a white substance that was not labeled. In an observation on 04/09/25 at 10:42 AM of the dry food storage area reflected the following: *one dented can labeled black eyed peas on the third wired rack of the shelf, *one dented can labeled great northern beans on the second wired rack of the shelf, *two dented cans labeled green beans on the last wired rack of the shelf, and *one dented can labeled black beans on the fourth wired rack of the shelf. In an interview on 04/09/25 at 10:37 AM, the DS stated the white substance in the plastic container could be white cornmeal or flour. She stated that the risk of not labeling the container could cause a mix up of ingredients. In an interview on 04/11/25 at 10:46 AM, the DM stated their policy stated everything must be labeled and dated. She stated she was not sure why one of the staff members had not labeled the container. She stated the risk of the container not being labeled was the wrong ingredient can be used. In a follow-up interview on 04/09/25, at 10:52 AM, the DM stated she typically threw the dented cans away, or she waited until Sysco came to drop off another shipment. The DM stated the risk of dented cans was a possible illness. In an interview on 04/11/25 at 1:51 PM, the ADM stated all food items must be labeled and dated. The ADM stated the facility wanted to ensure every item was labeled to confirm the correct ingredients were used. The ADM stated the facility had a designated area where all the dented cans were supposed to be placed to return to the vendor. The ADM stated he could not say why the facility did not place the dented cans in the correct area, but the expectation was for the facility to place those cans in the designated area. Record Review of an undated policy titled Food Contamination and Storage: All food handling, preparation, and storage practices are conducted in a manner that prevents contamination and promotes the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676351 If continuation sheet Page 17 of 18 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 676351 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/11/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Discovery Village at Southlake 201 Watermere Drive Southlake, TX 76092 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete health and well-being of residents. 2(k) All food items must be labeled with the product name, the date it was opened, and the use by date. (q) Maintain clean and organized storage areas, free from debris and unnecessary items that may obstruct airflow or cause contamination. (r) Perform regular inspections of dry and refrigerated storage areas to ensure all items are correctly labeled, dated, and stored according to the policy. Event ID: Facility ID: 676351 If continuation sheet Page 18 of 18